Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Robert Pearce, Coroner, having investigated a death of

Stephen David IND



(a) The deceased is Stephen David Ind born on 19 May 1980 and aged 29 years at the time of his death;

(b) Mr Ind died as a result of asphyxia;

(c) Mr Ind died on 20 November 2009 at Neena Care Centre, 32 Quarantine Road, Norwood in Tasmania;

(d) at the date of his death Mr Ind was unmarried;

(e) no other person contributed to his death.


1. On 22 November 1998, when he was 18 years old, Stephen Ind was injured in a car accident.  The severe traumatic brain injury he suffered rendered him a quadriplegic.  Less than a year after his accident he began living at the Neena Care Centre at 32 Quarantine Rd, Norwood established by the Motor Accidents Insurance Board.

2. In 2002 management of Neena was assumed by Anglicare.  Anglicare managed Neena at the time of Stephen’s death pursuant to a management agreement with the MAIB.  The MAIB paid fees under the agreement based on the proposition that each of the occupants of the facility required attendant care for 24 hours a day, 7 days a week.  However the manner in which the attendant care was provided was, under the agreement, the responsibility of Anglicare.  From time to time the MAIB sought independent advice by audit or other means of the standards of care being applied.

3. Stephen Ind was entirely dependent on others for his care.  He had little or no independent controlled movement.  He could not dress, feed or toilet himself.  He was not able to voluntarily roll.  He was principally fed through a tube to his stomach but was able to take some food orally.  He was unable to speak but communicated in a limited way by eye movements that his carers were able to convert into letters and thus words.  Because Stephen retained cognitive function he was, not surprisingly, sometimes frustrated.  As a way of attracting attention or indicating displeasure he was able to straighten his legs and stiffen his body, a practice his carer’s referred to as “toning”.  Toning also includes an involuntary component.

4. The Neena facility consists of a 6 bedroom main unit and six transitional units.  In November 2009 Stephen Ind was one of three high level care occupants in the main unit.  He occupied a room of his own.  Care of clients is provided by carers, referred to as support workers.  Carers operate in shifts.  One shift commences at 7.00am and concludes at 3.00pm.  The next shift commences at 3.00pm and concludes at 11.00pm.  The night shift commences at 11.00pm and concludes at 7.00am.  Two carers operate the night shift.  One is the active carer.  The other is able to sleep in sleeping facilities at Neena but is available if called on.

5. On 19 November 2009 the active night carer was CK.  The carer on duty but able to sleep was VK.  According to CK Stephen Ind slept soundly until 5.30am.  At 6.30am she flushed his feeding tube.  VK arrived from his sleeping quarters between 6.30and 6.45am.  VK had worked until 11.00pm the day before and was due to commence again at 7.00am.

Events leading to Mr Ind’s death

6. From time to time it became necessary to administer anal suppositories to Stephen to assist with bowel movement.  After reviewing his bowel chart on 19 November 2009 CK decided that administration of a suppository was necessary.  She asked VK to help her.  VK administered the suppository.  Mr Ind was turned on to his left side with his arms in front and his knees pulled up as in the recovery position.  He was naked as he slept without clothes.  After the suppository was inserted a pillow was put behind his back for support to stop him rolling back.  His head was on a pillow.  Neither VK nor CK say whether a pillow was placed in front of Mr Ind.  Both of the carers then left Mr Ind’s room.

7. VK went to have breakfast.  CK did not go back into Stephen’s room and left at the conclusion of her shift at 7.00am.  Another support worker, MP, took over from her.  He said he commenced his shift at 6.45am and there was a “hand over”.  He was told, I assume by CK, that Stephen had been given a suppository, and was to be checked and cleaned up.  MP went to the lounge to check the communications book and the general take over before he observed VK go to Stephen’s room.  VK’s statement indicates that before he went to Stephen’s room he asked MP to assist him to move Stephen to a commode chair.

8. When VK entered the room he saw that Stephen had rolled onto his stomach and his face was pushed either into the bed or his pillow.  He was blue.  A check revealed no heart beat.  CPR was commenced and an ambulance called.  It arrived about 10 minutes later.  Despite prolonged resuscitation attempts Stephen could not be revived.

9. A post mortem examination confirmed the cause of death as positional asphyxiation.

Comment and Recommendations

10. By s28 of the Coroners Act a coroner investigating a death is required to find, if possible, when and where the person died, how the death occurred, the cause of death and to identify any person who contributed to the cause of death.

11. The primary focus of an investigation is to seek out and record the facts concerning the death of a person.  It is a fact finding exercise of an inquisitorial nature.  The facts which are relevant are those which may enable findings about the matters the Act requires the coroner to, if possible, determine.  It is not the function of an inquest to attribute any moral or legal responsibility or liability for a death or to hint at blame.  It is not a means of apportioning guilt.  For that reason I have not published in full the names of the carers.  A coroner is to determine facts.  The facts, once determined, will speak for themselves and it is for others to, if necessary, draw legal conclusions.

12. Findings do not and should not involve a finding that the person has some criminal or civil responsibility for the death.  However it is proper that an investigation should identify not only the direct means or mechanism of death but also the circumstances attending the death.

13. I am satisfied that at the time of Stephen Ind’s death the support workers were adequately trained and the staffing levels were appropriate.  Stephen’s father, Eric Ind, expressed to the investigators some level of dissatisfaction with the standard of care.  However my investigation is to determine the circumstances that led to Stephen’s death and a broader examination of the standard of care is not necessary.

14. Similarly I see no need to further investigate a complaint of sexual misconduct made by Stephen against a different staff member a few weeks before Stephen’s death.  Without wishing to understate the obvious seriousness of such an allegation I am satisfied from my investigation that it is unrelated to his death.

15. There is however one area that requires comment.  Given Stephen’s disability, in particular his inability to support himself in bed or roll over, I would consider that being left unchecked for a period likely to be in excess of 20 minutes contributed to his death.  His propensity for or susceptibility to “toning”, which increased the risk that he may roll onto his stomach, was known.  He was supported at the back but not at the front.  He was in a vulnerable position.  Perhaps the extent of his vulnerability was not properly appreciated.  Although the period for which he was left may have been required to allow the suppository to be effective, the period for which he was left unchecked allowed the circumstance which caused his death.  More frequent checks would, I find, have prevented his death.

No inquest to be held

16. After earnest consideration I have decided not to hold an inquest.  I have weighed what an inquest may entail with the benefits that might follow.  I consider that the investigation into the death has sufficiently disclosed the matters I am required to determine.  Having conducted the investigation I have concluded that further significant relevant facts are unlikely to emerge were an inquest to be held.

17. I record that the investigation was substantially complete by mid-2011 but there has been delay arising from further inquiries I requested be made concerning the issue I have commented on.

18. I see no need to make any formal recommendation.

I convey my sincere condolences to Mr Ind’s family.


DATED: 30 August 2012 at Launceston in Tasmania

Robert Pearce