Record of Investigation into Death

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Olivia McTaggart, Coroner, having investigated the death of Luke Dale RHODES

WITH AN INQUEST HELD AT the Coroners Court, Hobart in Tasmania on 3, 4, 8 April 2014 and 20 October 2014

Find That:

(a) The identity of the deceased is Luke Dale Rhodes;

(b) Mr Rhodes died in the circunstances described in this finding;

(c) Mr Rhodes died on 5 May 2012 in the Royal Hobart Hospital in Tasmania;

(d) Mr Rhodes’ death was due to intravenous injection of crushed Ritalin tablets;

(e) Mr Rhodes was born on 25 June 1987 in Hobart, Tasmania and was aged 24 years at the time of his death;

(f) Mr Rhodes was in a de facto relationship with Cianna Lee Mabb and he was employed as an oyster farm hand; and

(g) No other person contributed to Mr Rhodes’ death.


Counsel Assisting the Coroner: Mr M Allen
Counsel for Ms Brockman and Mr  Prestage Mr: J McCarthy


On the afternoon of 5 May 2012, Luke Rhodes vomited and collapsed at his home. He reportedly told attending ambulance officers that he had taken possibly as many as 30 Ritalin tablets. Ritalin is the commercial name for the drug methylphenidate. He was not being prescribed Ritalin by a medical practitioner. Following his death on that day, a high therapeutic level of methylphenidate was found in Mr Rhodes’ blood. The post-mortem examination found that he died of acute methylphenidate poisoning. Later, approximately 13 Ritalin tablets were handed to police that had been found in a boxing bag owned by Mr Rhodes. Essentially, it was clear at that time that Mr Rhodes’ death was attributable to his illicit use of Ritalin. 

During the investigation, various accounts were given to investigating police by those people who had contact with Mr Rhodes in the days preceding his death. Those accounts included those of Mr  Prestage and Ms  Brockman, who admitted they had previously been involved in selling Ritalin to Mr Rhodes that had been lawfully prescribed to their daughter. They were charged and pleaded guilty in the Hobart Magistrates Court to drug trafficking, but this did not account for the amount of Ritalin said to have been used by Mr Rhodes prior to his death, or that were later found in his boxing bag.

Additionally, on the morning of Mr Rhodes’ death, Ms Brockman reported a burglary occurring overnight at her home in, Midway Point, during which an almost full box of 100 Ritalin tablets was alleged to have been stolen. No person was identified by the police as being responsible for these crimes.

Coincidentally, the investigation established that Mr Rhodes had gone missing in the early hours of 5 May 2012 (the day of his death) after he had left an informal function at a friend’s house in Midway Point. The absence of Mr Rhodes during the time the burglary and theft of Ritalin tablets was reported a short distance away in Midway Point raises obvious questions regarding his knowledge of and or involvement in either the burglary, or subsequent receiving of the stolen Ritalin.

When Mr Rhodes finally arrived home at around 4:00am on 5 May 2012, he had blood on his clothing, and reported to his fiancée, Cianna Mabb, that he had been involved in an altercation at the Midway Point hall with two men, being Mark Crocker and Aaron Busch. He said to Ms Mabb that he had been teasing Mr Crocker, and that Mr Busch had punched him in the nose. When spoken to by police following Mr Rhodes’ death, both Mr Crocker and Mr Busch denied any assault or even seeing Mr Rhodes on the morning of the day of his death. They also both denied any knowledge of where Mr Rhodes might have obtained the Ritalin used in his death, including any involvement or knowledgeof the burglary at Ms Brockman’s house.

In all of these circumstances, I determined the need to hold a public inquest in order to determine, if possible, the factual circumstances of, and leading to, Mr Rhodes’ death, including:

a) Where, from whom, and the circumstances by which Mr Rhodes obtained the Ritalin  that he used prior to his death;
b) The identity of any person who either provided Ritalin to Mr Rhodes or assisted him to obtain the Ritalin used in his death; and
c) Whether the actions or involvement of any other person caused or contributed to Mr Rhodes’ death.

Given the evidence in the investigation that Ritalin that had been lawfully prescribed to a child was being diverted by her parents to Mr Rhodes and others, I also determined it necessary to examine the following further issues in the inquest:

d) Whether the prescription of Ritalin to Ms Brockman’s daughter was consistent with accepted medical practice and appropriate in all the circumstances;
e) The extent to which the illicit diversion of lawfully prescribed Ritalin is a problem in the community; and
f) What can be done to prevent or limit the illicit diversion of prescribed medications such as Ritalin in order to prevent deaths associated with its non-prescribed use?


At the commencement of the inquest I received a number of affidavits from those close to Mr Rhodes, including his fiancée, Ms Mabb, and mother, Debbie Rhodes. Much of the background was uncontentious and allows me to make the following findings.

At the time of his death, Mr Rhodes was living together with Ms Mabb and their 23 month old son, at  First Avenue, Midway Point.

Mr Rhodes grew up in the suburb of Midway Point, attending the Sorell High School as part of the HARK (Helping At Risk Kids) programme, which was designed to keep Mr Rhodes at school. At the age of 16 years he left school. He then worked in a variety of jobs, including washing cars, grape picking, oyster splitting, seafood processing, delivery driving and strawberry picking.  He held these jobs for relatively short periods of time before moving onto the next and was sometimes unemployed between jobs. At the time of his death Mr Rhodes was working at an oyster farm, harvesting oysters.

Mr Rhodes had been in a relationship with Ms Mabb for approximately 4 years. Ms Mabb was 8 months pregnant with their second son. On 6 January 2012 they had become engaged to marry.  Mr Rhodes’ relationship with Ms Mabb was somewhat unstable and they would separate for short periods, before reconciling. Mr Rhodes would stay with his mother, Debbie Rhodes (Mrs Rhodes), during these times.

Mrs Rhodes and Ms Mabb, along with other family and friends were aware of Mr Rhodes’ illicit drug use.  Mrs Rhodes states he had told her that he had been injecting ‘speed’ and ‘dexys’ (dexamphetamine -  a controlled psycho stimulant drug similar to methylphenidate) since he was 16 years old. Ms Mabb indicated that during the early stages of their relationship, Mr Rhodes used speed and Ritalin as often as he could. However his drug use reduced, and then stopped completely, when she became pregnant with their first child.

Ms Mabb states that in April 2012, whilst at a party, Mr Rhodes was given speed, which he injected into his left arm. She states that it was his practice to also administer 5 Ritalin tablets at any one time by crushing the tablets and placing them into a syringe. He would then use boiling water to dissolve the crushed tablets before injecting the solution into his arm. As will be discussed further, this method of administration is inherently dangerous.

Circumstances Surrounding Death:

I will initially deal with an overview of the uncontroversial circumstances and then analyse the evidence at inquest in the areas that require detailed findings.

At 3.00pm on Thursday 3 May 2012 Mr Rhodes returned home after a day at work. He and Ms Mabb had an argument over his friend, Mr Hallett, staying at their house. Mr Rhodes left at 4.30pm to have ‘after work’ drinks at a fish processing factory with his friends Mr Wiggins and Mr Hallett. Mr. Wiggins was in fact the employer of Mr Rhodes. All three then went to Mr Wiggins’ house in Midway Point where they continued to drink and play darts.

Some time after 8.00pm Mr Rhodes and Mr Hallett walked to Midway Point where Mr Rhodes purchased between 10 and 15 Ritalin tablets from MrPrestage and Ms Brockman.  He paid between $15.00 and $30.00 for the tablets in total.

They returned to Mr Wiggins’ house. Mr Hallet states, and I accept, that he and Mr Rhodes used the Ritalin in the shed. He says he thinks he had five tablets and Mr Rhodes had ten, although his memory about this was affected by his intoxication and they may have had five tablets each. He said that Mr Rhodes snapped the tablets in half and placed them in the barrel of a syringe, before hot or warm water was drawn into the syringe to dissolve the tablets. Mr Rhodes then injected the substance into his left arm. The process was then repeated, with Mr Rhodes then injecting Mr Hallet with the dissolved Ritalin solution. This was about 10 or 11pm in the evening, and at that time only he and Mr Rhodes were present. Mr Wiggins was not there, having gone to either cricket or football training. There is in fact no evidence that Mr Wiggins was involved in or witnessed the use of Ritalin that evening. Mr Rhodes and Mr Hallett continued to drink until 1.00am.  Mr Rhodes sent a text message to his workplace advising that he would not be at work in the morning.

Mr Rhodes arrived home at 1.30am in a drunken state. Ms Mabb remembers Mr Rhodes coming home with a can of beer in his hand which she took off him. Later that morning Ms Mabb found a fresh needle mark in his arm. They had an argument about him drinking and using drugs and Ms Mabb reminded him that they had a baby on the way. Mr Rhodes told her that he and Mr Hallett had been down to Moony’s (Mr Prestage) and brought Ritalin and that they had five each.   He lay on the couch and then passed out. 

On Friday 4 May 2012 Mr Rhodes did not go to work. He made arrangements to extend an existing loan by $700 - $900 before going shopping at Eastland’s Shopping Centre with Ms Mabb, Mrs Rhodes and his son..   They made purchases in preparation for the expected baby with Mrs Rhodes estimating that Mr Rhodes would still have several hundred dollars left of the loan amount.

Later in the afternoon of 4 May 2012 Mr Rhodes returned to Mr Wiggins’ house and spent the evening drinking heavily. Ms Mabb and her son attended for a short time but returned home before dark.  By late evening Mr Rhodes was vomiting.  At around 1.00am Ms Mabb awoke and telephoned Mr Rhodes brother who was at the same address. He stated that Mr Rhodes was vomiting.  Ms Mabb went to collect him. However Mr Rhodes left before Ms Mabb arrived to collect him.

Ms Mabb then went looking for him around the streets in Midway Point, and at his grandmother’s house. Ms Mabb estimates that she was looking for him for about an hour. Mr Rhodes eventually got home at around 4:00am. When he first came home she noticed that he had blood on his top and sleeve. He said that Aaron Busch had “jobbed him”. Mr Rhodes told her that he and Mr Crocker were meant to be mates and that he was “shit stirring him” and called him a ‘goose’ or something similar and that Mr Busch had hit him. Mr Rhodes then said: “Then Crocker started on me, would have done something about it but didn’t want to get hit by two people.” Ms Mabb said that Mr Hallett was asleep at this time. She thought that Mr Rhodes seemed ok, just a bit drunk. She said that he didn’t want to lay down and go to sleep, which made her think he had taken something. She went to bed and sent him a text message while he was in the bath and asked him what he had taken. He said “nothing”, but then she asked him to swear and he said that he had taken something but that he hadn’t “paid for it or shot it up”. Ms Mabb thought it was a bit unusual that he had not injected, but didn’t think he was being dishonest. She said Mr Rhodes told him that it was given to him at the pub by a person called Monty but her evidence was that this didn’t seem true to her as she was told by Mr Rhodes’ brother that ‘Monty’ wasn’t a person who was involved in that type of thing.

Between 3.30pm on Friday 4 May 2012 and 10.00am on Saturday 5 May 2012 Ms Brockman discovered that her home at Midway Point had been broken into. At 10.30am she reported to police the burglary and stealing of a packet of Ritalin tablets (90 x 10mg) that were prescribed to her daughter.

At 3.00pm on 5 May 2012 Mr Rhodes collapsed in the hallway of his home. Ms Mabb thought at that point that he was having an asthma attack and put his son’s nebuliser mask on his face. She said she made him keep it on  strapped around the face. She reported seeing his arm while the ambulance officers were there, describing it as “an absolute mess”. She thought he was hung over; “he was like a bear with a sore head a bit”.  Ms Mabb said that he had been hit in the nose and it had been bleeding but recalled no other injury.

Mr Rhodes was conscious but struggling to breathe and an ambulance was called.  Around 3.31pm Ambulance Tasmania personnel arrived and Intensive Care Paramedic, Stephen Riley, noted Mr Rhodes sitting on the floor, against the wall in the hallway, complaining of chest and abdominal pains. Mr Rhodes admitted to Mr Riley that he had been self-injecting crushed Ritalin tablets into the vein in his right arm intermittently over the last 24 hours. He estimated that he had injected approximately 30 x 10mg tablets over that period of time, with the last administered at 2.00pm that afternoon. Ms Mabb also overheard Mr Rhodes say that he’d had too many drugs and had injected about 30 Ritalin tablets.

Mr Rhodes was transported to the Royal Hobart Hospital, arriving at 4.12pm. Medical staff continued his treatment. However his condition rapidly deteriorated and he went into cardiac arrest at 4.30pm. Medical intervention was unsuccessful and he was pronounced deceased at 5.34pm.

A post mortem examination was conducted by forensic pathologist, Dr Donald Ritchey on 7 May 2012. He determined that Mr Rhodes died as a result of acute methylphenidate toxicity, due to intravenous injection of crushed Ritalin tablets.

“The probable mechanism of death was cardiac arrhythmia complicating peripheral vascular failure caused by microcrystalline cellulose within small blood vessels. This foreign material would have blocked the normal blood flow to many tissues and caused widespread hypoxic injury resulting in the clinical symptoms of chest and abdominal pain prior to cardiac arrest and death.”

Dr Ritchey further explained that “microcrystalline cellulose is used as a binder in many different tablets, and is often seen in the lungs of people who crush tablets of any kind and inject them. Ritalin (methylphenidate) is popular by this method but also alprazolam (Xanax) and others (oxycodone and opiod pain relievers). The common theme is not the drug/s but the inert substances used to bind it all together in pill form (microcrystalline cellulose) that causes the problem in the lungs.” Dr Ritchey notes that while it is, of course, possible to die from an overdose of these drugs by this method, this does not appear to be the cause in Mr Rhodes’ case.

I accept the opinion of Dr Ritchey and find that Mr Rhodes died as a result of acute methylphenidate toxicity due to intravenous injection of crushed Ritalin tablets. There is no evidence that even if he was the subject of an assault in the early hours of 5 May that this played any part in his death. Dr Ritchey saw no evidence of assault on the autopsy.

Police officers searched Mr Rhodes’ residence that evening.  However no evidence of drugs or drug use was found. Further enquires revealed that Mr Hallett and his brother Leigh Hallett  went to Mr Rhodes’ residence and removed blister packets of Ritalin and a syringe, from a boxing bag in the carport. They later surrendered the tablets and syringe to police, explaining that they had removed the drugs before they could be found by Ms Mabb.  Subsequent forensic examination located only the DNA of Mr Rhodes on the syringe, plunger and needle.  The surrendered Ritalin consisted of 2 different sized blister packs, the larger packet could hold 20 tablets, with 16 missing, and the smaller blister packet was full and contained 10 tablets.

Ms Brockman and Mr Prestage were interviewed by police in relation to selling Ritalin tablets to Mr Rhodes and the stealing of Ritalin tablets from their house on 5 May 2012. Both Ms Brockman and Mr Prestage made admissions to selling Ritalin to Mr Rhodes.  Ms Brockman pleaded guilty in the Hobart Court of Petty Sessions on 9 July 2012; she was convicted and fined $750.00. Mr Prestage pleaded guilty to selling a controlled drug. On 2 August 2012, in the Hobart Court of Petty Sessions he was convicted and sentenced to 14 days imprisonment, wholly suspended on the condition that for 9 months he not commit another offence punishable by imprisonment. Ms Brockman and Mr Prestage both maintained in the interview, and in their evidence at inquest, that the subsequent burglary occurred as reported.

At inquest I heard oral evidence from Mr M Hallett, Ms Mabb, Mr L Hallett, Mr Wiggins, Mr Crocker, Mr Busch, Ms Brockman and Mr Prestage. In general terms I was able to place reliance upon the evidence of Ms Mabb, Mr Wiggins, Ms Brockman and Mr L Hallett on the significant issues. Their accounts were coherent and given in an honest manner, and with one significant exception, accorded with their original affidavits. The evidence of Mr Crocker and Mr Busch was inconsistent and against the weight of all other evidence. Their evidence was hostile and in key parts, I find, fabricated. Mr Prestage’s evidence was weak and unreliable, although in general accorded with the evidence of Ms Brockman surrounding the sale of Ritalin and the burglary.

In relation specifically to Mr M Hallett’s evidence, at inquest he conceded that his original affidavit did not contain details of his knowledge of Mr Rhodes’ use of Ritalin on the Thursday evening preceding his death. It also omitted details of his own drug use, including being injected with Ritalin by Mr Rhodes. Critically, Mr M Hallett’s evidence at inquest that Mr Rhodes had committed the burglary at Ms Brockman’s home and stolen Ritalin was a substantial omission from his original affidavit. When asked about these major omissions Mr Hallett said he did not put this information in his original affidavit as he “was just scared about what was going to happen.” He added that he had never been involved in “something like this” and was scared about disclosing his own use of drugs, describing it as not something he either should have been doing or of which he should be proud. In giving this evidence at the inquest he said he was being honest because “they deserve the truth about what happened.” Mr Hallett stated that he no longer uses drugs. Mr Hallett’s evidence, despite the omission from his original affidavit, was plausible, contained specificity, was consistent with the other credible evidence and was against his own interest. I accept his oral evidence.

I will proceed, in light of this assessment to deal with the factual issues for resolution under respective headings.

Where, from whom, and the circumstances by which Mr Rhodes obtained the Ritalin (methylphenidate) that he used prior to his death?

I firstly find that, accepting Mr M Hallett’s evidence, that the fatal dose of Ritalin was not part of the Ritalin tablets that were purchased from Ms Brockman and Mr Prestage on the evening of Thursday 3 May 2012. The evidence clearly indicates that Mr Hallett and Mr Rhodes injected all of those tablets at the house of Mr Wiggins that same evening. When asked about Mr Rhodes buying Ritalin on the Thursday evening preceding his death, Mr Prestage said: “Apparently I was in the laundry and sold him pills. I thought I only sold him three but apparently I sold him more than that.” He denied it was as many as 30, but conceded he had an extremely poor memory of events. Mr Prestage said he didn’t know whether he had sold Ritalin to Mr Rhodes on any other occasions, but conceded he could have. Mr Prestage’s evidence was most unsatisfactory, and he had an extremely poor memory. He could not assist the inquest to any significant degree. All the evidence indicates that the amount of tablets sold that evening was about ten to fifteen.

The evidence, when analysed as a whole, allows me to find that the Ritalin tablets that caused Mr Rhodes’ death came from those taken from Lake Vue Parade between Friday night and Saturday morning, being during the burglary reported by Ms Brockman. Before the testing of witnesses at the inquest, there were several possibilities regarding the alleged burglary. They were as follows:

1. That the burglary was “staged” by Ms Brockman and Mr Prestage, possibly to cover up for an illicit sale of a large number of Ritalin tablets or to obtain more supply;
2. That Mr Rhodes, knowing that there was a source of supply of Ritalin at the address, broke into the address, either by himself or with others and stole the tablets; or
3. That the burglary was coincidental and unknown third parties not associated with Mr Rhodes were responsible.

(a) The burglary

I find that Mr Rhodes was responsible, possibly in conjunction with Mr Crocker and/or Mr Busch, for the burglary. My reasons follow.

When Mr Hallett woke on Saturday morning, sometime around 9.00am, Mr Rhodes told him that the previous night he broke into ‘Moony’s’ house when they were not home and took some drugs. Mr Rhodes told him that he went down to Moony’s to get some more Ritalin, but when they weren’t home he broke in, possibly by smashing a window. He said that Moony was texting him or possibly messaging on Facebook that morning. Mr Hallett said that Mr Rhodes seemed concerned and was asking him for advice on what he should do as it seemed that ‘Moony’ may have known that it was him who had broken in. Mr Rhodes wondered if he should put a note in Moony’s letterbox to the effect that if he reported Mr Rhodes to the police then he would also be in trouble for ‘trafficking’ in drugs. Mr Hallett said he thought Mr Rhodes seemed a bit scared or concerned for his safety as a result of what he had done. Mr Rhodes did not tell Mr Hallet how much Ritalin he took in the burglary.

I accept the evidence of Mr Hallett that he was woken up when Mr Rhodes came home at 1.00am or 2.00am on Saturday 5 May, 2012. He said Mr Rhodes was really drunk and that he said that he had been punched in the nose. Mr Hallett was sleeping on a mattress on the floor in the lounge room. He recalled that Mr Rhodes told him that a person by the name of ‘Bushy’ had punched him in the nose. Mr Rhodes had explained to him that he had bumped into ‘Bushy’ and another person called ‘Crocker’ and that Bushy had punched him. Mr Rhodes said he was having a joke with Crocker when Bushy ‘arked up and punched him.’ Mr Hallett said that he had heard of Mark Crocker but never met him. He did not know anyone called ‘Bushy’. He recalled that Mr Rhodes had a jumper on and was wiping his nose with his jumper and noticed that there was blood on his jumper. He also said that Mr Rhodes told him when he got home that he was going to put the needle he injected himself with in the boxing bag.

In her evidence Ms Brockman explained that her bedroom is right next to the laundry and that Mr Rhodes and the other person (Mr Hallett) were able to see that she went into the bedroom to get the Ritalin. Mr Prestage also knew where it was kept, but no-one else to her knowledge, although she suspected Mr Crocker knew. The medication was not hidden, but just sitting in the wardrobe. Ms Brockman said ten tablets were sold to Mr Rhodes, who paid $30. Ms Brockman used the money to buy bread, milk and soft drink.

Ms Brockman adamantly denied falsely reporting the burglary. She accepted that it looked “strange, odd”. Ms Brockman said that the burglary was reported on the morning of 5 May 2012, before Mr Rhodes’ death. She had received a call about 9:30am on the Saturday from a neighbour to report her smashed windows. She got home at 10.00am and found “my bedroom window smashed and son’s scooter broken. Other lounge room window had been smashed. Blood on bedroom window. I was trying to keep my daughter away from glass. Dwayne’s sister rang police; they came about an hour later.” Ms Brockman said she also rang Helen at the Chemist and cancelledher daughter’s script, and later told Dr Whitelaw that she didn’t want her daughter on it any more.

Ms Brockman said she thought Mr Crocker was responsible for the burglary. “We’d had some arguments before and my cousin broke up with him and he had said some things. I thought Crocker had done this to get back at me.” She said the other person she thought might have been responsible was a Mr Leonard because he had a reputation in the area for burglaries and drugs. She didn’t think it would have been Mr Rhodes.

When asked about the reported burglary at Lake Vue Parade the investigating officer Constable Hinchen said the case “was eventually allocated to me for investigation.” He received the original police offence report that described the outcome of the investigation as: “DNA from blood tested from one of points of entry which was a smashed window, no person identified.” He said that no offender had been identified in relation to the offence.

Constable Hinchen said he was aware of the allegation that Mr Crocker and Mr Busch had met up with Mr Rhodes on the morning and that Mr Busch had assaulted Rhodes. As part of the investigation he said he spoke with the partner of Mr Busch, whose name he could not recall. Constable Hinchen said that she supported his version of events. He did not speak with Mr Crocker’s partner about his alibi.

Constable Hinchen said he was not able to identify any other suspected or known suppliers of Ritalin in the Midway Point area. He said the only known source of Ritalin at the time known to him was Ms Brockman at Lake Vue Parade.

When asked about the burglary at Ms Brockman’s house, Ms Mabb said she became aware of it when she went through Mr Rhodes’ phone. She saw that he had written to Moony and said “Are you home mate, can I grab some more Ritalin off you?” Moony had texted back to him the next morning and said something about his house being broken into.

In summary I find that Mr Rhodes was involved in the commission of the burglary for the following reasons:

o Mr Rhodes’s movements are unaccounted for in the period of time when it may have occurred;
o He used Ritalin and had recently purchased it;
o He admitted to his trusted friend Mr Hallett that he was responsible;
o His knowledge of Ritalin being at the premises as Ms Brockman told him she had a new supply;
o Text messages from him to Mr Prestage asking for Ritalin  – these were seen by Ms Mabb and Mr Prestage; and
o It is unlikely that the burglary is a fabricated account in the circumstances of the damage.

(b) Involvement of Mr Crocker and Mr Busch in the burglary

Mr Rhodes’ account of the assault by Mr Crocker and Mr Busch is corroborated by Mr Hallett to whom Mr Rhodes made similar statements. I find that there was some form of acrimonious physical contact between Mr Rhodes, Mr Crocker and Mr Busch resulting in a minor injury accounting for the blood seen by Mr Hallett and Ms Mabb on his nose and jumper when he returned home. The time of returning is uncertain but likely between 2.00am and 4.00am.

The evidence does not allow a finding about the exact circumstances of the meeting or any involvement in the burglary or the receipt of proceeds of the burglary.

Mr Crocker said he had known Mr Rhodes for about ten years, having grown up and lived in the same area as him. Mr Crocker also knew of Ms Mabb, having met her at a Matthew Bester’s house at Main Road in Sorell. Mr Crocker said that this was the last time he saw Mr Rhodes and that was about 8 months before his death. He claimed that he had always remained on good terms with Mr Rhodes, and there was no problem or ongoing issue between them.

Mr Crocker also gave evidence that he knew Mr Busch and had done so for six or seven years. Mr Crocker also said that Mr Rhodes knew Mr Busch and that they met through him and became friends “maybe five or six years ago”.

In relation to the events of 5 May 2012, Mr Crocker said that he was aware through Facebook of an allegation that he was involved in an altercation with Mr Rhodes. He vehemently denied that it happened, and denied seeing Mr Rhodes at all on that night, saying he was at home with his girlfriend and their three children. Mr Crocker said that he did see Mr Busch earlier that day when he came to his house, maybe around 1:00pm. He said that Mr Busch was driving a maroon Subaru sedan and they went for a drive to see a friend Ms Baker in Bridgewater and then Mr Busch dropped Mr Crocker to his home at around 3:00pm as the children were coming home from school. They drove on the Tasman Highway and Brooker Highway in both directions. He did not recall going anywhere else.  He said that they found Ms Baker wasn’t home and so travelled straight back to home at Ash Street. He said that his partner Ms Briers was home and that the next time he left home was the next day but he couldn’t recall the time.

Mr Crocker was challenged regarding the contents of his affidavit stating that on the Friday he went to the Granada Tavern at Claremont and also to his father’s work in Glenorchy. His affidavit said that he was home at 6:00pm that evening. Mr Crocker said “I forgot to mention that we called into the Granada.” When asked about there being no mention of Bridgewater or going to see Ms Baker in his affidavit he replied “there should have been.” Mr Crocker claimed he told police who took his affidavit that he went to Bridgewater but not for the reason’s Mr Crocker quite angrily said: “I haven’t done anything wrong; Luke was a good friend of mine.” He denied lying to police or the court.

Mr Crocker said he first became aware of allegation that he had been involved in an altercation with Mr Rhodes when his girlfriend showed him a posting on Facebook from “Cianna Mabb Luke Rhodes account.”  Mr Crocker said that he later got a call from Mr Bester and was told that Mr Rhodes had passed away.

 Mr Crocker denied meeting Mr Rhodes in the early hours of 5 May 2012, and denied even being in the area. He maintained that he was at home. He said he knew of no reason why Mr Rhodes would lie about this incident and said “that’s why it is so mind boggling to me, because it didn’t happen.”

Mr Crocker denied any knowledge of Mr Rhodes using Ritalin or of using or buying Ritalin himself. He admitted that he knows both Ms Brockman and Mr Prestage and where they live on the Esplanade at Midway Point. Mr Crocker said he is friends with Mr Prestage and used to visit his house when he lived at Midway Point.

It was put to Mr Crocker that Ms Brockman said she previously sold him Ritalin tablets. Mr Crocker said that this was a lie and denied that it happened. He said: “I can’t see why somebody would write that.” It was put that Ms Brockman said in relation to him previously purchasing Ritalin from her: “Pretty sure Crocker only got five.”  Mr Crocker replied: “None. Zero.” Somewhat confusingly, Mr Crocker then said “Miss Brockman is lying to cover her own bottom; I don’t know why she had to mention my name in this. I don’t know why they would say that I’ve brought them off them when I haven’t.” Mr Crocker denied knowing that Mr Prestage used drugs at all, but admitted he was a drug user and had previously been hospitalised for his own drug use.

Mr Crocker said that he had heard about the burglary at Ms Brockman’s house via Facebook and was aware Ritalin had been taken. He denied responsibility for the burglary or any knowledge of who committed it. He also denied receiving any proceeds from it.

Mr Crocker denied having any motivation to lie due to his alleged presence at an assault on Mr Rhodes before his death and also his alleged involvement in the illicit use of Ritalin.

His evidence was inconsistent, aggressive and inherently implausible, and against the evidence of other credible witnesses.

Mr Busch denied seeing Mr Rhodes on that morning, and became angry in his denials when Mr Rhodes’ version was put to him. Mr Busch repeatedly demanded to see video surveillance from Midway Point Service Station to prove he was there. Mr Busch said that he also doesn’t have any knowledge of what Mr Crocker did on that night and that he did not see Mr Crocker on that night.

Mr Busch said he was told by police that Mr Rhodes’ death may have been due to his use of dexamphetamine. “As far as I knew he died from an overdose.” He added: “If someone hit him it wasn’t me.” Mr Busch denied being concerned that Mr Rhodes’ death was because of an injury from the alleged assault.

He gave an inconsistent, implausible and vacillating account of the period of time he was alleged to have spent with Crocker earlier that day. There is no need to repeat it. I reject his denial that he was involved in an altercation.

In summary both Mr Crocker and Mr Busch were extremely unimpressive witnesses. I find that they did have a physical altercation in the Midway Point area as alleged by Mr Rhodes to two credible witnesses.

However the evidence does not allow a finding about exact circumstances of this meeting or any involvement in burglary or receipt of proceeds. It is quite possible that they acted jointly with Mr Rhodes in the burglary. It is quite possible that the altercation related to the Ritalin that was taken from Lake Vue Parade. In this regard I note that Mr Rhodes likely obtained 30 tablets being a one third share of the total of 90 tablets stolen.

In summary I find that:
(a) Mr Rhodes was involved in the burglary of the 90 Ritalin tablets from Lake Vue Parade;
(b) The Ritalin that caused his death was that stolen from Lake Vue Parade;
(c) I cannot find to the requisite standard that Mr Crocker and Mr Busch were involved in the burglary;
(d) I cannot find that any assault committed by either Mr Crocker or Mr Busch contributed to Mr Rhodes cause of death;
(e) Ms Brockman and Mr Prestage did not supply Mr Rhodes with the Ritalin that caused his death;
(f) Mr Rhodes voluntarily chose to inject himself with a solution made by crushing a large number of the Ritalin tablets and there is no evidence that any other persons assisted him; and
(g) Mr Rhodes did not intend to cause his own death by the administration of Ritalin.


Ms Brockman’s Daughter’s treatment and illicit Diversion of Ritalin

Before I commence this section of the finding, I record that Ms Brockman’s daughtermost tragically and unexpectedly passed away on twentyfifth and twentysixth October 2014. Her death is still the subject of a coronial investigation. However the preliminary finding of the forensic pathologist is that she died of natural causes.  I convey my most sincere condolences to Ms Brockman, Mr Prestage and their family.

Ms Brockman gave evidence that her daughter had autism spectrum disorder (which she said was moderate to severe) and developmental delay. Her daughter is 8 years old now. She was diagnosed at three and a half years. At inquest Ms Brockman said that she has three other children. None of the other children have this disorder.

Ms Brockman said she became concerned about her daughter saying that she had bad tantrums, avoided eye contact and had no speech. She said that eventually her daughter was referred by general practitioner Dr David Ridgers to see paediatrician Dr Charlotte Whitelaw at Calvary Hospital and later at the Royal Hobart Hospital.

Ms Brockman said the process of diagnosis took seven visits, and that her daughter had to see an occupational therapist, speech therapist, psychologist, and the paediatrician over about a six month period. Ms Brockman said that treatment with Ritalin commenced when her daughter was a little over four years, but that medication wasn’t commenced straight away “because I know what Ritalin is and what it can do and I didn’t want it in her body.” Ms Brockman said that in the end her daughter’s tantrums got too much and she agreed to trial Ritalin, which she understands to be “speed”. Ms Brockman candidly revealed that she was aware what it can do because she herself used to take it without a prescription.

Ms Brockman said Dr Whitelaw suggested treatment with Ritalin at the time of diagnosis. She said the choice was either “that or intensive therapy and I couldn’t afford $350 per hour for that.” She explained that up to age of seven Autism Tasmania has some money for funding but that she couldn’t afford intensive therapy. Ms Brockman said she initially said no to Ritalin, but later changed her mind. She explained that the Ritalin was used to slow down her “brain pattern” enough to allow her to concentrate on one thing at a time.

When asked about the external support provided , Ms Brockman said that Autism Tasmania bought her an iPad (which she said had applications that were very helpful) and there was about $12,000 worth of therapy but that she didn’t use all of this. Ms Brockman said that they also got her a trampoline, a pressure vest and a weighted blanket, but the support stopped when her daughter turned seven. Ms Brockman said speech therapy didn’t last very long.

When Ms Brockman’s daughter started on Ritalin it slowed down her tantrums, but otherwise Ms Brockman did not notice much change. When the Ritalin was stopped just after the burglary at her home Ms Brockman said “it wasn’t nice. She got sick, wouldn’t eat, got plenty of holes in my walls.”

Ms Brockman described her daughter’s tolerance as being quite poor, saying that she used to crush the tablet and put it on yoghurt or dilute it and that sometimes she would “go through a few just trying to get one in her.” Ms Brockman conceded that there were occasions where she wouldn’t take it and other occasions where they wouldn’t try to give it, particularly when her daughter’s asthma was bad. She said the dose was 10mg twice a day dispensed in packs of 100 every two months. Ms Brockman said they wouldn’t usually run short, and never ran out.

When asked what would happen to any leftover Ritalin Ms Brockman confessed that she would take them while others were sold. Left over tablets would be put in the laundry cupboard. Medication for her daughter was kept either in the wardrobe in Ms Brockman’s bedroom or in one of her bedroom drawers.

Ms Brockman explained that before diagnosis her daughter simply didn’t speak. She also wasn’t good with social interaction but has since improved and now gives eye contact and plays chasings with other children. Also, her daughter was aggressive, sometimes violent and was obsessed with drawing. Ms Brockman commented that her daughter likes routine, and that they often experienced tantrums when the routine changed.

Regarding available alternative therapies, Ms Brockman said her daughter  had speech and occupational therapy, and saw a psychologist. She said that she didn’t think visual cards were working, and that speech therapy stopped. Occupational therapy was continued through school (in grade 2).

Diversion of Ms Brockman daughter's Ritalin by Ms Brockman and Mr Prestage

Ms Brockman said that Mr Prestage is the father of her daughter and of her other children. She said Mr Prestage played games with their daughter but otherwise had nothing to do with the treatment of her condition. Mr Prestage would be at Lake Vue Parade more often than not even though he had another address. Ms Brockman also admitted that Mr Prestage would commonly take their daughter’s Ritalin, possibly three every few days. Ms Brockman said sometimes she would buy Ritalin from another person so she could swap it for marijuana.

Ms Brockman said that over a two year period Mr Prestage would take “a couple here and there, sell ten or so and the rest was her daughter’s. There was no pattern to it.” She said she didn’t use tablets during her pregnancy, but continued to use cannabis to which she was addicted. Both Mr Prestage and Ms Brockman would take it orally. She said that it kept her awake, and gave her more energy.

Mr Prestage estimated that he would have sold about 50 Ritalin tablets in total. He thought he might have used an additional 20 or 30 himself. He could not recall specifics, saying “it was too long ago.” Mr Prestage agreed he would have sold Ritalin to Mr Rhodes on more than one occasion, but could not say how often. Mr Prestage said he thought Mr Rhodes would take Ritalin orally. The account of his use and sale is likely to be significantly minimised by Mr Prestage.

Ms Brockman knew Luke Rhodes through Mr Prestage. They were friends and would have a drink together sometimes but not often. She had been living at Lake V ue Parade for about eight years. She knew Mr Rhodes liked to have the “occasional dab of speed for social purposes.” She knew that Mr Rhodes “likes tablets” because of Mr Crocker. Ms Brockman said Mr Crocker would get a lot of medication and come to her home where they would take it. Drugs such as valium, tramadol and seroquel. Ms Brockman met Mr Crocker about seven years ago. She described Mr Crocker and Mr Prestage as friends, who were involved in drug use together. She stated that she has seen Mr Crocker have Ritalin from her, “not very often, three times I think I sold to him; seven at the most.” Ms Brockman complained that sometimes Mr Crocker didn’t pay for the drugs he got from her. Ms Brockman was unequivocal that Mr Crocker was lying if he said he didn’t purchase Ritalin from her. She said that Mr Crocker didn’t hide his drug use from her, and that in her experience he usually says he loves Ritalin. She said that Mr Prestage has also sold Ritalin to him, but was not sure how many times. She admitted that sometimes they sold from  her daughter’s prescribed supply but also sold what they got from another supplier. There were occasions where Mark Crocker would ask to “tick it” where he would agree to pay later. On the last two occasions he didn’t pay. Last time Ms Brockman said she sold to him was 10 tablets in about February 2012, and would have cost $50 ($5 per tablet).

Ms Brockman didn’t think Mr Rhodes took Ritalin that often. She said he knew that Ritalin was readily available from her because she would tell him on Facebook. She recalled first providing it to him in the laundry at her home, and that Mr Rhodes had someone with him; it was just before his death. Ms Brockman said Mr Prestage said he had sold to Mr Rhodes before that. Christmas 2011 was the first time when she became aware Mr Prestage sold to both Mr Crocker and Mr Rhodes. She said: “I was really broke; children have birthdays at that time.”

When asked about the use of Facebook, Ms Brockman said Mr Rhodes had asked her on 29 April 2012 her if she had some Ritalin and she had replied that she wouldn’t have any until the middle of May. At the start of May she said she let him know that she had some Ritalin, being her daughter’s new supply. She was dispensed some at the pharmacy on the Wednesday and the following day. Thursday 3 May, she messaged Mr Rhodes to tell him that she had some to sell. Mr Rhodes visited that night with Mr Hallett. Ms Brockman said she was told by Mr Prestage to go and get ten. She said she got them from the bedroom out of her daughter’s new box, broke a sheet and took it out. She was certain that the drugs were not contained in a clear plastic snap-lock bag.  Ms Brockman explained that her bedroom is right next to the laundry and that Mr Rhodes and the other person (Mr Hallett) were able to see that she went into the bedroom to get the Ritalin. Mr Prestage also knew where it was kept, but no-one else to her knowledge, although she suspected Mr Crocker knew. The medication was not hidden, but just sitting up in the wardrobe. Ms Brockman said ten tablets were sold to Mr Rhodes, who paid $30. Ms Brockman used the money to buy bread, milk and soft drink.

Ms Brockman said that the Facebook postings from her account were all from her, as Mr Prestage didn’t know how to use Facebook. She knew Mr Rhodes shared his Facebook account with Ms Mabb, and was also aware that she didn’t like drugs. She commented: “I knew she’d find out anyway, I didn’t try and hide it.” Ms Brockman remembered Ms Mabb trying to find out if Mr Rhodes had been down to her place. She said: “I wasn’t going to dob on him.”

When asked about the other supplier, Ms Brockman said he was the one from whom she would buy extra Ritalin. She said: “So I’d swap his Ritalin for dope and he’d sit there and smoke it.” Ms Brockman thought the other supplier was 14 or 15 years old. He didn’t come round very often. She knew he was prescribed Ritalin from his doctor. She explained that the other supplier would give her ten (more or less) and swap it for cannabis which would cost her $25. “We would smoke it together. It was stupid, I didn’t really think about it at the time, being a drug addict. I was addicted to cannabis.” Ms Brockman thought the child’s grandmother would collect the script from which the supplier would be given his dose but wouldn’t take it. She doesn’t know how many transactions with the other supplier occurred, but said “if I told police it was four it must have been about that.” When asked what happened with those tablets, she said they were either sold or Mr Prestage took them. Mr Prestage confirmed that the other supplier provided him with Ritalin on a number of occasions. Ms Brockman agreed that this accounted for roughly between 24 and 40 tablets, but by comparison with her daughter’s prescription, was a relatively small amount. She agreed most of the Ritalin being diverted belonged to her daughter.

Ms Brockman said that her financial situation was quite desperate and that motivated her to selling drugs. After the burglary she said “I did not get any more tablets. I’ve never had them again since.”

Ms Brockman described Mr Rhodes’ death as having a sobering effect on her. She never saw him injecting drugs and said they would only take drugs orally at her house.

Ms Brockman and Mr Prestage made it known to others that they had Ritalin for sale at their residence; and they sold it to others, including Mr Rhodes. They are to be criticised for such practice, which had the potential to cause significant harm.

Evidence of Ritalin diversion in the community.

Constable Hinchen said he believed there was an issue with illicit sale of prescription Ritalin. In his experience he believes it is a sought after substance dispensed legally but often diverted to people who use stimulant drugs. He had dealt with other cases involving illicit diversion of Ritalin, but said that instances of diversion were dealt with on a “case by case basis”. He said that the police would receive a large amount of information about prescription drugs being diverted and so regarded it as a common problem.

In addition to the evidence of Constable Hinchen, I received an affidavit from Detective Sergeant Marco Cosentino, of Southern Drug Investigation Services. Detective Sergeant Cosentino agrees with Constable Hinchen, stating that:

“There is a history of abuse of Ritalin in Tasmania. Most commonly the parents of children who are prescribed with Ritalin may attempt to sell/share or trade other prescription drugs for an illicit drug of choice. Ritalin would not be considered a drug of choice for long term illicit drug users. I can indicate that there is no known street value for Ritalin in Tasmania. There is no current trend for abuse of Ritalin this drug would come under the attention of Drug Investigation Services very infrequently.

Ritalin is prescribed under carefully controlled conditions, if police become suspicious of cases of abuse; requests are made to Pharmaceutical Services for closer monitoring of dispensing. In many cases Ritalin is dispensed to the child at school on school premises. It is common prescription drug that is reported as stolen but again very infrequently.”

As discussed below, the two paediatricians providing evidence to the inquest also agree that misuse and diversion of Ritalin is a problem in the Tasmanian community.

Dr Charlotte Whitelaw

Dr Whitelaw is a paediatrician who had been involved in the care of Ms Brockman’s daughter since 2009. She initially saw Ms Brockman’s daughter at Calvary Rehabilitation Services as part of an Autism Assessment Team, and later at the Royal Hobart Hospital in the paediatric clinic. Her assessment of Ms Brockman’s daughter in April 2009 concluded that she met the diagnostic criteria for autistic disorder. Dr Whitelaw indicates that Ms Brockman daughter’s diagnosis followed ‘standard practice’ which can include repeated meetings with the chid to assess their social interaction, behaviours and language as well as assessment by other professionals such as psychologists and speech pathologists. Dr Whitelaw comments that Ms Brockman’s daughter also had Attention Deficit Hyperactivity Disorder (ADHD). She states that:

“In my consultations with her she was extremely active, roamed the room constantly, required an adult to shadow her at all times to keep her safe, and could not sit for any length of time to attend to a task or toy. Her mother said she could not be left in the care of another adult because she was too active.”

Dr Whitelaw indicates that her usual practice was to discuss early intervention options with the family at the time of diagnosis. She does not specifically remember doing it with Ms Brockman’s family, but it is clear that Ms Brockman was familiar with the options available to them when her daughter was diagnosed. Dr Whitelaw says that the early intervention funding option was not pursued by her family because according to Ms Brockman, “it was all too hard.”

In response to specific questions regarding her diagnosis and treatment of Ms Brockman’s daughter, particularly with Ritalin, Dr Whitelaw makes the following comments:

• She has no memory of Ms Brockman ‘being reluctant’ for her daughterto take Ritalin;
• In Ms Brockman’s daughter’s case, the trial of Ritalin was successful in that it had assisted to “decrease her high activity levels and poor concentration”;
• She was unaware that her parents were abusing Ritalin, that they were not giving their daughter the Ritalin that she prescribed  or that they were selling it to others;
• She recorded in April 2009 being aware that Ms Brockman used cannabis during her pregnancy with her daughter, but that Ms Brockman denied other drug use at that time;
• She held no concerns, while Ms Brockman’s daughter was under her care, that Ms Brockman’s recreational drug use meant that her daughter was not being properly cared for by her;
• She believes illicit diversion of Ritalin is a problem in the community, but that the extent of the problem is very difficult to know because of its nature. She comments that, understandably, paediatricians will normally believe parents in the absence of reasons not to do so. Also, she notes that concerns about diversion can be difficult to raise with a family because it potentially disrupts the relationship with them and affects the treatment of the child;
• A possible alternative in cases where diversion of prescribed medication is present or suspected is for school staff to administer the medication, but this relies on the cooperation of school staff and families; and
• Concerns about medication, such as it being dangerous if not taken in accordance with directions, should not result in a child being denied that medication if it is required as part of the treatment for the condition.

Dr Fiona Wagg

Dr Wagg is an experienced Child and Adolescent Psychiatrist. She was asked, as part of this investigation, to review and report on the specific issue of the adequacy of the medical treatment provided to Ms Brockman’s  daughterin this case, and also more broadly, to comment on issues relating to the problem of illicit diversion of prescription medication in the community and on alternatives to prescription of Ritalin.

I have received into evidence, a comprehensive report from Dr Wagg dealing with these issues. In relation to the medical treatment provided toMs Brockman’s daughter, Dr Wagg makes the following comments:

•  Ms Brockman’s daughter was prescribed Ritalin at the age of four years “for treatment of Attention Deficit Hyperactivity Disorder (ADHD) occurring as comorbidity with  her daughter’s primary diagnosis of Autistic Disorder;”
• Treatment of Ms Brockman/s daughter using Ritalin commenced eight months after her initial assessment, and after unsuccessful attempts had been made to engage both  daughter and her mother with early intervention services;
• In Dr Wagg’s opinion, Dr Whitelaw had correctly diagnosed Ms Brockman’s daughter with Autistic Disorder with comorbid ADHD symptoms;
• Dr Whitelaw acted appropriately in not prescribing Ritalin immediately upon diagnosis, but instead advising Ms Brockman of early intervention options. Such options include parent behaviour training and would have assisted Ms Brockman’s daughter if Ms Brockman and Mr Prestage could commit to them;
• The dose of Ritalin when prescribed was appropriate;
• Dr Wagg said “The effectiveness of other interventions in a child with Autism would have been limited. Prescription of Ritalin in this context is appropriate and within the parameters of accepted practice;”
• Dr Wagg comments that “[t]here is a strong evidence base for the effectiveness of Ritalin in treatment of ADHD in school age children; and an evidence base for the treatment of ADHD comorbid with Autism in school age children.” She notes that while Ritalin is not an effective treatment for the core symptoms of Autistic Disorder, by “improving a child’s capacity to settle and attend, Ritalin may enable the child to better engage in Autism specific therapies. Dr Whitelaw was clear in her notes that other treatment modalities available from early intervention services would be required to improveMs Brockman’s daughter’s  function in terms of her Autistic Disorder;”
• Dr Whitelaw’s treatment of Ms Brockman’s daughterwas appropriate, and notes that the failure of her  family “to engage with appropriate and available services compromised her treatment;”and
• In relation to the method of dispensing, Dr Wagg comments that use of cannabis is common in the community, and reported use by a parent would not normally lead to Ritalin not being prescribed to a child, or dispensed in a more restricted manner. Also, one reported incident of lost or damaged medication (as there was in this case) also does not on its own lead to the prescription being discontinued or dispensed in a more supervised or controlled fashion. I infer that Dr Wagg did not see anything in the material available to Dr Whitelaw that would have required a change in method of dispensing or more seriously, the cancellation of the prescription.

In relation to the issue of the diversion of prescribed medication, Dr Wagg makes the following comments:

• Diversion of stimulant medication in Tasmania is a significant problem, but need to be weighed against the impact of restricting prescriptions and dispensing methods on prescribed users; and
• Currently, one prescription allows supply of Ritalin for one month, taken in accordance with the prescription. Dr Wagg comments that one approach would be to impose a limitation on the quantity dispensed to all prescribed users, but notes that this would inconvenience the majority who use the medication as directed. Alternatively, Dr Wagg suggests guidelines could be established requiring smaller quantities to be dispensed where there is evidence of such features as a history of substance abuse, or a single occurrence of lost or damaged medication requiring a further dispensation. To be effective, such guidelines require truthful information to be provided to the prescribing doctor, and the cooperation of the school who might be involved in dispensing medication to children.

In respect of alternative treatments to Ritalin, Dr Wagg provides the following comments:

• “While Ritalin is the first line treatment for ADHD in school age children and older age groups this is not the case for preschool age children where parent behaviour training is the preferred intervention;”
• “In treatment of Autistic Disorder a multidisciplinary team assessment by Paediatrician, Child Psychiatrist, Psychologist, Speech Therapist and Occupational Therapist is best practice leading onto multidisciplinary team intervention to support the Autistic child and their family optimise adaptive function despite recognised persistence of core deficits of Autism. The team should provide coherent service from preschool into school age children, adolescents and transition to adult services;”
• “There is a lack of available treatments for ADHD and Autistic Disorder in Tasmania. There is no single pathway for assessment and therapeutic intervention for children with developmental disorders in this state…There is a need for a multidisciplinary team that brings together specialist expertise to meet the assessment and treatment needs of children with neuropsychiatric and developmental disorders, and their families, from preschool, through childhood and adolescence on to transition to adult services;”
• “This is in part a problem of planning and integration of services across government departments which are currently fragmented between education, health, mental health, disability services (in child and family services) and NGOs. However, it is also a problem of lack of resources directed to children’s services;” and
• “This lack of resourcing of services leads to the limited availability of appropriate services to preschool age children with developmental disorders such asMs Brockman’s daughter; the lack of a single clear pathway for neuropsychiatric and developmental disorders that brings together all the relevant service areas for assessment and treatment; and more generally a lack of appropriate range of services for preschool children with a variety of mental health disorders.

Summary of Ms Brockman's daughters treatment

Accepting the evidence of Dr Wagg and Dr Whitelaw that was not subject to challenge I find that;

o Dr Whitelaw’s treatment of Ms Brockman’s daughter was appropriate;
o Early intervention strategies in addition to the prescription of Ritalin, were important for her; they were made available but not taken up by Ms Brockman;
o Prescription of Ritalin was appropriate in her case;
o Dr Whitelaw had no reason to suspect diversion was happening in her case, even with disclosure by Ms Brockman of cannabis use;
o  Illicit diversion of psychostimulants is a problem in the community.

Comments and Recommendations:

For the investigation I obtained a report from the National Coronial Information System (NCIS) relating to deaths in Tasmania between 2000 and 2013 where illicit methylphenidate had been taken by the deceased at the time of death. The report shows that there were 10 deaths in this category. In some of these deaths methylphenidate was not the actual cause of death. However, in 5 of these deaths methylphenidate was injected intravenously and caused death. The NCIS data base deals only with deaths and can therefore not present a full account of the prevalence of methylphenidate abuse or the extent to which it is injected intravenously. However it certainly supports the other evidence in the inquest that there is illicit use of the drug in the Tasmanian community at relatively significant levels, and that intravenous use of the drug can be fatal.

The coronial investigation has not received evidence that indicates a pattern of inappropriate prescribing of psychostimulants in the community. Certainly in this case Ritalin was appropriately prescribed to Ms Brockman’s daughter by Dr Whitelaw. The Chief Pharmacist, Jim Galloway, has provided the inquest with a copy of the Pharmaceutical Services Branch (“PSB”) guidelines for prescribing of stimulants to children and adolescents. The document, based upon the New South Wales guidelines sets out, amongst other things, the matters that the PBS committee is to consider relating to misuse and diversion when issuing authorisations to prescribers. These include: prescribing by a psychiatrist or paediatrician only; assessment of a patient against DSM IV criteria; checking parents for their history of drug misuse against a recognised database; and restricting or stage the supply where there is concern about parental misuse. I note the guidelines are due to be updated in 2015.

In the circumstances of this case resulting in the tragic death of a young man, it is appropriate to issue the following cautions;

1. That the injection directly into the veins of any drugs intended to be swallowed can be lethal due to lung and vascular damage caused by the binding substances in the pill.  Death can occur in this manner as a result of a single injection. Methylphenidate (Ritalin), Xanax and Oxycodone are commonly injected in this manner. The evidence indicates that there is a lack of awareness of this dangerous practice.

2. That medical practitioners prescribing psychostimulant medication such as Ritalin continue to be vigilant in assessing the serious risks associated  with such prescription; and to  ensure that careful assessment, planning, diagnosis, treatment and monitoring occurs in association with such prescribing.

Further, I recommend as follows;

(a)  That relevant agencies consider whether there is a need for a public education campaign with a view to reducing the harm caused by illicit diversion of psychostimulants, and in particular, to highlight the dangerous practice of intravenous injection of such substances;

(b)  That in developing updated guidelines for the issuing of authorities to prescribers, the PSB consider current evidence of the prevalence of and harm caused by diversion and misuse of psychostimulants in the community; and

(c) That relevant agencies consider reviewing the availability and adequacy of treatments for ADHD and Autistic Disorder in this State, including the need for a single pathway for assessment and therapeutic intervention for children with developmental disorders.

I express my gratitude to Mr Allen for the high quality of his work as counsel assisting in this case.

In concluding I convey my sincere condolences to Mr and Mrs Rhodes, Ms Mabb and the family of Mr Rhodes. 

DATED:       4  November 2014 at Hobart in the State of Tasmania.



Olivia McTaggart