Record of Investigation into Death (without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Stephen Raymond Carey, Coroner, having investigated the death of
David Francis VALENTINE
WITHOUT HOLDING AN INQUEST
(a) The identity of the deceased is David Francis Valentine ("Mr Valentine") who died on 12 April 2010.
(b) Mr Valentine was born in Australia on 1 March 1953 and was aged 57.
(c) Mr Valentine was unmarried and an invalid pensioner.
(d) Mr Valentine died from a self inflicted stab wound of the left forearm, and at the time was suffering schizophrenia/bipolar disorder.
Circumstances Surrounding the Death:
Mr Valentine suffered severe chronic schizophrenia, alcohol and cannabis abuse and type 2 diabetes mellitus. He was reported as a difficult patient who neglected his health and was generally non compliant with medical treatment and despite warnings continued to abuse alcohol and cannabis which jeopardised the management of his diabetes and psychosis. Mr Valentine first presented to Mental Health Services, Department of Health & Human Services at the age of 21 years. He subsequently had numerous admissions to various hospitals for treatment of his psychiatric disorder. His admissions in the last few years were numerous and had become increasingly complicated by physical illness related to his diabetes. Alcohol and drug use were a consistent feature of his life throughout this time as were his propensity to be violent and uncooperative. Diagnoses were various over the time, including chronic schizophrenia, chronic paranoid schizophrenia, Schizo Effective Disorder and drug induced psychosis. In January 2010 Mr Valentine was admitted to the Royal Hobart Hospital after his family reported concerns about his deteriorating mental state to a community mental health team. On a home visit at that time the Crisis Assessment Team noted that Mr Valentine had flooded his flat, had been non compliant with his psychiatric medication and was neglecting care of a chronic ulcer on his foot. It was determined that Mr Valentine needed an extensive period of treatment both for his physical and psychiatric condition at that time and therefore he was admitted to the Milbrook Rise Centre on 23 February and remained an in-patient until 9 April 2010. He was initially admitted to Tyenna Blue, a secure ward, as he was displaying aggression towards patients and staff. However his mood and behaviour improved in order to allow a transfer to Tyenna Green, an open ward, on 10 March 2010. On formal review at that time his formal thought disorder had resolved, he was accepting of treatment and looked back on his illness behaviour with insight. Whilst a patient in Tyenna Green he was allowed to take unescorted leave from the ward and would visit shops in nearby New Norfolk during the day. It was determined that Mr Valentine was suitable for discharge and this occurred on 9 April with appropriate steps being put in place for support by his case management team, case manager and community psychiatrist.
Mr Valentine was seen by his father on Friday 9 April after being released from the Millbrook Rise Centre. He was provided with new accommodation by Housing Tasmania. His father visited him again on Saturday 10 April, ensuring that he had enough food and money and his father noted that Mr Valentine seemed fine although he appeared tired and listless. Mr Valentine’s father then left him at about midday on Saturday the 10 in order to give him time to settle in to his new unit. There is no indication of what Mr Valentine did then until he was next observed at some time between 8.30 and 9.30 am on Monday 12 April by Mr Malcolm Best to walk naked from his unit block across the road to another unit block on the other side of the road. At 10.05 am Ms Cheryl Coppleman was driving by and noted Mr Valentine slumped in a chair outside Unit 12 of 11A Bedford Street, New Town. He was naked and a large quantity of blood was on the ground near him. Police and ambulance attended but no resuscitation endeavours were commenced as Mr Valentine was deceased.
Dr Christopher Lawrence, Forensic Pathologist, conducted an autopsy on Mr Valentine. He noted numerous scars on the left forearm which appeared to be self inflicted and healed. Scars were also present on the left wrist and on the back of the left hand. Dr Lawrence noted two stab wounds, the first in the left forearm approximately 10 cms below the elbow. This wound was 50mm long and penetrated the skeletal muscle and severed the radial artery. The second stab wound was located on the anterior left forearm but this was superficial and had not penetrated the skeletal muscle or damaged any major vessels. Broken glass from a beer bottle was found nearby and this was believed to be the weapon used to inflict the stab wounds.
A full police investigation was conducted with no suspicious circumstances identified and I am satisfied that the stab wounds were self inflicted by Mr Valentine.
Mr Valentine unfortunately suffered a severe psychiatric condition since adulthood and this was exacerbated by his alcohol and drug abuse, together with non compliance with prescribed medication. Given scarring on his arm found at post mortem it is obvious that Mr Valentine had in the past self harmed by cutting his arm. For some reason unknown, but possibly non-compliance once again on taking medication, he has once again inflicted wounds to himself. Although I am satisfied that this was deliberate and intentional by Mr Valentine, it was something he did due to his psychiatric condition. There is no basis to find that he performed this act with an intention or wish to end his life.
I am satisfied that based upon Mr Valentine’s improved mental state after a period of hospitalisation it was appropriate that he be released with appropriate arrangements made for ongoing care and supervision. Unfortunately this tragic incident occurred before these arrangements were implemented.
Before concluding I wish to convey my sincere condolences to the family of Mr Valentine.
This matter is now concluded
DATED: The 1 day of February 2011 at Hobart in the State of Tasmania