Record of Investigation into Death (Without Public Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Glenn Hay, Coroner, have investigated the death of
Patrick Robert Burdon
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.
I Find That :
(a) Patrick Robert Burdon ('Mr. Burdon') died on 31 January 2008 at Goodwood in Tasmania.
(b) Mr Burdon was born in Tasmania on 17 September 1961 and was aged 46 years on the date of his death.
(c) Mr. Burdon was a single man and was unemployed at the date of his death.
(d) I find that Mr. Burdon died as a result of a suspended ligature hanging leading to asphyxia and death consistent with suicide.
Regrettably this inquest has taken an inordinate time to conclude due to various investigating officers being tardy in the investigation or alternatively investigating officers retiring or changing duties before completion.
Background :
Mr. Burdon's general practitioner reported that between the early 1980's and July 2006 Mr. Burdon experienced many medical problems especially inflammatory arthritis affecting the lower limbs including numerous fractures and probable recurrent gout in foot joints. He also suffered from chronic headaches and suffered liver damage from excessive consumption of paracetemol. Mr. Burdon's pain management was complicated by him accessing non-prescription codeine medication. It is also reported that Mr. Burdon failed to accept advice to be reviewed by a physician and a pain clinic. In April 2005 this general practitioner referred Mr. Burdon to the Psychiatric Crisis Assessment Team as she was concerned about his chronic pain, excessive medication use and depression including suicidal ideations. She expressed concerns that he may have been suicidal.
Mr. Burdon saw another general practitioner in September 2007 and this doctor received a call from a social worker at Centrelink concerned about Mr. Burdon's mental health and believed he was depressed and suicidal. This doctor spoke with Mr. Burdon a week later about his mental health and confirmed Mr. Burdon was expressing intermittent suicidal thoughts but did not want to die. He also stated that alcohol seemed to be the only way to control his pain.
Anti-depressants were prescribed.
On 15 September 2007 this doctor referred Mr. Burdon to Mental Health Services Helpline as he was in a depressed mental state and had suicidal plans. He was referred to Adult Community Mental Health Service (Gavitt House) as being a 'non-urgent referral - to Mental Health team within 2 weeks'. That triage response time was not complied with because it was not until 3 October a letter was sent to Mr. Burdon with an assessment appointment for 5 November 2007, but he failed to keep 2 appointments and despite attempts could not be contacted.
Referrals had been made to Gavitt House for Mr. Burdon between April 2005 and January 2008. In 2005 he was noted as being depressed and 'perhaps suicidal', although Mr. Burdon denied this at the time. In September 2007 he presented as 'depressed and suicidal as a result of arthritis pain.'
Mr. Burdon was sentenced to 2 months imprisonment on 6 November 2007 for drink/driving offences and was released from prison on 11 January 2008. This may well explain why he did not keep his appointments at Gavitt House.
Mr. Burdon saw a Rheumatologist in late 2007 who attempted to get his chronic pain under control. This doctor reported that on 18 January 2008 Mr. Burdon sought narcotics to be prescribed and he displayed depressant behaviour. Narcotics were not prescribed but there was a change in medication including a change to his anti-depressant medication. It was not believed he was suicidal at this time but he was agitated and manipulative. This medical practitioner candidly conceded that a change in pain medication by prescription may have been enough for Mr. Burdon's mental state to change sufficiently for him to commit suicide.
Circumstances Surrounding Death :
On the morning of the 31 January 2008, Helena Strates visited her former de facto partner and close friend Mr. Burdon. At that time he was living alone in his rented unit at 2/27 Renfrew Circle, Goodwood. Ms. Strates reports that at about this time Mr. Burdon had been sad, depressed and making threats that he intended to kill himself. She had known him closely for some 7 to 8 years and that he had an alcohol problem and a history of making threats of self harm.
At approximately 9am, Ms. Strates contacted Mental Health Services Helpline by telephone while at Mr. Burdon's unit and requested a staff member come to see him. She was put through to a community psychiatric nurse at Gavitt House. She was concerned that Mr. Burdon was at risk of suicide due to his girlfriend having left him some 6 months earlier. At that time Ms. Strates was provided with some advice and a 'category 5 referral' was raised in relation to Mr. Burdon.
At 10.50 am Ms. Strates again telephoned the nurse at Gavitt House stating she was still concerned for Mr. Burdon. It seems this nurse referred Ms. Strates back to the Helpline and there is evidence that at 11.40 am a 'referral' was made but regrettably not sent to Gavitt House until 12.57 pm by fax. However, in the meantime the Helpline had telephoned the Crisis Team at Gavitt House to inform of a 'category 2 referral (response to commence within 2 hours - risk high and imminent)' was on the way for Mr. Burdon due to his reported level of agitation, his articulation of suicide plans, increased alcohol intake, reduced self care, appetite and sleep.
Dr Cole of Gavitt House reports that due to an incorrect mobile telephone number and incorrect client details being provided, there was a delay in locating Mr. Burdon. Gavitt House was unable to provide any evidence as to how long it took crisis staff to obtain correct details for Mr. Burdon.
It seems clear from all available evidence that the proper identity of Mr. Burdon and his whereabouts was known to the Helpline and the Gavitt House Crisis Team at the time of the category 2 referral.
The evidence is not entirely clear but it is likely that at 12.57 pm Mark Bonnitcha, the psychiatric nurse at Gavitt House received the 11.40 am referral. Mr. Bonnitcha understood that Mr. Burdon had the potential to be aggressive when under the influence of alcohol and so was to seek assistance from another employee, Mr. Pavlovic who was, regrettably, not due to start work until 2.45pm, although it is the evidence of Mr. Pavlovic that he was due to start at 2pm.
Ms Strates left the unit at approximately 1.30pm. At that time Mr. Burdon was speaking with a friend and former partner on the telephone. He was crying.
Sometime after 2.45 pm Mr. Bonnitcha located Mr. Pavlovic at Gavitt House in the staff room talking to colleagues.
At approximately 3.10pm Ms. Strates returned to the unit and initially was unable to open the door although she was able to force it open. She found Mr. Burdon hanging from a door. There was an upturned table beside him. Ms. Strates was unable to cut him down and telephoned Tasmania Ambulance Services (TAS).
Upon arrival at 3.18pm TAS officers cut Mr. Burdon down. There was no attempt to resuscitate as he was obviously deceased.
Police officers attended and found a number of notes on a bookshelf addressed to Mr. Burdon's former partner and the contents were consistent with expressions of suicide. Anti-depressant medication and many other medications were found within the unit.
Following a detailed investigation, Tasmania Police found there were no suspicious circumstances surrounding the death of Mr. Burdon.
Mr. Bonnitcha and Mr. Pavlovic both had left Gavitt House at 3.05 pm and had trouble locating the residence and when they arrived ambulance personnel were present and informed them that Mr. Burdon was deceased. It is the evidence of Mr. Pavlovic that he and Mr. Bonnitcha arrived at Mr. Burdon's address shortly after 2pm. I do not accept that.
I prefer the evidence of Mr. Bonnitcha where it is in conflict with that of Mr. Pavlovic.
Tasmanian Forensic Pathologist, Dr Christopher Lawrence conducted an autopsy which revealed the circumstances of death were consistent with ligature hanging. Mr. Burdon was also suffering from severe ischaemic heart disease at the time of his death, but in all likelihood this did not contribute to his death.
Toxicology results showed that alcohol was present in the blood along with Codeine, diazepam, paracetemol and doxylamine present at greater than therapeutic levels. Codeine was identified at a concentration approaching the reported fatal range. THC (cannabis) was also present and it is probable cannabis exposure occurred within the previous several hours before death. The high level of codeine combined with other central nervous system depressants such as alcohol and diazepam meant that the toxic adverse effects associated with the drugs identified were likely to be enhanced.
Findings and Comments :
I am satisfied that a thorough and detailed investigation has occurred into the death of Mr. Burdon and that there are no suspicious circumstances.
I find that Mr. Burdon died as a result of a suspended ligature hanging leading to asphyxia and death.
There were suicide notes found after investigation. I find that this death was a deliberate act sadly undertaken by Mr. Burdon with the express intention of ending his life and there is no evidence that he was assisted by any person. The contributing factors in his ultimate action were his essentially untreated depressive illness including long-held suicidal ideations and depressed state of mind as clouded by a cocktail of drugs and alcohol ingestion at the time of his death.
Regrettably he had not availed himself of specific professional counselling for these issues. It is clear on the evidence that these problems have contributed significantly to his decision to end his own life.
It is most regrettable that in this case Adult Community Health Services including Mental Health Services Helpline did not properly follow protocol and triage guidelines. It is clear that it took from between 11.22 am until approximately 3.20 pm (4 hours) to respond when Mr. Burdon had been subjectively categorised as 'category 2' with a response time of 2 hours - risk high and imminent'. Had triage protocols and guidelines been properly followed in a timelier and more responsible way it is possible Mr. Burdon may not have carried out his expressed desire to suicide at that time. Having said that I do not find any person responsible for having caused or contributed to his death. It is just a pity he was not attended to earlier.
Dr Cole as Team Leader at Gavitt House has assured me that since this event at the end of 2008 improvements have been made to the Gavitt House intake system by the introduction of Clinical Coordinators to ensure that all referrals are followed up in a timely and efficient manner. Further, in May 2009 the Mental Health Helpline (Triage) intake processes were reviewed and revamped to include protocols to call on the assistance of Tasmania Police in cases where there may be concerns for the safety of clinicians attending.
I wish to conclude by conveying my sincere condolences to Mr. Burdon's family.
DATED: 14 March 2012 at Hobart in the State of Tasmania.