Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Rod Chandler, Coroner, having investigated the death of
Timothy David NICHOLS
WITHOUT HOLDING AN INQUEST
Find That :
Timothy David NICHOLS ("Mr Nicholls") died on either 11 or 12 January 2009 at 16/8 Merry’s Lane in Launceston.
Mr NICHOLS was born in Launceston on 17 May 1969 and was aged 39 years. He was single and a disability pensioner.
I find that Mr Nicholls died as a result of hanging.
Circumstances Surrounding the Death :
At about 12.25pm on Monday 12 January 2009 Tasmania Police attended at 16/8 Merry’s Lane in Launceston after receiving a report that a person was hanging by the neck from a television antenna at the rear of the unit. That person was identified as Mr Nichols. It was evident that he was deceased.
A post-mortem examination was carried out by pathologist, Dr Preethika Angunawela who determined the cause of death to be ‘hanging.’ Toxicology testing of a sample of Mr Nichols’ blood was negative for alcohol and other drugs.
Mr Nichols had a long history of mental illness having been diagnosed with schizophrenia in 1989. He had, on multiple occasions, attempted to commit suicide and had regularly received treatment for his illness as an inpatient at the psychiatric facility of the Launceston General Hospital ("the LGH") In 2007 Mr Nichols was hospitalised for almost 12 months following a suicide attempt. On 6 June 2008 a guardianship order was made authorising the Public Guardian to manage his affairs. At the time of his death his schizophrenia was being treated with fortnightly doses of risperidone. He had his last dose on 31 December 2008.
An investigation of the circumstances surrounding Mr Nichols’ death was undertaken by Tasmania Police. That investigation did not reveal any suspicious circumstances relating to the death. It did reveal detail of Mr Nichol’s activity in the days preceding his death, particularly as it related to his mental state and its management. Details are as follows:
On 4 January 2009 Mr Nichols presented at LGH’s Department of Emergency Medicine (DEM). He was upset because of a "mistake" he had made concerning his girlfriend. He also complained of hearing voices. He demanded to be seen immediately and later became abusive to staff and other patients. A code black (because of the threats to staff) was called and the other patients were removed from the waiting room. Later, Mr Nichols was assessed by members of the Crisis Assessment Team (CAT). He was given 100mg of chlorpromazine (an anti-psychotic medication) and it was noted that he was to see Michael Van Der Molen, his case manager the following day.
On 5 January Mr Van Der Molen visited Mr Nichols at his home. Mr Nichols was concerned about his relationship with his girlfriend. He also said he was having difficulty sleeping and that he was still hearing voices.
On 7 January Mr Van Der Molen re-visited Mr Nichols but he was not at home.
The LGH records show that on the morning of 9 January a psychiatric nurse recorded receiving a ‘phone call from Mr Alan Johnstone of Mission Australia. Mr Johnstone was Mr Nichols’ volunteer support worker under a government funded Personal Helpers and Mentors Programme. Mr Johnstone was concerned about Mr Nichols’ mental state. Apparently Mr Nichols told Mr Johnstone that he "loved him." Mr Johnstone thought this statement odd and questioned Mr Nichols about suicide. Although Mr Nichols denied any suicidal intent Mr Johnstone felt uneasy with his response and he suggested that a health worker make contact with him later in the day. The records indicate that Mr Johnstone’s call was discussed that day at a CAT meeting and it was resolved for psychiatrist, Dr S S Johl to contact Mr Nichols. There is no record of that contact having been made.
Later on 9 January Mr Nichols again presented at DEM and was assessed by CAT members. He complained of hearing voices from the skylight, was upset about his relationship breakdown, had had an argument with his mother, was not sleeping well and was drinking excessive quantities of coffee. He denied any thoughts or intent of self-harm. The assessors concluded that it had been "difficult to elaborate extent of current risks due to presenting difficulties" and hence determined that Mr Nichols should be reviewed by Dr Jonsson, the Psychiatric Registrar. However, Mr Nichols left DEM before the review could take place. Dr Jonsson then discussed the situation with the CAT team and it was decided that as there had been no indication that Mr Nichols was at immediate risk to himself or others it would suffice to make follow-up contact with him the following day.
Whilst Mr Nichols was at DEM he telephoned his mother, Mrs Denise Rigby, and asked her to visit him. She did so and they had a conversation outside the hospital whilst Mr Nichols had a cigarette. Towards the end of their meeting Mrs Rigby was feeling a "bit fearful" of her son. Their conversation ended with him saying to her, "don’t worry about it, I won’t be seeing you again anyway, goodbye."
At 9.20pm on 9 January a member of the CAT team telephoned Mr Nichols. She recorded that in this conversation Mr Nichols seemed bright and spontaneous. He explained that he had not waited in DEM for the psychiatrist’s review because he had started feeling better. It was agreed that the CAT worker would call him again the next day.
The LGH records indicate that a CAT member attempted to make telephone contact with Mr Nichols twice on the 10 January 2009, but was unsuccessful.
On 10 January an acquaintance found Mr Nichols who seemed in a confused state and who was wandering in the area of Ward 1E. He had a towel wrapped around his left arm. She escorted him to DEM where he was seen by a triage nurse. He told her that he was hearing voices and needed his "injection." She spoke to Psychiatric Registrar, Dr Ben Sketcher. According to the triage nurse Dr Sketcher stated that he was not overly concerned about Mr Nichols because he was a narcissistic personality and was attention seeking. (Dr Sketcher has a different interpretation of this conversation. He says that there was a general discussion upon narcissistic personality traits and how they may relate to Mr Nichols but he did not attach these terms to Mr Nichols). The triage nurse arranged for Dr Abraham Jacob to suture two lacerations on his left arm. After the suturing was complete Dr Jacob contacted Dr Sketcher. He was advised to give Mr Nichols 200mg of quetiapine (an anti-psychotic medication) and to have the CAT team review him. However, when a CAT member attended at DEM, Mr Nichols could not be located and the review did not proceed. Dr Sketcher was again contacted and he advised that no further action was required at that stage.
In the early evening of 11 January a report was received of an intoxicated male at 7 Lawrence Street in Launceston. Police officers attended and found Mr Nichols. He had an abrasion to his head and appeared disoriented and confused rather than intoxicated. He agreed to be taken to the LGH. The police officers left Mr Nichols in the care of DEM staff. However, it seems that he left the hospital before any examination or treatment was undertaken.
Sometime that evening Mr Nichols left a message on his mother’s messagebank. He told her that he was at the hospital and that he "was not going too good."
It was about 7.00am on 12 January 2009 when a neighbour saw what he thought to be a mannequin hanging at the rear of Mr Nichols’ unit. It was not until about 11.30am that another neighbour recognised that it was a male person and summoned the police. Mr Nichols was then identified to be that person.
In a report provided to the investigators, Dr Sketcher has advised that he was aware of Mr Nichols as he had participated in psychiatric staff reviews where Mr Nichol’s risks were discussed but he had never been part of his treating team. He had also attended Mr Nichols on two occasions when he had presented at DEM out of hours, the last of these being on 4 April 2008. Dr Sketcher further says that on 10 January 2009 he would have reviewed Mr Nichols’ case notes if he had been referred to him following an assessment by CAT. However, the referral was not made hence he did not review the notes.
Comments & Recommendations :
I am satisfied that there are no suspicious circumstances surrounding the death of Mr Nichols. I am also satisfied, accepting the opinion of Dr Angunawela, that Mr Nichols death was due to hanging. I am satisfied too that the death was the consequence of an intentional act on Mr Nichols’ part.
The evidence does not permit me to make precise findings upon the time or date of death. Instead, it only enables me to find that Mr Nichols died at an unknown time in the period between the late evening of 11 January 2009 and before 7.00am the following day.
It is apparent from the history that I have set out above that Mr Nichols, in the week prior to his death, believed himself to be unwell and in need of treatment. It is a matter of real concern that in that week he had attended at LGH on four occasions without being seen by a psychiatrist (despite CAT assessments recommending a psychiatrist’s involvement) and without any adjustment of his treatment plan. The failure to ensure Mr Nichols’ psychiatric review on 10 January is particularly concerning. It is apparent that on that day both the triage nurse and Dr Jacob recognised that Mr Nichols may benefit from psychiatric treatment and they hence sought the assistance of Dr Sketcher. His response was to direct that Mr Nichols be medicated and then reviewed by CAT. Clearly this course was recommended by Dr Sketcher and accepted by Dr Jacob without either consulting Mr Nichols’ case notes. Had they done so they would have seen that the previous day CAT had assessed Mr Nichols to be in need of a psychiatric review and that such review had not taken place because he had departed the hospital. This information should have, in my view, made it apparent firstly, that a further CAT assessment was unnecessary and secondly, that Mr Nichols was a flight risk, a risk which may be heightened if Mr Nichols was informed that he was required to wait and to undergo a repeat of the assessment which he had undertaken less than 24 hours earlier.
I am unable to find that Mr Nichols’ death would not have occurred if he had undertaken a psychiatric review in that week prior to his death. However, such a review may have led either to his hospitalisation or to an adjustment to his treatment plan, either of which may have deterred Mr Nichols from his fateful and tragic act. These matters lead me to recommend that LGH carry out a review of its management of Mr Nichols during the last week of his life with a view to identifying and implementing any appropriate strategies which may help to avoid a like tragedy in the future.
I conclude by conveying my sincere condolences to Mr Nichols’ family.
DATED : Monday, 20 September 2010 at Hobart in the State of Tasmania