Record of Investigation into Death
Coroners Act 1995
Coroners Rules 2006
29 June 2011
I, Glenn Hay, Coroner, having investigated the death of
Duncan Joseph Lee
WITHOUT HOLDING AN INQUEST
(a) Duncan Joseph Lee (Mr Lee) died on 1 May 2010 in the Derwent River, Hobart in Tasmania, aged 31 years;
(b) Mr Lee was born in Hobart, Tasmania on 23 December 1978. He was a single man without dependents, and was unemployed at the time of his death;
(c) Mr Lee died as a result of multiple injuries and drowning following a jump from the Tasman Bridge, Hobart. A complicating factor was his diagnosed condition of schizophrenia.
Mr Lee lived at home in Howden with his mother (Mrs Lee), his step father and one of his younger brothers. Mr Lee’s father died in 2003 after suffering bowel cancer. Mr Lee had previously worked as a computer engineer but left his job in 2006 to study at the University of Tasmania. He moved out of home for a period during part of his study.
At the completion of his degree Mr Lee took a break from work and study. At this time he was again residing at home and began riding his bike and gardening around the house, as well as spending a lot of time on his computer. He established a small computer business of his own and had a contract with an overseas firm.
According to his mother, Mr Lee had never seemed to like to be physically close to other people. It is reported he became more socially withdrawn and started to spend most of his time in his bedroom. He stopped talking to his family and his dietary intake decreased. Mr Lee began wearing a hoodie over his head and ear phones listening to music. He blocked the entrance to his bedroom and began to use the window to enter or leave the room.
In January 2010, Mrs Lee discussed her concerns about her son with her general practitioner (G.P.). They decided to try to get Mr Lee to see another G.P. within the practice, experienced in psychiatric issues. Mr Lee refused to go to this appointment.
On 8 April 2010 Mr Lee collapsed at his residence and his mother took him to his G.P. and this provided an opportunity for him to be more fully assessed. From there he was transported to the RHH by ambulance. Whilst waiting to be seen in the emergency department he tried to abscond. He was restrained. After assessment Mr Lee was admitted to the psychiatric intensive care unit (PICU).
Whilst in this unit Mr Lee continued to be very withdrawn and tense. He communicated rarely and spent extended periods sitting outside his room in the corridor. Mr Lee was encouraged to eat as his nutritional intake had been very poor and he was in poor physical condition.
Later in the month Mr Lee began to make statements such as, "I need to be better to get home" and seemed to be making a gradual improvement with his medication and talking with staff.
On 20 April 2010 on returning from a visit to the general psychiatric ward, Mr Lee absconded. He was found later at the airport and returned to the hospital by Federal Police.
Mr Lee stayed on in the PICU but was allowed to have supervised leave with his mother which he seemed to enjoy. It was decided to transfer him to Mistral Place, which is a government-run in-patient mental health service facility located not far from the RHH. The purpose of admission to Mistral Place was to prepare him for discharge home and the aim was for this to occur about two weeks after transfer. On 28 April 2010 Mr Lee’s Continuing Care Order was cancelled and as a voluntary patient he was transferred to Mistral Place the following day.
Circumstances surrounding the death of Mr Lee:
On 30 April 2010 Mistral Place staff noted that Mrs Lee was tearful when she returned him to the unit after taking him on an outing and stated to staff that Mr Lee was "still not right", and had concerns that he was depressed.
On 1 May 2010 Mr Lee went out with his mother, returning just before lunch. At lunch time a friend came to visit Mr Lee and took him out for lunch. The friend stated that he was concerned about Mr Lee as he had confided that he felt ‘couped up’ and wanted to go for a walk on his own. Mr Lee’s friend suggested that they return to the unit which they did.
At 2:00pm that afternoon, a ‘Clinical Risk Assessment’ was carried out and it stated that he was not at risk of self harm but was at mild risk of unintentional self harm.
At about 4:00pm Mrs Lee took Mr Lee home for dinner. Once at home he went to his bedroom with his earphones on and his hood over his head. After being told his dinner was ready he eventually came out of his room. Once in the kitchen he picked up Mrs Lee’s car keys and said, "I think I might go for a drive". He left the house and sat in the car but Mrs Lee also got into the car. She tried to talk him out of going out and to return inside for dinner. He appeared to agree to this and began returning to the house. Mrs Lee entered the house via the laundry door, believing he was using the front door. By the time she walked into the kitchen she saw Mr Lee driving away. She immediately telephoned the Mistral Place unit at 6:10pm to inform them Mr Lee had absconded from the house, and also called police.
About an hour later the police attended Mrs Lee’s home and advised that her son had been observed jump from the Tasman Bridge. Mr Lee had been observed, by an off-duty marine policeman, to stop the vehicle he was driving in the middle of the Tasman Bridge, exit the vehicle, mount the railings and jump off.
Just after 7:10pm on 1 May 2010, Mr Lee’s body was found by a passing vessel in the Derwent River.
The medical care for Mr Lee:
Mr Lee had an 18 month to two year history of becoming increasingly isolated and withdrawn.
Dr Jonathan Lane, Psychiatric Registrar at the RHH, has provided a detailed and thorough description of Mr Lee’s medical presentation and clinical course whilst an in-patient in the PICU. He states that throughout Mr Lee’s admission he was consistently assessed as having low risk for self harm or suicidal thoughts/ideation. Mr Lee had agreed to stay on the medication Olanzapine but frequently expressed a desire to go home.
Dr Lane handed over Mr Lee’s care to the Mental Health ‘Eastern Team’ of Dr Michael Evenhuis and his registrar Dr Bowe on 29 April 2010 when Mr Lee was transferred to Mistral Place. He stated that "a summary of care was given by telephone call, and a comprehensive discharge summary accompanied Duncan with his admission history, treatment, and ongoing management plan."
Dr Lane was informed on 3 May 2010 that Mr Lee had committed suicide. He states, "This was a shock, as Duncan had appeared to have been doing very well in his recovery process."
A family meeting was arranged including Dr Lane and this was held on 4 May 2010. Dr Lane states,
"The meeting lasted for nearly an hour and we discussed Duncan’s care, and Duncan himself. Gillian expressed on several occasions that she was grateful and pleased with the care Duncan had received here, and that she felt his suicide was a tragic event that she had not been able to anticipate."
Dr Milford McArthur, Acting Director of the Department of Psychiatry at the RHH, provided an affidavit in which he gives a précis of Mr Lee’s psychiatric history including his presentation to the RHH. Once admitted Mr Lee "was assessed and reviewed regularly over the next twenty days by medical and nursing staff and there were a series of consultation with his family regarding diagnosis and treatment options."
Dr McArthur was also, until recently, in charge of the Psychiatric Intensive Care Unit.
Under a section of the statement entitled ‘Management Plan’ Dr McArthur discusses Mr Lee’s clinical course in the PICU. He states,
"Especially in the first week of his admission, Mr Lee displayed psychotic phenomena… As Mr Lee’s mental state improved over the next three weeks as evidenced by the patient becoming more reactive to staff, more able to converse with staff and appearing less suspicious and distressed, he had a series of transitions to the less restrictive ward, the Department of Psychiatry.
However, Mr Lee reported he did not like the more robust atmosphere in the Department of Psychiatry and it was decided to attempt rehabilitation to the step-down unit (Mistral Place) which had a quieter and less intrusive environment.
This plan was devised in conjunction with the patient and his family and included a visit to the Unit prior to the actual transfer."
Dr McArthur described the events of the day Mr Lee absconded and was eventually located at Hobart Airport. Mr Lee was returned to the PICU by police and Dr McArthur states,
"The patient was reviewed by medical staff immediately following his return and an assessment revealed no significant change in his level of risk or in his mental state.
Following this episode, there was a further family meeting where it was decided that the rehabilitation program would continue and there would be no repercussions or changes to the management plan.
The rationale for making on change to Mr Lee’s treatment plan was the result of an assessment including a review of risk plus the request and wishes of his family that the original plan proceed."
Dr McArthur states that a series of assessments and questions regarding self harm did not lead any of the medical or nursing practitioners to predict Mr Lee was a high suicide risk. Moreover, Mr Lee had frequent accompanied leave with his family to help him to re-integrate into his life. He states, "There was no obvious indication that he was at high risk of self harm. In particular, there was no evidence to suggest command hallucinations may have caused him to suicide."
Mr Lee’s Community Care Order was cancelled on 28 April 2010 and he was made a voluntary patient following discussion with him and as
"a result of the fact that he was now having so much leave and was agreeing to go to the less restrictive environment at Mistral Place in compliance with the Mental Health Act. The Mental Health Act requires that the patient be managed as a voluntary patient as preference."
As time progressed Mr Lee was deemed well enough to be transferred to Mistral Place and his regular leave was continued. Dr McArthur states,
"There was a formal transfer of care and the new Treating Team was expected to gradually form a treatment alliance with the patient over the next few weeks. Unfortunately, there was limited opportunity for the Treatment Team to form this alliance due to the tragic event occurring 48 hours after transfer."
Dr McArthur concludes his statement,
"In retrospect, I think it most likely that Mr Lee’s action occurred as he was improving in his mental state in that he may have regained some insight into how psychiatrically unwell he had been and that his prognosis with this very serious illness was uncertain.
The medical and nursing staff were greatly distressed to hear of Mr Lee’s death… Following Mr Lee’s death, staff from Mental Health Services have had face to face and telephone contact with Mr Lee’s mother, Mrs Gillian Lee, to express our condolences and distress and to attempt to answer questions that she had regarding her son’s admission and unexpected death."
In a report produced by Forensic Pathology Research Nurse, Libby Newman, the following was noted,
"Mr Lee’s case was discussed at the medico legal meeting held on 02.02.2011 between the coroner, coroner’s associates, forensic pathologists and research nurse. Mr Lee’s death was seen as unexpected and tragic".
Findings & Comments:
I am satisfied there are no suspicious circumstances surrounding the death of Mr Lee.
I am satisfied there has been a full and thorough investigation into the circumstances surrounding his death, including a thorough review of his medical care prior to his death. I accept the opinions of his treating medical practitioners that despite his diagnoses and the events within his life for a period of at least 6 months prior to his death, Mr Lee did not at any time give any indication that he planned to harm himself.
I am satisfied that no further investigations are required into the tragic death of Mr Lee.
I find that Duncan Joseph Lee died on 1 May 2010 in the Derwent River, Hobart in Tasmania, when aged 31 years. He was born in Hobart, Tasmania on 23 December 1978. He was a single man without dependents, and was unemployed at the time of his death;
Mr Lee died as a result of multiple injuries and drowning following a jump from the Tasman Bridge, Hobart. I find that this was a deliberate act sadly undertaken by this pleasant and polite young man with the intention of ending his life.
A complicating factor was his diagnosed condition of schizophrenia.
I conclude this matter by conveying my sincere condolences to the loving and caring family and friends of Mr Lee.
DATED: 29 June 2011 at Hobart in Tasmania.