Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

These findings have been partially de-identified in relation to the name of the deceased and friends by direction of the Coroner pursuant to S.57(1)(c) of the Coroners Act 1995

I, Stephen Raymond Carey, Coroner, having investigated the death of Ms I


Find That:

(a) The identity of the deceased;

(b) The deceased was born in Barrow, Alaska, United States of America on the July 1983 and was aged 29 years at the time of her death;

(c) The deceased was unemployed and in receipt of Commonwealth benefits;

(d) The deceased had never married; however she had been in a defacto relationship during which two children were born;

(d) The deceased died in 22 March 2013; and

(e) The deceased died as a result of mixed drug toxicity, in particular morphine, methamphetamine, olanzapine, quetipine, citalopram and metronidazole.

Circumstances Surrounding the Death:

The deceased came to Tasmania in 1998 with her father and younger sister.  Her parents had divorced before her father moved to Australia; however he remarried upon relocating to Tasmania. It is believed that the deceased's exposure and use of drugs and alcohol dates from her early teenage years. Due to behavioural issues Ms I's secondary schooling was significantly disrupted and she concluded schooling at grade 10. Even at this time she was involved in incidents of violence involving other pupils. Soon after this her behaviour became the subject of police attention and she spent minor periods of detention at the Ashley Youth Detention Centre in 2001. When the deceased was aged approximately 18 years, she gained employment with a carnival agency and travelled around Australia assisting with side show activities for rural shows and similar. She returned to Tasmania approximately 3 years later when she re-engaged with her family and began a course associated with agriculture and gained employment as a roustabout in the Midlands area of Tasmania. It was at this time that she met and commenced a relationship with Mr S and they moved to live at Longford. The deceased ceased employment shortly after this time.

At this time Mr S notes that the deceased was a heavy drinker of alcohol and was using illicit drugs occasionally. On occasions, Ms I managed to cease the consumption of alcohol and the period of her first pregnancy was such a time. However, such periods were not long standing. Ms I was apparently aware of her failing mental health and in particular her episodes of anger and in 2009 she gave Mr S primary care of their children as she believed that she was in danger of hurting them. The relationship was fragile but they remained together and in 2010, Ms I fell pregnant again. Unfortunately this resulted in a miscarriage and at this time, the deceased admitted that she was alcoholic and she engaged with the Drug and Alcohol Services at the Launceston General Hospital to attempt to address her alcohol addiction. Mr S notes a significant deterioration in Ms I's behaviour and mental health following this miscarriage. The deceased's drinking became a significant issue and eventually the relationship failed, approximately 18 months prior to her death.

Ms I's treating general practitioner from April 2008 through until the time of her death was Dr Roberts-Thompson who provided a report dated 13 May 2013. This report summarises each attendance and illustrates a long history of depression, alcohol and drug abuse, violence towards herself and to others, a lot of suicidal thoughts and several actual suicide attempts. Ms I also came under the care of a consultant psychiatrist both as an in-patient after suicide attempts or within the community where endeavours were being made to address her psychiatric health. A report was provided from Dr Rosemary Schneider, psychiatrist, dated 30 April 2012 following her assessment of Ms I on 27 April 2012. At this time she was aware that her level of alcohol consumption was placing at risk her relationship with her partner and children and she feared she might "lose her family". She gave a history of always being an angry person but believed that this was now out of control as she had come close to hurting people. She had a past history of self-harm by burning and cutting. Dr Schneider concluded with a diagnosis of probable borderline personality traits derived from a disrupted upbringing. In December 2012 she was admitted to the Intensive Care Unit at the Launceston General Hospital following an overdose of prescribed medication. This followed an argument she had with her partner concerning access to her children on Christmas Day. It appears that the situation of not being able to see her children was her main stressor at that time. It was thought that this suicide attempt was impulsive and concern was expressed that this impulsivity and issues with anger persisted as features of her personality. Arrangements were made for ongoing community support to her and this continued when she moved to the Hobart area where she was referred to the Clarence and Eastern Districts Adult Community Mental Health Service by a general practitioner. At that time it was noted that she was concerned about her anger towards others including her parents, her lack of remorse or guilt for prior violence events, impulsivity, emotional volatility and relative lack of happiness in her life. She complained of fluctuating mood, primarily depressed or angry with associated emptiness, impaired concentration and memory. She was able to relate to suicide ideation at that time and voluntary admission was offered but refused. It was noted that the deceased's drug and alcohol history appeared extensive although it was difficult to obtain accurate details; however prior patterns were primarily with amphetamines (oral and intravenous) and alcohol, with experimental use historically of opiates. She also alluded to prior dependence of the use of benzodiazepines. The assessing doctor, Dr Jonathon Peach, noted:

"She did not display any formal thought disorder. Prominent themes of the interview were of anger towards others, externalising of control, lack of remorse and rationalising of prior actions and chronic suicidal ideation. Both her suicide ideation and aggression towards others did not appear to involve planning or premeditation, but rather results of poor impulse control, frustration, intolerance and effective ability."

The conclusion was one of a person suffering alcohol abuse together with borderline personality disorder with significant anti-social traits. Once again endeavours were made to put in place community service support for the deceased but in the meantime she returned to reside in Launceston.

Finally, there was a report of 18 March 2013 following Ms I's admission to the Intensive Care Unit at the Launceston General Hospital, on 10 March 2013, following an overdose of prescription medication. Once again it was noted that the deceased had longstanding issues with alcohol dependence and poor anger and impulse control. This incident was once again seen as an impulsive act following agitation and anger over custody issues with her ex-partner and her concerns as to the welfare of her children and her belief that his alcohol consumption was in excess of hers. She was, however, making plans to take legal action in order to address the custody issue. She was referred back to her general practitioner with a recommendation that her prescription medication dispensing be controlled on a weekly basis in order to minimise the risk of future overdoses.

Ms I saw her general practitioner on 14 March 2013 where it was noted that:

"Has been in the ICU at LGH following a serious overdose. Had a fight with former partner. Agreed to having her tablets dispensed weekly to minimise her ability to overdose. This was arranged with her pharmacist. Discussion re need to take herself to Northside if she was feeling violent or suicidal."

She saw her general practitioner on 21 March 2013 where it is noted:

"She felt she had had a better week, felt more in control. She said she had made her peace with her sister and had written to her parents."

The deceased's sister has made an affidavit in which she confirms issues concerning her sister's mental health and her struggle with alcohol addiction. However, during the period 16 - 18 March 2013 she stayed with her sister in Launceston at her residence. She says that her sister was talking about wanting to make things better between the whole family and she wanted her old life back. She also expressed wishes of re-establishing her relationship with her partner and children as the current arrangement was distressing for her. When her sister left to return to Hobart, she was handed a letter addressed to her father from her sister. She noted that during that stay, her sister was "up and down in her emotions" but she did not think she was depressed. She also spoke with her sister on 3 days during the following week and she seemed happy and was making long-term plans to travel to Hobart to see her.

On 20 March 2013 Ms T Bessell and her boyfriend, Carl Maxwell Hall, moved into Ms I's residence. This was as a result of an invitation provided by the deceased who had a close relationship with Ms Bessell reportedly treating her as a younger sister. Also present from time to time over that day and following was Mr J Campbell who was a friend of the group. On the night of 20 March 2013 Ms I, together with Messrs Hall and Campbell, were using methamphetamine, the drug was described as good quality and the deceased was noted to have used the drug both by inhalation and intravenously. On the following day, 21 March 2013, Ms I attended her general practitioner's appointment as noted previously. She was driven to the appointment by Messrs Campbell and Hall and was collected afterwards returning to her home. They arrived back at the residence in the early hours of the evening and the deceased sat with Ms Bessell in the lounge room of the residence and they spoke for approximately one and half hours. During this conversation Ms I spoke on how happy she was that Ms Bessell and Mr Hall had moved in with her. The deceased commenced to show signs of tiredness stating that she was "on the nod" and, after giving keys to the residence to Ms Bessell, she went to bed.

After Ms I went to bed, Ms Bessell and Messrs Hall and Campbell, left at around midnight returning in the early hours of the next morning. When they returned Ms I could be heard snoring in her bedroom and this was commented on by the others. Ms Bessell then went to her bedroom and Messrs Hall and Campbell once again left the residence returning in the early hours of Friday morning. When they returned, Mr Hall woke Ms Bessell pointing out funny noises being made by Ms I in her sleep. At that time Ms Bessell moved from her bedroom to the couch in the lounge room and as she went past the deceased's bedroom she could hear her snoring.

Messrs Hall and Campbell came and went from the residence throughout Friday, 22 March 2013 and Ms Bessell was sleeping on the couch in the lounge room throughout the day. At one stage she can recall Ms I calling out to her.

Ms Bessel awoke on the couch at around dusk on 22 March 2013; she entered the deceased's room and attempted to wake her without success. She felt under the deceased's stomach which appeared to be still warm, she thought that something may be wrong but she states that she did not know what to do. She therefore wrote a note for Mr Hall advising him to wake her when he got home and she went to bed.

During this period Messrs Hall and Campbell had been at various locations throughout Launceston. Mr Hall had consumed a significant quantity of methamphetamine to the extent that Mr Campbell believed he may overdose. He eventually drove Mr Hall back to the residence arriving there at approximately 1:00am on Saturday, 23 March 2013. Matters become confused at this time but apparently during the endeavours to get Mr Hall into the house, the concerns about the deceased were conveyed to the group, Mr Campbell realised that Ms I may be deceased and ambulance services were contacted. Upon arrival ambulance personnel concluded that Ms I had been deceased for a number of hours and no resuscitation endeavours were undertaken.

Given the positive indications as to deceased's mood at the time and the plans she was making for the future I do not consider that Ms I acted with an intention to take her own life. Her death was as a result of the combined effect of the drugs (both prescribed and illicit) taken by the deceased. Although there was no intent of suicide, the consumption of the amount and combination of drugs was action taken recklessly by the deceased with little or no regard to the risks involved.

This is an all too common occurrence and I am concerned as to whether those treating or otherwise supporting persons who are taking illicit drugs in combination with prescribed drugs, especially drugs that depress the central nervous system, forcefully and graphically describe the likelihood of death in such circumstances. I am well aware that this is a complicated and difficult circumstance but in investigations of this type of matter I rarely see reference in reports by or the records of medical practitioners where such stark warnings are given. Whilst appreciating the need to retain the therapeutic relationship between treater and patient, there is surely a need to counsel, in strong terms if necessary, the significant prospect of death associated with such risk taking activity.

Comments and Recommendations:

I have decided not to hold a public inquest hearing into this death because my investigations have sufficiently disclosed the identity of the deceased, the date, 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.

Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.

This matter is now concluded

DATED: 6 November 2014 at Hobart in the state of Tasmania.


Stephen Raymond Carey