Record of Investigation Into Death (Without Inquest)

Corners Act 1995
Coroners Rules 2006
Rule 11

 I, Stephen Raymond Carey, Coroner, have  investigated the death of Kylie ROBERTSON

Find That:

(a) The identity of the deceased is Kylie Robertson (“Miss Robertson”);

(b) Miss Robertson was born in  Melbourne, Victoria on 13 December 1975 and was aged 38 years at the time of her death;

(c) Miss Robertson was single and was in receipt of a disability pension at the time of her death; and

(d) Miss Robertson died on 17 January 2014 at her residence in Cygnet;

(e) Miss Robertson died as a result of hepatic steatosis due to chronic alcoholism;

(f) No other person contributed to Miss Robertson’s death.

Circumstances Surrounding the Death:

Miss Robertson’s mother died when she was 9 years old and it is reported that this had a significant impact upon her requiring visits to a psychologist.  Miss Robertson completed her schooling to year 12; however she left home when she was 17 years old.  It is reported that she started consuming alcohol after she left home and habitually drank heavily with her friends.  Miss Robertson moved to Sydney when she was in her early 20s.  It was at about this time that significant psychiatric problems became apparent and she was granted a disability pension.  She was initially diagnosed with a borderline personality disorder; however she was also prescribed anti-depressant, anti-panic and anxiety medication.  This period also included episodes of self-harm where by Miss Robertson would cut herself.  Miss Robertson would contact her family every few months whilst she was living in Sydney.

Miss Robertson returned to Tasmania in 2010, residing with her father and his wife for approximately 1 month before she left their home and admitted herself to the Royal Hobart Hospital where she stayed in the psychiatric unit for a period of 3 months.  Subsequent to her discharge she was assisted by external support services in particular requiring accommodation in residential care.  In early 2011 Miss Robertson moved to the Cygnet area and at this time she had ceased all communication with her family.  In December 2013 she moved into a unit in Cygnet and struck up a friendship with a neighbour in that unit block, Mr Hodgson.  Both Miss Robertson and Mr Hodgson were alcoholics and were known to drink with each other on a daily basis.

The medical records of Miss Robertson dated back to 2010 upon her return to Tasmania and in them there are references to schizophrenia, anorexia/bulimia, bipolar disorder, anxiety, depression, self-harming behaviour and alcoholism.

During the time that she lived in Cygnet from 2011 to 2013, Miss Robertson was an intermittent patient at the Cygnet Medical Centre.  Her general practitioner, Dr D Dubetz, reports that:

“Her attendances at this surgery were related to alcohol, mental and relationship issues.  She was twice referred to Drug and Alcohol for rehabilitation who knew her well from previous visits.  She tended to disintegrate to schizophrenia ideation.  She would hear voices and become fretful.  She had a tendency to self-harm in the form of superficial cuts to her forearms.

Her last attendance at this practice was on 11.12.13 when her depressive condition was reviewed.  She was sober.  Her mood was subdued and steady.  Her cognition was upbeat.  She was looking forward to sharing Christmas with her new friend from the units, Ian.  Her motor function was normal.  She was encouraged to continue her medication and was given a repeat script for escitalopram, 40mg, daily.”

Due to the absence of Dr Dubetz, she attended upon another general practitioner, Dr U Athukorala on 9 January 2014.  At that time the doctor recalls she was dishevelled, unkempt and had strong body odour.  She did not smell of alcohol although she appeared to be possibly drug affected.  She attended with a complaint of a perianal rash, which was diagnosed as an infection and a prescription of a 5 day course of oral antibiotics was provided.

On 17 January 2014, Miss Robertson spent the evening in company with her friend, Mr Hodgson, at her unit; they were both consuming alcohol.  Mr Hodgson arrived at the unit at approximately 5:00pm and left at about 11:00pm.  Mr Hodgson noted that during his visit Miss Robertson had several coughing fits and at times vomited in a bucket beside her mattress.  When Mr Hodgson left her unit he noted that Miss Robertson was awake and lying on a mattress in the living room.  Mr Hodgson noted that he believed that Miss Robertson may have been sick because he had observed that when she had a cigarette, this would cause her to cough and end with her vomiting.  He also noted other occasions where she could vomit after drinking.

Mr Hodgson returned to Miss Robertson’s unit at approximately 2:30pm on 18 January 2014 with the intention of consuming alcohol with her.  He entered her unit as he had a key and observed Miss Robertson lying on the mattress in the lounge room where he had left her the previous evening.  He touched her arm, noted it was cold and also noted that her “arms were all stiff and twisted”.  He immediately left the unit and advised a Mr Scott Turnbull as he did not know what else to do.  Mr Turnbull returned to the unit with Mr Hodgson and, having noted the condition of Miss Robertson, called emergency services.  Tasmania Ambulance Services attended the scene and confirmed that Miss Robertson was dead.  Tasmania Police arrived at the scene at approximately 3:10pm and their investigation concluded that there were no suspicious circumstances.

An autopsy was conducted.  The opinion of the forensic pathologist was that:

“The autopsy revealed a well developed, well nourished adult Caucasian woman with marked fatty replacement of the liver.  Toxicology testing of specimens obtained at autopsy revealed a ‘toxic level’ of the antidepressant drug citalopram in addition to nicotine but no ethanol (alcohol) was detected.  Citalopram may undergo post-mortem redistribution complicating the interpretation of this result.

Hepatic steatosis (fatty replacement of the liver) is known to be associated with unexpected death often in the setting of chronic alcoholism.  The mechanism of death in hepatic steatosis is unclear and may be the result of fatal hypoglycaemia or other metabolic derangement.”

Comments and Recommendations:

I have decided not to hold a public inquest into this death because my investigation has sufficiently disclosed the identity of Miss Robertson, the time, place, relevant circumstances concerning how her death occurred, and the particulars needed to register the death under the Births, Deaths & Marriages Registration Act 1999.  I do not consider that the holding of a public inquest is likely to elicit any important additional information further to that disclosed by the investigation conducted by me.

Before I conclude this matter, I wish to convey my sincere condolences to Miss Robertson's family.


DATED:   22 August 2014 at Hobart in the state of Tasmania.


Stephen Raymond Carey