Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Glenn Hay, Coroner, having investigated the death of
Christopher James NEWELL
WITHOUT HOLDING AN INQUEST
Find That:
(a) Christopher James Newell ('Dr Newell') died on or about 21 June 2008 at Old Farm Road, South Hobart.
(b) Dr Newell was born in Sydney on 2 March 1964 and was aged 44 years.
(c) Dr Newell was a married man and a University Lecturer at the date of his death.
(d) I find that the Dr Newell died as a result of multiple drug toxicity (ethanol, oxycodone, codeine, diazepam, temazepam, and tramadol).
Background:
At the time of Dr Newell's death he was being treated by Doctor Ian Crawford ('Dr Crawford') of 57 King Street, Sandy Bay.
It is regrettable there has been a significant delay in publishing my findings, specifically brought about by a delay by medical staff at the Royal Hobart Hospital in providing relevant clarifying information following my numerous requests.
I have decided not to hold a public inquest hearing into his death because my investigations have sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning how the death occurred and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me and would not assist any further in my findings or recommendations.
Circumstances Surrounding the Death:
Dr Newell was the co-ordinator of and lecturer in the 'Ethics, Personal and Professional Development' study unit at the University of Tasmania School of Medicine. In addition to his academic career Dr Newell had an active role within the Anglican Church as a priest and as Acting Dean at Saint David's Cathedral.
Dr Newell suffered from numerous health complaints from childhood, including asthma, hypoxia, severe allergies and sensitivities. Due to his extensive health problems, Dr Newell required on-going steroid treatment and was steroid dependant for the past 20 years.
Mrs Merle Newell is the mother of Dr Newell and assisted with his care until his marriage in 1994. She states that due to her son's complicated regime of medication, any imbalance would result in periods of deep depression which would last for 48 hours. Mrs Merle Newell states that Dr Newell's behaviour during these episodes was characterized by him appearing to be rational, but that in her experience his thinking and perception appeared distorted and he would think that everything was getting too much for him. Mrs Merle Newell states that constant family support was vital during these times.
Dr Newell suffered from long-term side effects of steroid induced osteoporosis and cataract formation and required supplementary oxygen treatment. In 2005 Dr Newell was hospitalised with prolapsed discs and this resulted in chronic pain requiring doses of narcotic analgesics along with a complicated regime of medication to manage his severe asthma and multiple illnesses. Dr Newell's medications included adrenaline, amoxil gabapentin, hydrocortisone sodium, succinate, maxolon, minomycin, nilstat oral capsule, norspan, nuelin, prednisolone salbutamol seretide mdi, Tagamet, tramadol hydrochloride - tramal and valium.
He frequently had to resort to a motorised scooter to get around Hobart.
While Dr Newell had significant health issues he was described as being a workaholic, pushing his physical capacity to its limits; a champion of the rights of the disabled and the vulnerable; a strong voice for human and medical ethics; a strong advocate for pro-life and an opponent of euthanasia.
Mrs Newell first met Dr Newell in 1992, when she worked as his part-time carer. In 1994 Dr and Mrs Newell were married and lived with Mrs Newell's two daughters from a previous relationship, Hayley Collyer and Natasha Collyer along with one daughter of their marriage, Christine.
Mrs Newell states that due to Dr Newell's illnesses he was taking very strong painkillers which appeared to affect his memory and made him drowsy. Although she did not consider Dr Newell suffered any major battle with depression, she did notice that, as his disabilities and work load increased, so did his need for pain killers.
Mrs Newell states that in May of 2008 she and Christine left for a trip to visit family in the United Kingdom. Whilst Mrs Newell was away Dr Newell suffered a professional setback when he failed to obtain his "Doctor of Letters" which would have enabled him to be promoted to full Professor. During a conversation on the telephone, Mrs Newell states that Dr Newell said that as a result he had "nothing to live for" and that he had a "cocktail of drugs to take".
Friend and professional colleague Lindsay Stoddart was aware that increasing pain was influencing Dr Newell to increase his morphine doses and that drug was less and less effective. He also reports that for some weeks prior to his death, Dr Newell was significantly stressed because his proposal for his D. Litt. was refused and further he was distressed over recent information he had received that Lindsay Stoddart had purportedly resigned from a role within the Church.
Father David O'Neill ('Fr. O'Neill') had known Dr Newell for 16 years since coming to work at St David's Cathedral. Fr. O'Neill states that Dr Newell was someone who wanted to make a difference, and on top of his work at the University and the Cathedral, Dr Newell was on several committees, many based on the mainland and they required him to regularly fly interstate and sometimes to France and England. Fr. O'Neill believes that Dr Newell was suffering physically because he was overworking which in turn caused him to suffer emotionally and he also appeared frustrated because there was more he wanted to do, but could not because of his medical conditions. Fr. O'Neill states that he was aware that Dr Newell may have suffered from depression, but it had not come to the stage that Dr Newell should have sought professional help.
Miss Hayley Collyer observed that during a dinner conversation during the Queen's Birthday long weekend in 2008, Dr Newell started to behave in an unusual manner. She observed that when talking about retirement, Dr Newell said that he had been putting one of his wages away in superannuation, but that he would be dead before he saw any of it. Miss Hayley Collyer states that she thought Dr Newell was referring to his illness but it seemed out of character.
Mrs Newell arrived back from the United Kingdom on 17 June 2008. During the evening of 19 June 2008, Mrs Newell noted that Dr Newell's thoughts were not clear and he was talking about walking out on her and leave her with the problems. Mrs Newell states that they went to bed around two o'clock on the morning of 20 June 2008. Dr Newell was saying things which made Mrs Newell believe he was trying to say good bye.
At seven o'clock in the morning of 20 June 2008, Mrs Newell found Dr Newell in the kitchen with a quantity of morphine tablets. His breathing had become suppressed. An ambulance was called and he was transported to the Royal Hobart Hospital, after initially being uncooperative.
Dr Newell spoke with Dr Wilson who signed an 'initial order' (3 day order) under the Mental Health Act. Dr Wilson believed that his patient appeared to have a mental illness and may be a significant risk of harm to himself or others and had taken more medication than he was prepared to admit. Dr Newell was referred to a psychiatric team.
A little later, consultant Dr Warwick Ashley ('Dr Ashley') in consultation with psychiatry registrar Dr Robinson spoke with Dr and Mrs Newell at some length and in detail. Mrs Newell expressed her concerns her husband had deliberately overdosed on that day and that she was expecting such an incident. Initially Dr Newell denied taking an overdose and Dr Ashley was of the opinion that Dr Newell was not psychotic and not otherwise certifiable under the Mental Health Act. Dr Ashley cancelled the initial order and discharged Dr Newell into the care of Mrs Newell and provided her with a three week certificate from employment to care for her husband. Dr Ashley noted that Dr Newell was happy to go home saying, 'he would be safe there'.
A little later that afternoon, Mrs Newell disclosed to Drs Ashley and Robinson that whilst at the hospital and in the absence of hospital staff, Dr Newell admitted to her he had deliberately taken an overdose and had not made that admission earlier because he did not want it noted on his medical record as it might affect his professional career. The doctors again spoke with Dr Newell who responded that he was confused by the medication he had taken and what had happened. Due to the ambiguities that had arisen, Dr Ashley decided to keep Dr Newell in hospital overnight for clarification of what he was saying and further observation in the Department of Emergency Medicine. He signed another initial observation order with a request that Dr Newell be reviewed the following day by Dr Saxby Pridmore, Professor of Psychiatry. Dr Ashley was of the opinion that Dr Newell was suffering from a situational crisis rather than a pychosis or serious mood disorder.
The following day (21 June 2008) at about 9.00am, psychiatric registrar Dr McDougall and Professor Pridmore examined Dr Newell. Other than the probability of Dr Ashley's notes being available, there is no evidence that there was any consultation between Dr Ashley and Doctors McDougall and Pridmore Dr McDougall on this day. There is no evidence that Doctors McDougall and Pridmore were particularly aware of the discussions and agreements made the previous day that Dr Newell wanted to go home to be cared for by his wife where he would feel safe and for what appeared to be obvious 'keeping a watch' reasons bearing in mind the ambiguity in whether Dr Newell had intentionally taken an overdose or not; or that Dr Ashley had provided Mrs Newell with a three week absence from work certificate to assist in the provision of that care.
Dr McDougall reports that Dr Newell said 'I accept I took an overdose and stuff. It was taken as me being a suicidal person. I am not suicidal now'. Dr McDougall reports that his impression was that Dr Newell suffered from an "Adjustment Disorder", which I note is a mental illness under the Mental Health Act.
This note of events by Dr McDougall is in contrast to and ambiguous with the evidence of Professor Pridmore who states that Dr Newell reported he (Dr Newell) had significant stressors extant in his life at that time ¨he was separated from his wife…and his chances of achieving promotion to full-professorship had recently been somewhat reduced. He said that with these stressors and an episode of back pain, he had taken more narcotic that (sic) was prescribed, leading to an accidental ingestion of an excessive amount of narcotic on the previous day. He denied he had taken a purposeful overdose and he denied that he currently had any suicidal intentions'.
Professor Pridmore diagnosed that Dr Newell was not suffering from a mental disorder according to the Diagnostic and Statistical Manual Edition IV, and his condition reflected normal distress resulting from a distressing situation.
I accept that many within the psychiatric discipline may diagnose an adjustment disorder while others in the same situation may call it a social crisis.
In any event, Dr Newell was offered admission to the Department of Psychological Medicine ward for a couple of days, which he declined as he considered it would have a devastating effect upon his professional career and stated further that he would prefer to spend time with friends and that he would make his own arrangements to do so and follow up with his general practitioner.
Following consultation between Dr McDougall and Professor Pridmore, it was their opinion that Dr Newell was oriented in time place and person; was able to articulate his wishes and to argue his case; he was exhibiting no delusions or hallucinations; his movements were brisk and indicated; he had the ability to make arrangements to leave the hospital without assistance; he did not satify the diagnostic criteria for major depressive disorder but rather in the opinion of Professor Pridmore his condition reflected normal distress resulting from a distressing situation; he stated he was not a danger to himself or others and was no longer suicidal. It was their opinion that his suicide risk was low, he was not certifiable under the Mental Health Act and as there was no obligation to detain Dr Newell any longer and they considered they had no obligation to release him into the care of any other person, at about 9.40am he was discharged from the initial order. He specifically stated that he did not want information relayed to his wife and that he would not be alone as there were a number of persons who could be supportive of him, including a priest and his parents.
Mrs Newell attended the Royal Hobart Hospital at about 10.20am on that day and discovered Dr Newell had already been discharged and that he had unfortunately left instructions she not be told where he was going. She made contact with Dr Newell by mobile telephone in which he stated that he was walking up Strickland Avenue, South Hobart near their home. Mrs Newell returned home and discovered that Dr Newell's briefcase and a suitcase had been removed. Further enquiries proved negative in locating Dr Newell, although several persons did speak with him briefly by telephone.
At four o'clock on the afternoon of 21 June 2008, Mrs Newell reported Dr Newell as a missing person at the Hobart Police Station.
At 12.10pm on 24 June 2008, Michael Henry Wakefield Richmond ('Mr Richmond') was riding his mountain bike along a track on the foot hills of Mount Wellington, near Old Farm Road when he located Dr Newell lying on the track. There was an amount of personal property lying nearby. Mr Richmond states that he believed Dr Newell to be deceased as his arms were purple and with a strange colour to his face. Mr Richmond contacted the emergency services.
Emergency services attended the scene a short time later and confirmed that Dr Newell was deceased. Attending police reported that Dr Newell was located 40 metres south west of Old Farm Road, South Hobart on a small track about 600 metres along the road from the Cascade Brewery. Attending police also noted two computers, two mobile telephones, two empty alcohol bottles, two open suit cases and a large amount of prescription medication and syringes lying near to his body.
Attending police conducted an extensive examination of the scene and concluded that there appeared to be no suspicious circumstances surrounding the death of Dr Newell.
A post mortem examination was subsequently conducted by Forensic Pathologist, Dr Donald Ritchey. Dr Ritchey concluded that Dr Newell died as a result of multiply drug toxicity (ethanol, oxycodone, codeine, diazepam, temazepam and tramadol). Dr Ritchey notes that there were no marks of trauma or natural disease to account for the death. Dr Ritchey noted that Dr Newell's blood alcohol reading was 0.227 grams of alcohol per 100 millilitres of blood. This markedly elevated blood ethanol concentration was combined with a toxic concentration of oxycodone and therapeutic concentrations of codeine, diazepam, temazepam and tramadol. Dr Ritchey states that all of these are strong central nervous system depressants and that in combination they reduce the level of consciousness and result in fatal respiratory depression.
Investigating police conducted an examination of the computer equipment located with Dr Newell. Dr Newell's laptop contained 10 emails sent by Dr Newell on the morning of 21 June 2008 between 12.15am and 11.51am. A message sent to Lindsay Stoddart read in part "I am finished. PLEASE pray I may pass quickly". Other email messages to others also suggested he may be about to end his life.
Comments & Recommendations:
I am satisfied that a thorough and extremely detailed investigation has occurred into the death of Dr Newell, and that there are no suspicious circumstances.
I find that Dr Newell died on or about 21 June 2008 as a result of multiple drug toxicity (ethanol, oxycodone, codeine, diazepam, temazepam and tramadol). I am satisfied that no other person directly caused or contributed to Dr Newell's death.
I am unable to make any findings as to whether Dr Newell was suffering from any specific mental illness or whether he was of fully sound mind at the time, although there is a likelihood he was depressed or otherwise experiencing an unclassified/undiagnosed emotional crisis. It is now not possible to know.
It possibly could not be ruled out that Dr Newell accidentally or unintentionally ingested excessive amounts of central nervous system depressants when disoriented by the influence of a significant amount of alcohol or a combination of both. However, taking into account all the circumstances surrounding Dr Newell's death as noted, including - his increasingly difficult medical problems; his feelings of failure in relation to his professional and family life; the probable effect of medication and alcohol upon his appropriate decision-making process; the likely admitted attempt to overdose on morphine on the morning of 20 June 2008 and the email sent to Lindsay Stoddart, I find it likely that Dr Newell intended to take his own life by the deliberate act of overdosing on multiple drugs and ingestion of alcohol.
It seems clear from the evidence of Dr Ashley and Mrs Newell that Dr Newell did not always tell his treating doctors or others all that they needed to hear. It is likely he told medical practitioners on 21 June 2008 what he believed they needed to hear for him to receive the outcomes he desired.
In my view it is regrettable there was no consultation between Drs Ashley and Robinson with Dr McDougall and/or Professor Pridmore prior to discharge from RHH. If there had been then it is quite possible the discharging doctors would have had more objective information available to assess his mental health status, including the arrangements of the previous day to discharge into the care of Mrs Newell and this may have ensured a reasonable chance of a continuing watch over Dr Newell. While it would seem there was no obligation to do so and Dr Newell specifically made a request his wife not be informed, it is unfortunate that Mrs Newell was not informed of his pending release.
It is also regrettable that Dr Newell was not prepared to seek professional counselling for his problems, particularly when he was admitted as an inpatient at the Royal Hobart Hospital on 20 June 2008. When given the chance to speak openly about his thoughts it seems that Dr Newell, with his great knowledge of the medical system and legal rights due to his role as a lecturer within the Medical Faculty of the University of Tasmania, was able to say what was required to satisfy consulting doctors that he was no longer suicidal. This resulted in Dr Newell's discharge from the hospital, before he could be collected by Mrs Newell.
Dr Newell was then able to leave the hospital alone, with what was likely an intention to take his own life.
I wish to conclude by conveying my sincere condolences to Dr Newell's family.
DATED: 31 October 2011 at Hobart in the State of Tasmania.