AMENDED RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Christopher P Webster, Coroner, having investigated the death of
Daniel Ashley CHALLENGER
WITHOUT HOLDING AN INQUEST
FIND THAT :-
Daniel Ashley Challenger (‘Daniel’) died on 27 May 2005 at the Royal Hobart Hospital, Liverpool Street, Hobart.
Daniel was born in Hobart, Tasmania on 20 January 2004 and was aged 16 months.
I find that Daniel died as a result of methadone intoxication.
At the time of Daniel’s death he was being treated by a medical practitioner.
CIRCUMSTANCES SURROUNDING THE DEATH : -
Daniel lived with his parents Bryce Leslie Challenger (‘Mr Challenger’) and Jodie Anne-Maree Freeman (‘Miss Freeman’) at their unit. Both Mr Challenger and Miss Freeman had been participant in the methadone program for several years prior to Daniel’s birth. Consequently, Daniel was born opiate dependant.
On the morning of Friday, 27 May 2005, Mr Challenger and Miss Freeman had attended the Jerry Hampton Pharmacy at North Hobart for the purpose of obtaining their doses of methadone. Miss Freeman consumed her dose at the pharmacy but did not receive any additional doses to ‘take-away’ from the pharmacy. Mr Challenger, however, states that he took a dose while at the pharmacy, but was allowed to take two additional doses away from the pharmacy, for the purpose of having over the weekend.
On arriving back at their unit late in the morning, Mr Challenger and Miss Freeman spent some time moving furniture from Mr Challenger’s mother’s (‘Mrs Pauline Challenger’) unit next door into their own unit. Evidently, Mr Challenger and Miss Freeman had recently returned to Tasmania after a brief period residing interstate, and had been residing at a friend’s house at Snug and later at Mrs Challenger’s unit.
During the afternoon, more furniture and personal items were moved into the unit. It is here, however, that there commences a significant variation in the version of events given to police by Mr Challenger and Miss Freeman.
On Mr Challenger’s account, amongst moving furniture, he spent some time setting up the television and attempting to connect Austar. At around 6:00pm, Mr Challenger recalls sitting in front of the television with Daniel sitting between his legs. At this time, he recalls that Daniel was tired, and Miss Freeman has made him a bottle and was going to put him to bed. It was possibly around this time that Mr Challenger states that he removed the two bottles of methadone from his pocket and placed them on the coffee table in the lounge room. The bottles were fitted with a ‘safety lid’, which to open requires the lid to be concurrently pressed down and twisted. Mr Challenger stated that he took the methadone bottles out of his pocket because he was intending on going to the shop and was checking his pockets for loose change.
Mr Challenger then walked across the road to the service station to purchase some items. He states that he was away for approximately ten minutes, and that on his return Miss Freeman was either in the process of putting Daniel to bed, or was maybe lying in bed with him. She spent a further period of time in bed with Daniel before returning to the lounge room. It was approximately an hour later that she returned to the bedroom to check on him. Mr Challenger states that Miss Freeman called out to him that something was wrong with Daniel, and it was at this time that Mr Challenger became aware that one of his methadone bottles was on the floor. The lid was off the bottle, prompting Mr Challenger to ask Miss Freeman whether she had touched the bottle. She told him that she hadn’t at which point Mr Challenger immediately went into the bedroom, and picked up Daniel. He immediately noticed that he was limp and unresponsive. He then took Daniel next door to his mother’s unit and asked her to call an ambulance, as he was unable to make telephone calls from his own unit.
On Miss Freeman’s account, they had been moving furniture, and it was during the afternoon that her, Mr Challenger and Daniel had gone to sleep on the couch in their unit. She estimates that she was asleep for no longer than an hour, and states that at sometime around 4:30pm or 5:00pm Daniel woke her by hitting her on the head with a toy block. When she woke, she observed that Mr Challenger was still asleep on the couch. A short time after Daniel had woken her, she observed an open methadone bottle on the floor. She states that she screamed at Mr Challenger, asking him why the bottle was on the floor. She recalls seeing both of Mr Challenger’s methadone bottles on the coffee table earlier, and supposed that they may have been placed there when Mr Challenger sat down on the couch.
Miss Freeman states that she became concerned that Daniel may have ingested the methadone, and frantically checked the carpet near the bottle. She noticed a wet patch, which she smelt and even licked to determine that it was in fact methadone. She observed that Daniel appeared fine, and that following this she and Mr Challenger closely observed Daniel for the next two hours and that he appeared to be all right.
Miss Freeman then states that at around 6:00pm Daniel appeared tired and that she prepared him a bottle of milk, following which she got into bed with him. It was approximately 8:45pm that she got up and returned to the lounge room, where Mr Challenger was still engaged attempting to get Austar working on the television. On her account, about half an hour had elapsed when she asked Mr Challenger to go and check on Daniel. She states that he told her that he was busy, so she went into his room. On entering the room, Miss Freeman recalls the overwhelming smell of vomit, which was not present when she left his bed earlier. She observed that Daniel did not appear to be moving and he had not removed his bedding as was commonly the case.
Miss Freeman recalls calling out to Mr Challenger, who came into the bedroom and picked up Daniel. It was then that they observed that Daniel was limp at which point they ran over to Mrs Challenger’s unit and arranged for the ambulance.
Mrs Challenger states that it was at about 9:30pm that Mr Challenger and Miss Freeman arrived at her unit. She recalls that they sounded stressed and she suspected that something was wrong. Mr Challenger asked Mrs Challenger to immediately call an ambulance which she did. This is supported by the record of attendance provided by the Tasmanian Ambulance Service (TAS), which indicates that the call was received at 9:40pm.
Instructions were relayed to Mrs Challenger over the telephone by the TAS on how to conduct cardio-pulmonary resuscitation (CPR). Mr Challenger was performing this on Daniel, during which a thick white coloured fluid came from Daniel’s mouth. This was cleared by Mr Challenger, and CPR was continued until the ambulance arrived at approximately 9:53pm. Daniel was treated at the scene by ambulance officers, after which he was transported to the Royal Hobart Hospital (RHH).
At the RHH an attempt at resuscitation was unsuccessful, and Daniel was pronounced deceased at 10:45pm.
A post-mortem examination was conducted on 28 May 2005 by State Forensic Pathologist, Dr Christopher Lawrence. Dr Lawrence concluded that Daniel died as a result of methadone intoxication. Toxicology revealed a concentration of 0.5mg of methadone in one litre of blood, which is within the reported fatal range. Dr Lawrence states that ‘known or suspected methadone-intoxicated children should be hospitalised, since respiratory depression may be observed as long as 48 hours after ingestion.’
I also note that DNA testing was conducted on several items taken from the unit following Daniel’s death, and specifically, that no traces of methadone were found in the baby bottles found in the unit.
COMMENTS & RECOMMENDATIONS -
I am satisfied that a thorough and proper investigation has occurred into the death of Daniel. I find that Daniel died at the RHH on 27 May 2005 as a result of methadone intoxication. The investigation however discloses several possibilities by which he has ingested the methadone which led to his tragic death, which regrettably, I am unable to satisfactorily resolve to make a conclusive finding regarding the circumstances.
Firstly, it is considered possible that Daniel was deliberately given the methadone by either Mr Challenger or by Miss Freeman, I infer, for the purpose of sedation. I note particularly the affidavit from Mrs Challenger, given in November 2007, providing evidence that Miss Freeman had previously told her that she had given Daniel methadone for the purpose of keeping him calm. She recalls two other occasions where Daniel was brought to her unit by her granddaughter (Mr Challenger’s daughter) Genna Anne Challenger (‘Miss Challenger’) where it was possibly suggested to her by Miss Challenger that Daniel had been given methadone. Mrs Challenger states that while she has never seen Miss Freeman actually give Daniel methadone, following his death she has maintained the belief that this is what occurred. I note, too, the affidavit of Miss Challenger, who details her concerns with Miss Freeman breast feeding Daniel in the RHH immediately following his birth, and specifically her concern that methadone prescribed to Miss Freeman would be passed on to Daniel in the breast milk. Miss Challenger outlines her concerns generally regarding the drug use of both her father and Miss Freeman, and their irresponsible approach towards the proper care of Daniel as well as specific instances that have caused her to also believe that Miss Freeman had, on occasion, been giving methadone to Daniel. I note that both Mr Challenger and Miss Freeman have refuted the allegation that they gave Daniel the methadone.
Alternatively, it is possible that Mr Challenger has placed the bottles of methadone on the table, following which Daniel has taken one of them, and managed to remove the top and ingest the contents himself, while his parents were either asleep, or while he was out of their view. It is on this point that I find the evidence of Miss Freeman more compelling. Her account that all three persons had been sleeping while the bottles of methadone were sitting on the table, and that Daniel, being the first to wake has accessed one of the bottles while Miss Freeman and Mr Challenger remained asleep, appears more plausible than the version proffered by Mr Challenger. If Mr Challenger’s version is to be accepted, this would have given Daniel only approximately ten minutes in which to access the bottle of methadone on the table, open the ‘safety lid’ and ingest the contents. It is also considered that on the accounts of both Mr Challenger and Miss Freeman, at the time Mr Challenger went to the service station, Miss Freeman was in the process of attending to Daniel in preparation for taking him to bed, including dressing him in his pyjamas and putting him into bed with a bottle, reducing the likelihood that Daniel would have had the opportunity to ingest the methadone at this time.
In respect of the bottle, I find it difficult to accept that a child of Daniel’s age would be capable of opening a ‘safety lid’ which is purposely designed to resist such attempts by children. It seems more probable that the bottle had been opened earlier by either Mr Challenger or Miss Freeman and then not replaced sufficiently. I note in the report from psychiatrist Dr Ian Sale, that on 8 November 2006 both Mr Challenger and Miss Freeman provided him with their account of how this could have occurred. Mr Challenger advised Dr Sale that he had placed the take-away bottles of methadone on a table as he was involved in moving household items. He told Dr Sale that he had opened one of the bottles ‘to have a look’ and make sure that the correct amount had been given, and he suspects that he has then failed to put to cap back on properly. Miss Freeman, however, has advised Dr Sale that after returning from the chemist with their ‘take-aways’, she and Mr Challenger have used an additional amount from one of the bottles. Miss Freeman states that she must not have placed the lid back on the bottle properly. Miss Freeman advises Dr Sale that they all then fell asleep.
However, it is extraordinary that neither Mr Challenger nor Miss Freeman provided this explanation to the police. In fact on the day following his original interview with police, Mr Challenger attended the Glenorchy Police Station in order to demonstrate to Sergeant Twining how easy it was to remove the cap from a bottle of methadone, indicating that it was his belief that the bottle was properly sealed.
Regrettably, on the available evidence I am unable to state conclusively which of the conflicting accounts regarding Daniel’s ingestion of methadone accurately represents the circumstances of his tragic death. While the version given by Miss Freeman appears to me to be generally the more probable of the accounts, the evidence unfortunately does not allow me to make such a positive finding, or satisfactorily exclude the other possibilities.
On any account, it is clear that the actions of both Mr Challenger and Miss Freeman were irresponsible in the extreme and are deserving of condemnation. If it could be categorically accepted that Daniel was not deliberately given the medication, it is reprehensible that a child was able to access such a dangerous and potent medication and ingest it, and of equal concern that, suspecting that he had ingested methadone, that medical treatment was not immediately sought. In this regard, I find the conflicting and varied accounts of Mr Challenger and Miss Freeman both unsatisfactory and contrived.
I note that during his life Daniel was a person subject to the child protection system, and that following his death, the Minister for Health and Human Services approved the establishment of a committee to review the circumstances of his death. The subsequent review contains 19 recommendations for improvements to this system, which clearly demonstrate a proactive and appropriate response to the tragic circumstances of Daniel’s death. I endorse the recommendations of the committee, and consider that they will operate to improve the provision of child protection services in Tasmania. I note particularly recommendation (xv) as it relates to the practice of providing parents with take-away doses of methadone, and further recommend that in circumstances where such takeaway doses are approved as necessary, that strict legislative requirements for the storage of such medication be implemented.
I wish to conclude by conveying my sincere condolences to Daniel’s family.
DATED : Tuesday, 10 June 2008 at Hobart in the State of Tasmania.
AMENDED: 26 June 2008 due to a typographical error in relation to year of post mortem and the number of recommendations made by the Committee established by the Minister for Health.