Record of Investigation into Death
Coroners Act 1995
Coroners Regulations 1996
I, Olivia McTaggart, Coroner, having investigated the death of
Russell Charles Doodt
AT AN INQUEST held in Hobart on 7 and 8 December 2009
Find That :
Russell Charles Doodt died outside 8 Champ Street, Bicheno in Tasmania on 16 October 2008.
Mr Doodt was born in Tasmania on 6 September 1966 and was aged 42 years. He was unemployed and divorced.
I find that Mr Doodt died as a result of drug toxicity by venlafaxine and diazepam. Significant contributing factors were depression, alcohol dependence and the absence of medical intervention.
Mr Doot's Background :-
At the time of his death Russell Charles Doodt was a 42 year old divorced man living on a disability pension. He had one adult child, an 18 year old daughter, who now lives in the United States. He suffered from Bipolar Disorder and had a significant problem with alcohol abuse/dependence and also benzodiazepine dependence. He was under the care of a general practitioner and consultant psychiatrist.
Mr Doodt had a moderate degree of cognitive impairment from alcohol abuse over a long period of time. His ability to plan and organise matters was impaired, as were his social skills. The evidence indicates a pattern of fractured relationships with friends, family and other persons he encountered in various aspects of his life.
Most recently he had been living at Bilton Lodge, 61 Cadburys Road, Claremont. This address is a supported residential facility managed by Anglicare. He moved into the residence on 29 August 2008 but was evicted for inappropriate behaviour on 14 October 2008. He removed his personal belongings from the address on 15 October 2008.
Mr Doodt was raised in Penguin in a stable and caring family. He was one of three children. Mr Doodt lived at home until he got married. He got married when he was about 21 to Linda Mailo from Don. Shortly after they got married Linda joined the Navy and they both moved to Victoria. Their daughter Monica was born in 1990. Mr Doodt started drinking heavily around that time. When Monica was about seven years old the marriage broke up due to Mr Doodts alcohol problem and consequent abusive behaviour.
The evidence indicates that Mr Doodt had not worked for many years. It appears that he had no serious relationship since his marriage, and was not in a relationship before his death. For many years before his death he was taking anti-depressant tablets.
In 1999, when Monica was aged nine, he signed papers to allow his former wife to take Monica to America to live, as Linda Doodt remarried an American citizen. Mr Doodt had a close relationship with his daughter. Mr Doodts mother, Merridene Doodt, states that it would have broken his heart to see his daughter leave.
Over the next six years Mr Doodt lived with his mother intermittently but for extended periods at a time. When he was living with her she observed him to spend his Centrelink payment on alcohol within a short time of its receipt. After consuming the alcohol his mood would be angry until he could afford to purchase more alcohol. Mr Doodt was often abusive towards his mother when he had been drinking. However, his mother and other family members often assisted him by buying him food and clothing.
Recent Events Before Mr Doodt's Death : -
In August 2008 Monica Doodt came to Tasmania from America for her eighteenth birthday. She went to visit her father and stayed with him for a few days. She then stayed with Merridene Doodt, her grandmother, for a few days. Monica told her grandmother that she had had a troubled life with her stepfather in America and said that she had spoken to her father about her last nine years in America. I accept Mrs Merridene Doodts evidence that this would have been very upsetting to Mr Doodt.
Mr Doodt's general practitioner, Dr Danny Rimmer, states that he treated Mr Doodt since May 2006. His primary problem was alcohol abuse but he also suffered Bi-Polar Disorder including social anxiety. He considered Mr Doodt to be a 'significant long term risk for suicide'.
Dr Rimmer states that he treated Mr Doodt with regular anti-depressant and anti-anxiety medications. Dr Rimmer further notes that Mr Doodt attended regular supportive counselling at Centrelink and saw Rosemary Dobber, psychologist, over a long period. Dr Rimmer also referred him to psychiatrist Dr Marzena Rybak. He was also successfully engaged with Alcoholics Anonymous and that continued into 2008.
Dr Rimmer states that Mr Doodt was admitted to the Psychiatric Unit at the Royal Hobart Hospital (RHH) on three occasions in 2008:
January - for 3 days - thoughts of self harm;
28 February - after a relapse, and following an overdose of diazepam; and
3-7 August - suffering depression - failed to follow-up with him as recommended at the RHH.
My examination of the RHH records confirms Dr Rimmers above summary. In addition the notes for the February and August admissions indicate deliberate overdoses of medication by Mr Doodt with the intent to commit suicide.
In a report provided to the Coroner, Dr Rybak states:
'I saw him the first time on 12 December 2007 for psychiatric assessment at the request of his general practitioner, Dr Danny Rimmer. On that occasion, my assessment was that Mr Doodt suffered from Bipolar Disorder which, at that time, was in remission and that he also had a significant problem with alcohol abuse/dependence and benzodiazepine dependence.
Roughly from July 2008 his general condition improved markedly. He significantly decreased his use of benzodiazepines and his periods of sobriety became longer and longer. Over all, I was quite pleased with his progress.
I last saw him on 11 September 2008 on which occasion he presented really well. He had just gotten a new unit in Claremont. He had also been abstinent for a couple of weeks and he was hopeful that he would find a new job. During our last interview we discussed possibilities of appropriate jobs for him.
At no stage during my contact with Mr Doodt did he indicate any suicidal intent. However, he was admitted to the Royal Hobart Hospital for three days following a small overdose of poly-pharmacy, which was believed to have been done under the influence of alcohol. The psychiatrists assessing him at the time, at the Royal Hobart Hospital, did not find any evidence of depressive illness.
During my last review, Mr Doodt certainly gave no indication of any suicidality. He was very optimistic about his future and felt that his psychiatric disorders were quite well controlled at that time.'
Mr Doodt was not seen at Dr Rimmers practice again until 10 October 2008, when he was seen by Dr Michael Salter. On that day Mr Doodt told Dr Salter that he had suffered an injury to his shoulder due to rough treatment by police when he was locked up in the Remand Centre on 8 October.
On 14 October, when he was informed of his eviction by Steven Wieinert, Anglicare accommodation coordinator, Mr Doodt became verbally aggressive and abusive.
Dr Rimmer states that on 15 October 2008, he received a telephone call from Centrelink staff in which they reported Mr Doodt had exhibited poor behaviour toward staff and demanding extra money for 'expensive medication' hed been prescribed.
Despite an apparent general improvement in his mental state and use of alcohol since July, the August hospital admission and the downturn in his state and behaviour in the days before his death indicate that he remained a troubled individual.
Circumstances Surrounding Death :-
I set out below my findings about the circumstances surrounding Mr Doodts death. The evidence was not in conflict as to the general movements of Mr Doodt and the other main witnesses in the 24 hours before his death. The evidence was plentiful and therefore easily allows me to narrate these circumstances without the need for findings of credit. More detailed circumstances and considerations pertaining to each witness are set out later in this finding.
I find the circumstances of Mr Doodt death are as follows:
On 15 October 2008, one Gary Wynne and one Darren Keene drove as arranged to Mr Doodt's residence at Bilton Lodge, 61 Cadburys Road, Claremont. Mr Doodt, having been evicted, moved his possessions out of his residence and into the vehicle being driven by Mr Wynne. Mr Doodt was intending to share rental accommodation with Mr Keene.
Mr Keene was a friend of Mr Doodt, having known him for about 10 years. Mr Wynne had known Mr Doodt for about 2 years but it appears that he did not have regular contact with him.
Mr Keene made the decision that they travel to Launceston to visit a friend of his who had sent him a text the day before.
The three companions initially travelled to Geoff Deacons Pharmacy in Bayfield Street, Bellerive where Mr Doodt collected his prescription medication for depression. This prescription from his psychiatrist was for the supply of 112 x Efexor, 150mg capsules.
With Mr Wynne driving, they travelled to Launceston and arrived around 5pm. There they purchased some cans of beer and travelled to Bicheno. Mr Doodt and Mr Keene consumed alcohol throughout the whole episode of driving.
North of the Bicheno township Mr Keene commenced driving despite not holding a drivers licence. Shortly after Mr Keene commenced driving the vehicle was intercepted by police. Mr Keene was required to accompany police whilst he was charged with breathalyser offences. Analysis of his breath returned a reading of 0.207 grams of alcohol per 210 litres of breath.
While Mr Doodt and Mr Wynne were waiting for Mr Keene to return to the vehicle after being processed by police, Mr Doodt appeared to be upset and threw items such as paper rubbish out of the vehicle.
When Mr Keene returned to the vehicle, Mr Wynne drove to the boat ramp at Bicheno. Mr Keene fell asleep in the back seat. Mr Doodt was seated beside Mr Wynne in the front passenger seat and commenced taking a large quantity of his prescription medication. Whilst it is difficult to be precise the evidence suggests that this occurred at around midnight.
Early the next morning Mr Wynne drove to the Redbill Beach car park for a short period of time. Mr Doodt was unwell and vomited outside of the vehicle.
At the instigation of Mr Keene, the three companions travelled to a residence at Unit 5/8 Champ Street, Bicheno. Mr Keene knew an occupant of that address, Russell Baines. The vehicle, driven by Mr Wynne, was parked on the street outside the unit complex. Mr Keene went inside the residence leaving Mr Wynne and Mr Doodt in the car. A short time later Mr Keene came back to the vehicle. Then both he and Mr Wynne went inside the residence. Mr Doodt was left apparently asleep in the front passenger seat.
Later in the morning Mr Wynne and Mr Keene returned to the vehicle with Russell Baines. He was an occupant of 5/8 Champ Street and an associate of Mr Keene. Mr Wynne drove the three males, including Mr Doodt, to the BP service station in Bicheno to purchase petrol. Mr Doodt remained in the front passenger seat. At that time he was clearly unconscious or in an altered state of consciousness.
Tom Pearce, an attendant at the BP service station observed the vehicle parked on the apron of the service station. He saw Mr Doodt (not known to him) swaying back and forth in the front passenger seat. He then observed a sudden spasm and Mr Doodt nodding his head rapidly. He then saw him then lean down towards his knees and continue to sway. Mr Pearces evidence is that he heard one of the males in the vehicle say, "fuck him, well let him die".
After purchasing petrol, they left the service station and drove to a property north of the Bicheno township near Diamond Island Resort. They parked on the Tasman Highway facing north.
Mr Doodt was motionless, slumped and leaning over the gear stick. So that the vehicle could be driven, Mr Baines lifted Mr Doodt from under his arms and Mr Keene lifted Mr Doodts feet. They manoeuvred him out of the front seat and put him on the roadway. Mr Doodt remained unresponsive while Mr Baines dragged Mr Doodt into the rear seat of the vehicle. Mr Keene rolled Mr Doodt over so that he was positioned face down. His legs were folded up and the rear door was shut.
At the same time a vehicle being driven by Vanessa Wallace was travelling south on the Tasman Highway. She stopped her vehicle and observed two males moving an unresponsive third male from the front seat of a vehicle into the rear. They laid this male horizontally across the back seat. His feet were hanging out of the car door. At that time Mr Doodt was alive as he coughed.
Believing the situation to be unusual and suspicious, Ms Wallace asked if she could render any assistance or telephone an ambulance. One of the males approached Ms Wallaces vehicle and said, "you shouldnt have seen that" and "he has overdosed on Morphine". Feeling unsafe, Ms Wallace left the vicinity and immediately reported the matter to police.
Mr Baines sat in the front passenger seat while Mr Wynne drove. Mr Keene travelled in the back passenger seat behind Mr Baines with Mr Doodts legs on his lap. They returned to Unit 5/8 Champ Street and parked the vehicle in the driveway.
Mr Doodt was left face down on the back seat while the other occupants went inside the unit.
A short time later police attended the residence and found Mr Doodt deceased on the back seat of the vehicle.
Cause of Death :-
A post-mortem examination was conducted by Forensic Pathologist, Dr Donald Ritchey. Dr Ritchey ascertained that the cause of Mr Doodts death was drug toxicity from venlafaxine and diazepam.
Venlafaxine hydrochloride is the active chemical in the anti-depressant medication Efexor. The toxicological analysis of Mr Doodts blood revealed venlafaxine at a level of 82mg/L3. Forensic scientist Dr Andrew Griffiths states that such a level is within the reported fatal range for this drug taken alone. He notes that overdose of venlafaxine can result in serious complications including seizures, respiratory failure, severe hyperthermia, coma and death. There was alcohol detected in Mr Doodts blood at a moderate level of .090g/100ml. The level of diazepam was 0.1mg/L being therapeutic (also moderate).
Whilst Mr Doodt had consumed alcohol and diazepam, I agree with the conclusion of Dr Griffiths and Dr Ritchey that he died primarily as a result of venlafaxine toxicity.
Dr Ritchey noted that significant contributing factors in Mr Doodts death were depression and the failure of his companions to seek medical assistance for him.
It is worth fully setting out Dr Ritcheys comments made in a supplementary affidavit of 14 July 2009:
'Specifically, it has been requested that I expand on my opinion that had appropriate medical attention been sought on behalf of Mr Doodt by his companions his death might have been prevented.
By appropriate medical attention, I mean that Mr Doodt should have been seen by a physician, i.e. taken to a local emergency room or doctors surgery. Specifically what might then have been done depends on many variable clinical factors as assessed by a treating physician. Life-saving interventions might have included measures to evacuate gastric contents and/or the administration of activated charcoal to decrease the absorption of orally ingested drugs from the gastrointestinal tract. General supportive measures like intravenous fluids and mechanical ventilation are mainstays in the treatment of drug overdose. Dialysis has been used in some situations to remove drugs from the blood that were already absorbed from the GI tract. Drug induced seizures can be controlled using various medications.
Accounts of the events that occurred in the hours prior to Mr Doodts death indicate that there were multiple opportunities to recognise the seriousness of Mr Doodts condition and summon assistance.
It is not scientifically meaningful for me to postulate a specific time period during which medical intervention definitely would have saved Mr Doodts life however, in general, the sooner the intervention, the greater the likelihood of successful treatment. Appropriate medical intervention at any time prior to his death may have been successful at preventing Mr Doodts death.'
The evidence does not permit me to make a finding that Mr Doodt specifically intended to end his life by taking the Efexor tablets. There was evidence that Mr Doodt was agitated and upset before taking the tablets, but no evidence that he was talking about ending his life. Mr Wynnes evidence was that Mr Doodt did not say anything before or whilst taking the tablets. Mr Wynne gave evidence that he believed Mr Doodt committed suicide'. However he appeared not to have formed this view until after Mr Doodt had died.
Mr Doodt was an unhappy and deeply troubled person. His medical records confirm that he regularly experienced suicidal thoughts. As recently as August he had attempted to take his life by an overdose of medication. However, the records also indicate that Mr Doodt regularly abused medication by recklessly taking large and potentially fatal doses but not necessarily with the specific intent to end his life.
Therefore I am not able to determine whether on 15 October 2008 Mr Doodt intended to end his life or whether he took the medication without caring whether he lived or died. On either scenario, I am satisfied that he deliberately took the medication knowing that death might occur.
Failure to Obtain Medical Assistance for Medical Assistance for Mr Doodt :-
The oral evidence given at the Inquest focussed upon failure by witnesses to render assistance sought for Mr Doodt from the time he was seen to have ingested the tablets until the time he was discovered deceased in the car by police. Each of the witnesses called to give evidence at the Inquest had contact with or had observed Mr Doodt during this critical period. Their reasons for their respective actions and inaction during this period were examined.
In the previous paragraph I have not made detailed reference to times of significant events. Before dealing with each witness evidence, I set out my findings as to the approximate time of relevant events. Again, there was clear evidence from witnesses as to time and no need to make findings of credit.
15 October 2008
12.00pm - Mr Keene and Mr Wynne drive to collect Mr Doodt from the Claremont residence
2.30pm - They collect Mr Doodt's prescription, Efexor 150mg, from Pharmacy in Rosny
5.00pm - Beer is purchased from a hotel in Launceston and travel to Bicheno
8.00pm - Mr Keene takes over driving from Mr Wynne
10.30pm - Police charge Mr Keene with drink driving in Bicheno
16 October 2008
12.00am - The three remain in vehicle at Bicheno boat ramp. Mr Wynne observes Mr Doodt taking many tablets
6.00am - The three drive to Red Bill Beach car park. Mr Wynne observes Mr Doodt vomiting. Mr Keene remains asleep
7.00am-7.30am - The three drive to unit complex at 8 Champ Street. Mr Doodt is very unwell. Mr Wynne suggests hospital
7.30am - Mr Doodt left alone in front passenger seat of car
8.00am - Mr Wynne and Mr Baines walk by themselves from the units into town to buy cigarettes and food
8.10am - Messrs Wynne, Keene, Howell and Mr Baines aware Mr Doodt is very unwell. Mr Keene checks him in car two or three times, once with Mr Howell. Mr Doodt is unconscious
9.30am-10.00am - Messrs Wynne, Keene and Baines drive to the BP service station for petrol. Mr Doodt has seizure in car
10.15am - They drive to block of land owned by Mr Keene's father. Mr Doodt remains unconscious and they move him into back seat of car. Witnessed by Vanessa Wallace. Ms Wallace notifies police
10.30am - Arrive back to Champ Street units. All enter units, leaving unconscious Mr Doodt in back seat. Mr Keene checks on Mr Doodt
11.24am - Police locate Mr Doodt deceased in car
At the date of Mr Doodt's death Gary Wynne was aged 49 years.
It was apparent through the investigation and in giving evidence at the Inquest that he was of low intellect. He is unable to read or write. His mother and a Mental Health Services carer were present to assist him in Court. His mother read to him his previous affidavit.
Mr Wynne described himself as suffering schizophrenia 'for years'. The Inquest did not seek further medical clarification of Mr Wynnes condition. Despite his difficulties Mr Wynne was able to give coherent evidence based upon memory. I accept significant portions of his testimony.
Mr Wynne has known Mr Keene for many years but did not see him regularly. He said Mr Keene would sometimes call him to come and work at his home when his girlfriend was out. Mr Keene is a dominant, aggressive and cunning individual. Mr Wynne, by virtue of his difficulties, was at a significant disadvantage in terms of sustaining friendships on an equal footing. However, for reasons which will become apparent, Mr Keene used Mr Wynne unscrupulously to further his own ends. Mr Wynne was also fearful of Mr Keene and did not have the capacity to resist him or effectively challenge his decisions.
In evidence Mr Wynne said about Mr Keene 'Im shit scared of him, excuse my language … he said "when your mother dies youre - hes going to kill me". I accept that this threat was uttered. Although, it was probably well before the day of Mr Doodts death, its impact remained.
Surprisingly, Mr Wynne had a driver's licence. His ability to drive adequately, taking into account the need to understand road signage, was apparently limited to short and known routes on very irregular occasions. It seems from his evidence, and also that of Mr Keenes, Mr Wynne needed a passenger to direct him otherwise he would be in danger of an accident. He had little ability to think ahead and interpret signs.
On 15 October Mr Keene prevailed upon him to drive him to Launceston - a task that he well knew was beyond Mr Wynne's capabilities. Mr Wynne felt he had no choice but to comply with this request.
The evidence indicates Mr Wynne had great difficulties in completing the drive despite assistance with driving. Mr Wynne indicates, and I accept, that Mr Doodt and Mr Keene were drinking in the car all the way to Launceston. Mr Wynne did not drink, he says, until 'halfway off the Midlands Highway', when he had 3 cans. I interpret this as meaning 3 cans of beer for the whole drive to Bicheno.
The evidence did not indicate that Mr Wynne was consuming alcohol at any stage to the extent that he would have exceeded the legal blood alcohol limit.
Mr Wynne was not a resourceful or courageous man. It would seem that his capacity to manage all aspects of his life is limited by his intellectual and mental health difficulties. Even with such unfortunate limitations Mr Wynne showed clearly in evidence that he had a reasonable memory, the ability to reason and make moral judgments. Further he was sober throughout the period of time in question.
Mr Wynne was the one who saw Mr Doodt taking the tablets. He thought they were Morphine. He knew there were many of them. By 6.00am Mr Wynne saw that the tablets had caused Mr Doodt to be sick. At that time it would have been possible for Mr Wynne to walk into town to seek some help. Mr Keene was asleep then. At that time Mr Doodt was conscious. I accept that given his limited capacity he would have found it difficult to take this measure alone.
By 7.00am, when Mr Keene had woken, Mr Wynne knew that medical attention was needed for Mr Doodt. By that time Mr Keene had taken charge of the situation and Mr Wynne felt powerless. Mr Keene had told Mr Wynne that he would be all right upon Mr Wynne suggesting taking Mr Doodt to hospital.
The evidence indicates that throughout the remainder of the morning, until Mr Doodt died, Mr Wynne remained very worried about Mr Doodt and wanted to help him. However he was not only fearful of the increasingly aggressive Mr Keene but had little capacity to think clearly and take initiatives to find help.
Mr Wynne however had an obvious opportunity to seek help when he and Mr Baines walked into town by themselves. At that point he could have called an ambulance. If medical help had been obtained at that point Mr Doodt may have lived. Mr Wynne was Mr Doodt's companion and should have acted to help him. His neglect in failing to do what any reasonable friend would do was apparent in his testimony.
Of all those persons who were in contact with or observed Mr Doodt before his death, Mr Keene was by far the one who had the greatest capacity and opportunity to seek medical help for him. His failure to do so was reprehensible.
I am not able to find on the evidence that Mr Keene observed Mr Doodt taking the tablets at around midnight on 15 October or being sick in the Gulch at around 6.00am on 16 October as it appears Mr Keene was asleep in the car at these times.
However, at around 7.00am after the car arrived at the Champ Street units, Mr Keene saw the empty pill packets on the dashboard of the car. At the same time Mr Doodt, then still conscious, told Mr Keene directly that he had 'taken the whole lot'.
Later Mr Keene said to police 'He goes "I've taken a hundred and twenty mls" or oh fuckin whatever that was. Hed taken the whole lot'. Mr Keene then told police "I didnt take any notice, it didnt matter to me right". That single statement typified Mr Keene's attitude to Mr Doodt's predicament from the time he knew of the ingestion of the tablets to the time Mr Doodt was found dead in the car by police at 11.24 am. Mr Keene was familiar with the drinking patterns of Mr Doodt. He had previously seen Mr Doodt 'smashed' and 'not able to hold a GLASS'. However on the evening of 15 October he told police that Mr Doodt was not significantly intoxicated. He further stated in evidence that he did not see Mr Doodt drink at all the next morning. I therefore reject Mr Keene's attempts in evidence to portray Mr Doodt's state as simply sleeping off the effects of a large amount of alcohol. Mr Keene actually stated to police and in evidence that he believed from an early time that Mr Doodt had ingested morphine. It appears that he believed it may have been from an illegal source and wanted to distance himself from that situation. Whether or not that was the case, Mr Keene at no time demonstrated that compassion towards Mr Doodt or any desire to help his friend.
I find that after the short conversation at around 7.00am between Mr Doodt and Mr Keene, relating to Mr Doodt ingesting the tablets, Mr Doodt was not in a conscious state until his death. He was obviously in need of careful monitoring or medical attention. A caring and responsible friend at that point would at least have made attempts to rouse Mr Doodt or to seek immediate help. It was at that time outside the units when Mr Wynne said to Mr Keene "we should get him to hospital", to which Mr Keene replied "stuff him, dont worry about him".
Accordingly Mr Keene did nothing, left Mr Doodt unconscious in the car and returned to the unit to continue drinking.
Inside the unit Mr Keene repeatedly spoke about Mr Doodt, asking Mr Howell to check on him and yet declining Mr Howell's suggestions to take him to the nearby medical centre saying "no hell be right". Mr Howell stated in his evidence:
'Well as you say there's my back door and here's the car and I just seen him slouched there. When we come out Darren's saying to me, "Oh, feel his pulse and check him out", and I says, "No, he's your mate you do it", and I says, "if you're not sure take him up to the medical clinic".
And they just kept on saying, "Oh, no, he's all right". Well Darren - Gary wasn't saying a word about it but Darren is saying, "No, he's right, don't worry about him". And I says, "Well why keep on bringing him up and mentioning him if you know he's not all right", I says, "take him up to the medical clinic". And then when they did go for a ride with - there's was Russell, Gary and Darren, when they went to look at this block of land, or whatever it was, they've had to move the body again because it's laying down on - with the three of them sitting in the car, and that's what I asked them…'
Mr Howell goes on to state that on four or five occasions in total he told Mr Keene to take Mr Doodt to the medical clinic.
I accept this evidence. It indicates further repeated prompting of Mr Keene to obtain medical help for Mr Doodt. Yet again Mr Keene did not seek to help Mr Doodt.
Mr Keene's attempts to shift responsibility for Mr Doodt to Mr Howell were selfish and very unfair. Mr Howell did not know Mr Keene. He did not request an early morning visit from persons who had been drinking heavily and who had left an unconscious friend outside in the car.
Whilst Mr Keene at this time may have expressed concern about Mr Doodts condition, his concern was purely in relation to avoiding responsibility for the situation. Ironically if he had sought help at that time he could not have been criticised; he played no part in Mr Doodt taking the tablets.
Thus from about 7.00am to 10.00am Mr Keene remained in the unit and left Mr Doodt gravely ill and unattended in the car. Checking him on two or three occasions involved no more than a cursory view to see if Mr Doodt was still breathing. The level of Mr Keene's anxiety and aggression as observed by Mr Howell and Mr Baines indicates a belief by Mr Keene, from a very early stage, that Mr Doodt was dangerously ill.
It appears that from this time of commencing driving to his fathers block, Mr Keene's attitude to Mr Doodt's health became callous in the extreme. I find that he thought Mr Doodt would die and was prepared to let him die justifying it as a situation of Mr Doodts own making.
At the service station he made the comment "fuck him, let him die" in face of Mr Doodt having an obvious seizure during a comatose state. I find it was a comment that Mr Keene intended literally. Mr Keene still did not seek medical help for Mr Doodt, who at that point must have been close to death.
At his father's block this time the rough manner in which Mr Doodt was put in the vehicle indicates Mr Doodt was being treated as a mere body albeit still with a semblance of life left in it. I find that the most likely explanation for moving Mr Doodt was to conceal him from view.
Mr Keene spoke to Ms Wallace. He did not accept her offer to call an ambulance.
Instead he chose to drive back to the units and to again leave Mr Doodt in the car unattended. Once again he had the opportunity there to seek help for Mr Doodt who by that time appeared lifeless.
In summary, Mr Keene failed to seek help for Mr Doodt from the period of about 7.00am until 11.24am by which time he was deceased.
Mr Keene was in charge and made all of the decisions. He presented as domineering and manipulative. I can well understand that Mr Wynne and Mr Baines would not have had the strength of character to challenge him on his decisions.
Mr Keenes evidence was punctuated by untruths and excuses to suit his own cause. He would say anything to make him appear in a better light, often contradicting himself. He repeatedly, yet unconvincingly, asserted that he was a caring person.
Mr Keene did not mention the visit to the pharmacy, and in fact denies to police they stopped anywhere to get tablets. I find this was a lie to disguise his knowledge that Mr Doodt had medication.
Initially he did not tell police about stopping at the service station, although in evidence he admitted it. However, throughout his evidence he denied saying the words, "Fuck you, let him die" despite the clear evidence of 5 witnesses.
He maintained in evidence that Mr Doodt was simply drunk, a state that he would 'sleep off'. Such evidence was absurd in light of the fact he knew that Mr Doodt had taken an overdose of tablets.
In evidence he justified his dominion over Mr Wynne by implying that Mr Wynne was equal to him in intelligence. He volunteered to the Court that Mr Wynne was more skilled than he in relation to the area of bee keeping. Again this is an example of Mr Keene's deflection of his own responsibility and onto a person obviously intellectually inferior.
Further, at the time of his breathalyser interception, he tried to coerce Mr Wynne into taking the driver's seat and asserting to police that he was the driver.
His blatant lack of honesty was further evidenced by telling the Court that he was able to communicate with Mr Doodt at the time when the vehicle had stopped at the block. He told the Court that Mr Doodt was able to acknowledge his comment about the beauty of the view.
Over a period of almost 4½ hours Mr Keene displayed an utter lack of compassion towards his friend. It should be expected that any decent human being over such a long period of time would willingly take every step available to help a dying friend.
His actions did not appear in other respects irrational. He was able to make decisions and, indeed, took on the role of leader. I find his alcohol consumption the previous evening apparently had little impact on his ability to function. I cannot see that intoxication played any real part in his failure to help his friend.
Police and ambulance were readily available in Bicheno for the whole period that Mr Keene was in charge of Mr Doodt's life. He had access to a vehicle and telephones.
It is incomprehensible that Mr Keene so shamefully failed in his duty to his friend.
Mr Howell attempted many times to get Mr Keene to seek medical help for Mr Doodt.
He didnt know Mr Keene. To him, and in reality, Mr Keene was clearly in charge of the group including Mr Doodt.
He didnt invite them in, and was reluctant that they were there. Mr Howell didnt drink and didn't want them drinking in the house. He had the care of a young school student who was just leaving for school upon the arrival of the group.
He didn't see Mr Doodt until Mr Keene eventually persuaded him to come out to the car to help check him. Whilst Mr Howell did not check Mr Doodt's pulse as requested by Mr Keene he viewed Mr Doodt. At that time Mr Howell was aware of Mr Doodt's serious condition.
To Mr Howell it must have been obvious that Mr Wynne was somewhat simple. He was also fully aware of Mr Keene's callous attitude towards Mr Doodt's condition.
Calling an ambulance or a doctor was certainly an option for Mr Howell. He had a phone in his house. It would have been reasonable for him to make a phone call, at least after the vehicle had left. He was sober and sufficiently intelligent to do so. In addition he had a lengthy period of contact, with the group, approximately 3 hours, over which time he could have rendered assistance.
Mr Baines was 39 years old at the time of Mr Doodt's death.
It was immediately apparent that Mr Baines was not of high intelligence and had a significantly lower than normal ability to understand situations, think clearly and make rational decisions. The Inquest did not explore reasons for this. His ability to function was higher than that of Mr Wynne but in my view not by a significant margin. He knew Mr Keene as a former fellow prison inmate. He too had a fear of Mr Keene and believed he might extract retribution if he was crossed.
Having seen Mr Keene as a witness I can well understand that he would be intimidating to both Mr Baines and Mr Wynne, both of whom did not possess the presence of mind to challenge him. However in respect of Mr Baines I am not prepared to state that his failure to seek help for Mr Doodt can be fully explained by fear of Mr Keene. In evidence he indicated only a moderate level of concern. In this regard I set out the following relevant passage from the transcript of Mr Baines evidence:
'MS LOWE (Counsel Assisting): And when Darren said, "Fuck him, let him die", what did you think when he said that?.......That's when he got back in the car, said, "Fuck him, let him die", and I didnt take any - much more interest.
In the front passenger?.......Yeah.
Why didnt you take any interest in him?.......I didnt want to cause any hassles.
With?.......The - Darren.
HER HONOUR: But why wouldn't you have wanted to cause a hassle with Darren if someone's life depended on it?
WITNESS: I didnt want to cause any fights or, you know, and he's bringing trouble up to the units.
MS LOWE: (Resuming): So were you afraid of Darren?.......A little bit.
Has he been violent to you or has he done anything to you directly before?.......No.
So you headed out to Darren's father's block?.......Yep.'
As can be seen from the above chronology Mr Baines knew that Mr Doodt had taken an overdose of drugs as early as 7.00am. At that time he went to the car and saw a man passed out who 'didnt look healthy'. He saw the boxes of tablets and was told by Mr Keene that Mr Doodt had taken them. From that time he was in close proximity to Mr Doodt. Whilst Mr Baines expressed some concern to Mr Wynne and Mr Keene about Mr Doodt's state of health, he did nothing to help him at all. He did not seek help when he was in town with Mr Wynne at around 8.00am. He did not call an ambulance or ask for help from service station personnel when the vehicle was stopped there for fuel. This was apparent because Mr Keene said they were not to do so. There was no evidence of any threat issued by Mr Keene at that time to either of his companions.
Mr Baines owned a mobile phone and the unit had a phone. He could have made a call to police, anonymously if necessary.
Instead he was happy to take a trip to Mr Keene's father's block whilst an unconscious man was in the front of the car. He was then instrumental in moving Mr Doodt to the back seat with Mr Keene. I find at that time that Mr Baines held the belief that Mr Doodt was approaching death. He was fearful by that stage about the trouble he would find himself in. He was not mentally or morally equipped to handle the situation and relied upon the direction of Mr Keene.
When he made his first statement to police, an affidavit on oath, he deliberately made no mention of travelling in the car and moving Mr Doodt to the back seat. He corrected this falsehood by swearing another accurate affidavit on the same day admitting his involvement.
Mr Anderson is a mechanic and long term employee at the BP service station in Bicheno. At the time of Mr Doodts death he was aged 26 years. Like fellow employee Mr Pearce he noticed the vehicle containing Mr Doodt, a person unknown to him. He says he noticed the car because the man in the front was 'in a bad way'. He describes his face twisted off to the side and pressed to the passengers front glass. He appeared to be fitting. Mr Anderson describes the passenger twitching and his arms flapping. He assessed 'the person with the rats tail' (Mr Keene) as the dominant one in the group. He thought the group appeared unruly and haggard and looked like they had been 'on the grog all night'. He clearly heard the person with the rat's tail say about the sick passenger, "fuck him he can die".
He stated in evidence that he didnt think to call the police or ambulance. When asked why not by Counsel Assisting he stated:
'... - you see a lot of strange looking things come through the service station and my boss, he's always been to mind my own business generally when it comes to those sorts of things'.
He said he would call the police if someone is assaulted or if a driver of a car was obviously drunk. He stated that he interpreted the comment by the person with the rats tail as simply a way of saying that the condition, presumably drunkenness, was self-imposed and so sympathy was not warranted. However, it must have been very obvious to Mr Anderson that Mr Doodt was not simply suffering the usual effects of an excess consumption of alcohol; that Mr Doodt in fact was in a dangerously ill state. It was further obvious that none of his companions were going to seek medial attention for him.
Mr Anderson was an experienced employee in a place where he was in a good position to observe members of the public using the service station. He was able to at least make a phone call to local police or the ambulance service. If he was concerned about reprisals from the group he could have taken the vehicles registration number and called police after they had departed. His failure to adequately consider the danger to Mr Doodt and to respond by making a phone call to police is concerning. His evidence conveyed the attitude that as he was not involved in the situation that he witnessed, he bore no responsibility to assist in any way.
Mr Pearce had been working at the BP service station for only 4-5 months and was aged 18 years. He says he noticed the vehicle as all four males were around 50-55 years, and that composition of occupants was not a common sight. His observations are very similar to those of Mr Anderson. He noticed the front seat passenger having a spasm and nodding his head rapidly. He then leant down towards his knees and started swaying more.
Mr Pearce couldnt hear the mens conversation but heard them mumbling. One of the men then said, "fuck him let him die". He didnt think that they really meant let him die, but he stated the whole thing 'looked dodgy'. He formed the view that the sick mans companions were not going to help him in any way. Nevertheless it did not occur to him to call the police.
He stated in evidence:
'If I was a bystander I probably would have thought differently it was just because I was an employee and I was working and I - it didnt come to my attention to call the police. But if I was someone that was maybe not working and just watching from the other side of the road I probably would have called the police.'
Mr Pearce said that he would call police if the driver was intoxicated but he didnt think to do this in light of an even more worrying situation. It seems in fact he did have real concerns that the four men were drunk or under the influence of drugs.
After the car left Mr Pearce spoke to Mr Anderson whom he considered his mentor. He said "Did you see that"? to which Mr Anderson replied "dont worry about it". Perhaps it is understandable that Mr Pearce, as a junior employee, was comforted by the comment of a more senior employee not to think further about what he saw. However, further independent reflection on this unusual and serious situation might have led him to take the important step of calling the police. He concedes that in hindsight that is a step he would have taken.
Ms Wallaces actions deserve the highest praise.
Upon returning from her friends house and driving back into Bicheno with her 20 month old son, she saw an apparently unconscious Mr Doodt being placed into the rear seat of the car. Despite being a young female with an infant and thus in a potentially vulnerable position, she stopped her car to question the males. Her conversation was with Mr Keene. She offered to ring the ambulance on her mobile phone. However she started to feel unsafe as the males began to talk about her in a lewd manner. She therefore immediately drove to the police station to notify police of her observations. As no police officer was present Ms Wallace then drove to the private residence of a local police officer. She then told that police officer of her observations.
As a motorist with no connection to the other vehicle or its occupants, Ms Wallace could easily have driven past, justifying it on the basis that it would not be safe for her or her son to be involved. Instead she had the presence of mind and courage to ascertain the situation and provide all the assistance she could.
Unfortunately, that assistance came too late for Mr Doodt. Nevertheless the actions of Ms Wallace are to be commended as those of a courageous and community minded citizen.
In this matter the evidence does not allow me to find that Mr Doodt would necessarily have been saved if timely assistance was provided. However, I find in accordance with Dr Ritcheys opinion that such failure was a significant contributing factor in his death. There were various medical measures that may have been successful to prevent his death. Each witness, apart from Ms Wallace, could have helped Mr Doodt by taking the small step of alerting police or ambulance.
I wish to comment on the reasons why no action was taken to help by witnesses Mr Howell, Mr Anderson and Mr Pearce. I would categorise all three as independent witnesses, or 'bystanders'.
The bystander effect is a social psychological phenomenon that refers to cases where individuals do not offer help in an emergency situation when other people are present.
The circumstances of the murder of American woman Kitty Genovese (1935-1964) and the lack of reaction of numerous neighbors were reported by a newspaper article published two weeks after her death. The article melodramatically portrayed many neighbors being fully aware of the crime but unwilling to help. The article was later criticized as inaccurate. However it generated such widespread community concern that it prompted investigation into the social psychological phenomenon that has become known as the bystander effect.
The bystander effect was first demonstrated in the laboratory by John Darley and Bibb Latane in 1968. These researchers launched a series of experiments that resulted in one of the strongest and most replicable effects in social psychology. In a typical experiment, the participant is either alone or among a group of other participants. An emergency situation is then staged - examples include smoke pouring from a vent in the room, a woman falling and becoming injured, a student having an epileptic seizure, etc. The researchers then measure how long it takes the participants to act, and whether or not they intervene at all. These experiments virtually always find that the presence of others inhibits helping, often by a large margin.
There are in fact many reasons why bystanders in groups fail to act in emergency situations, but social psychologists have focused most of their attention on two major factors. According to a basic principle of social influence, bystanders monitor the reactions of other people in an emergency situation to see if others think that it is necessary to intervene. Since everyone is doing exactly the same thing (nothing), they all conclude from the inaction of others that help is not needed. The other major obstacle to intervention is known as diffusion of responsibility. This occurs when observers all assume that someone else is going to intervene and so each individual feels less responsible and refrains from doing anything.
There are other reasons why people may not help. They may assume that other bystanders are more qualified to help, such as doctors or police officers, and that their intervention would be unneeded. People may also experience evaluation apprehension and fear losing face in front of the other bystanders. They may also be afraid of being superseded by a superior helper, offering unwanted assistance, or facing the legal consequences of offering inferior and possibly dangerous assistance.
It is disappointing that Mr Howell, Mr Anderson and Mr Pearce failed to alert police or ambulance services as to their observations. It does indeed appear that some of the factors described in the research were operating upon their minds. I would however urge members of the community generally who witness someone in a serious predicament to make an effort, if they safely can, to contact police or ambulance. It can not be assumed that someone else has already taken such steps.
Both Mr Wynne and Mr Baines are of low intellect and were heavily under the influence of Mr Keene. Nevertheless, for the reasons already given, I have found that both could and should have sought help for Mr Doodt. Having heard their evidence I have no doubt that their failure to do so remains upon their conscience.
Mr Keenes callous neglect of his friend defies human decency. He may have been able to save Mr Doodts life. However, whilst still exercising control over the person and fate of Mr Doodt, he decided not to help him. Subsequently he formed the express intention to leave him to die.
I intend to forward the transcript of evidence from the Inquest to the Director of Public Prosecutions for him to determine whether any criminal charges might lie against Mr Keene.
DATED: 23 April 2010 at Hobart in the State of Tasmania.