RECORD OF INVESTIGATION INTO DEATH (WITHOUT HOLDING AN INQUEST)
Coroners Act 1995
Coroners Rules 2006
I, Stephen Raymond Carey, Coroner, having investigated the death of
WITHOUT HOLDING AN INQUEST
(a) The deceased is Ms W who died on 1 February 2012 at the Royal Hobart Hospital.
(b) Ms W was born in Melbourne, Victoria and was aged 18 years.
(c) Ms W was a single person who was unemployed.
(d) Ms W died as a result of global hypoglycaemic brain injury caused by insulin overdose. I am satisfied that such insulin overdose was as a result of deliberate action taken by Ms W to administer that insulin to herself.
Circumstances Surrounding the Death:
Ms W is reported as having a normal childhood as part of a loving and supportive family. She was involved in school sporting and social events and attended the one local school from kindergarten through until Year 9. However, one aspect relating to Ms W’s health impacted negatively on her life, this being the diagnosis of Type 1 Diabetes at the age of 10. At times Ms W struggled to deal with this condition. This manifested itself in periods of non-compliance or issues with food which she used as a means of comfort. Her mother suspects that for some time Ms W was affected by depression as although she maintained an extraverted facade, she was on other occasions found crying by herself. One disturbing behavioural trait, possibly linked to her mental health status, was the prevalence of her stealing money from her parents.
The family relocated to Dubai in September 2008 and Ms W’s medical treatment was continued at the American hospital in Dubai. Although her diabetic condition remained stable, Ms W found it difficult to fit in at her new school and struggled with the transition from schooling in Australia to international schooling. After the family had relocated to Dubai Ms W’s stealing of money escalated. One particular incident when Ms W was 16 involved the misuse of her mother’s ATM card and the withdrawal of a significant amount of money. After a period of denial Ms W eventually admitted that she had made the unauthorised withdrawal and explained that she felt a compulsion to steal money. After this incident she became guilt-ridden and reclusive. Shortly after, in November 2010, she attempted to commit suicide by taking an overdose of Panadol. This was categorised by her mother as a cry for help. It was during her hospital admission that she underwent psychiatric assessment and this care continued upon her discharge from hospital as she was prescribed anti-depressant medication. She also commenced counselling with a clinical psychologist and over time there was an improvement noted in Ms W’s general health and state of mind.
In January 2011 her behaviour changed again when she started associating with a different group of friends. She started missing school and neglecting her health and her behaviour was becoming of concern to her parents as unacceptable for an Australian living in a foreign land, and the family made the decision for Ms W and her mother to return to Australia. Upon their return in March 2011 priority was given to attending to Ms W’s general health and mental health issues. Ms W and her mother spent time together during which endeavours were made to improve her self-esteem and to try and have her make a decision as to what she wanted to do with her life. During this time she completed her senior first aid course and qualified to be an Austswim instructor. She also completed a Responsible Service of Alcohol course and made enquiries of various Drysdale College courses. After three months, Ms W’s health and wellbeing had improved and she was back under control so she and her mother returned to Dubai. There she found employment at a children’s clothing and accessory shop and her life was very settled both physically and mentally. However after approximately six weeks she again started associating with the same group of friends that had contributed to her problems previously, she lost her job and once again commenced self-destructive behaviour both mentally and physically. It once again became necessary for Ms W to be returned to Australia.
In July 2011 Ms W, her mother and two siblings relocated to Australia on a permanent basis. Ms W enrolled in a course at Drysdale College and although she found it difficult to fit in once again, she was enthusiastic about attending Drysdale College and in developing skills within the hospitality industry. There was another incident of stealing money from her parents and on 16 August 2011 she underwent a further psychiatric assessment by Dr T. Dr T noted a history that:
“There was however, deliberate self-harm in the form of under/over injecting insulin which she required on a regular basis as she suffered from insulin-dependent diabetes I. She stated having been using this as a tension relief but also to gain the family’s attention and to “scare them”.”
During this assessment Ms W admitted to “significant and ongoing problems with irritability. She would regularly scream at people, to the extreme leave the house, take whatever money she could find, then not answer her phone. She complains of feeling empty. Her mood was changeable and very reactive to social factors. She admitted to significant, almost daily, dissociative symptoms in the form of depersonalisation and derealisation.”
This assessment concluded with a number of treatment options being provided to Ms W. However it was left to her to decide to engage in any particular specific treatment as it was thought there would be no positive result unless she was prepared to take responsibility for her own actions.
Ms W’s mother describes that she was in a “very dark frame of mind” after this psychiatric assessment and two days later attempted to commit suicide again by overdosing on Panadol. She was once again an in-patient at the Royal Hobart Hospital and upon release her treating general practitioner, Dr N, arranged for a mental health plan to enable her to access psychological counselling which would be indemnified by Medicare. There was also a change in her anti-depressant medication and within two weeks Ms W is reported as having an improved mental state and functioning more normally again. Over the Christmas holiday period Ms W was reported to have been in a “good way”, she had gained her learner’s licence, was finishing her Drysdale College course and was working as a swimming instructor. She also worked at the Taste of Tasmania Festival and had met a new group of friends during that time which allowed an active social life.
Tragically this once again changed dramatically in the period leading up to the weekend of 28 January 2012. The new group of friends that Ms W was associating with included Mr M to whom Ms W was apparently particularly fond. However a few days prior to that weekend some money went missing from Mr M’s bedroom at his house. Due to knowledge by others of Ms W prior incidents of stealing money, she was suspected and this caused particular tension between her and Mr M. On Saturday afternoon, 28 January 2012, Ms W attended Mr M’s house where a barbecue was being held for a group of friends. Tension apparently arose between Ms W and Mr M and also another female, Ms R, who was a friend of Ms W. In any event Ms W left the barbecue after a short period of time and apparently returned to the family residence. Later that evening there were a number of SMS communications between Ms W and Mr M of which the topic of the theft of money, honesty and trust were exchanged. Unfortunately some of those messages in retrospect provide an indication as to Ms W’s state of mind and in particular indications of a possible intention to self-harm. No criticism is levelled at Mr M in failing to recognise the seriousness of some of Ms W’s comments and it is noted that his messages to her were at all times positive and that he concluded with an indication of wishing to meet Ms W in person to deal with their issue and resolve it appropriately.
Unfortunately by that time Ms W may well have administered what was to be a fatal dose of insulin.
On Sunday 29 January at approximately 5.30pm Ms W’s mother returned to her home having been away for the Saturday night, as arranged with Ms W, with the understanding that Ms W would be staying at Mr M’s residence on that night. She discovered Ms W in bed, blue in colour and noticed she was unresponsive and unconscious. Ms W’s mother, who is a Registered Nurse and a diabetic herself, suspected a diabetic coma therefore checked Ms W’s blood sugar levels and found the reading to be unrecordable. An ambulance was called and after significant difficulties in having to clear the airway of vomit, the paramedics managed to successfully ventilate Ms W and also administer glucose by an intravenous cannula. Upon admission to Royal Hobart Hospital she was moved to the Intensive Care Unit, however there was a marked deterioration in her neurological signs on 31 January 2012. Urgent CT brain scans were conducted which disclosed extensive global cerebral oedema and ischemia which gave a poor neurological prognosis. Over the next 24 hours Ms W progressed to brain death and brain death tests performed on 1 February 2012 confirmed that Ms W was deceased.
Notwithstanding the tragedy of this situation and the grief this incident would have caused her parents, I publicly recognise their wonderful gesture in ensuring that multiple body organs from their daughter were made available for others.
COMMENTS AND RECOMMENDATIONS:
This is tragic case of a loved and supported child being unable to be protected from acts of self-harm and other negative conduct that occurred as a result of poor mental health. I do not conclude that this was necessarily a case of suicide, being a deliberate act intended to cause death, but rather it is just as likely to have been a reckless act initiated for any number of reasons (perhaps distress for once again letting herself down by her conduct) or even another “cry for help”.
It is a sad reality that appropriate mental health treatment is itself dependent upon medication compliance and voluntary submission to other recommended forms of treatment. This appears to have been an issue in relation to Ms W. However Ms W’s mother comments that;
“…I feel that the mental health system for young people 15-25 years of age is inadequate and hard to access.”
I am unaware of the basis for such comment but I encourage the appropriate authorities to contact Mrs W and address what the circumstances were that led her to form this opinion.
Before I conclude I wish to convey my sincere condolences to the family of Ms W.
Dated: 12 October 2012 at Hobart in the State of Tasmania.