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 Ricky Charles Scott.

Find That:

(a) Ricky Charles Scott (“Mr Scott”) died on or about the 31 March 2013 in Youngtown. 

(b) Mr Scott was born in Hobart, Tasmania on the 19 November 1969 and was aged 43 years at the time of his death.

(c) Mr Scott was single Aboriginal male who was receiving a pension at the date of his death.

(d) I find that Mr Scott died as a result of mixed prescription and illicit drug toxicity (tramadol, codeine, morphine, amphetamine, diazepam, paracetamol, THC-COOH) complicated by marked lung disease (emphysema and micro crystalline cellutose of lungs), bronchio pneumonia, chronic Hepatitis C and hypertensive cardiovascular disease.

Circumstances Surrounding the Death:

Mr Scott had served numerous periods in Risdon Prison throughout his life.  In 1989, during one occasion in prison, he met Damien Maynard and they became good friends.  It was through Damien Maynard that he met Belinda Bannister and they developed a relationship via writing to each other and prison visits by Ms Bannister.  In 1994, Mr Scott was released from prison and commenced a relationship with Ms Bannister but this was concluded after a short period.  Subsequent to this, Mr Scott was in at least one other relationship of which twin girls resulted and he remained in contact with his girls after the relationship ended. 

Mr Scott had a close relationship with his mother.  She died in 2010 and comments are made that this had a significant emotional effect upon Mr Scott and affected his behaviour subsequently, in particular his abuse of alcohol, illicit drugs and prescription drugs.  In 2012, Mr Scott was again in Risdon Prison with Mr Maynard and he decided to re-establish contact with Ms Bannister.  When he was released during 2012 he recommenced his relationship with Ms Bannister and moved in with her at her residence with her four children.  At this time it is noted that Mr Scott was drinking heavily, and exhibited numerous health problems including pneumonia, Hepatitis C and chronic right ankle pain.  His treating general practitioner at the time, Dr Gardner, comments that:

“He was on a combination of analgesics and diazepam, which he stated he had been on for some time.  Specifically, he was taking eight Panadeine Forte tablets, two 200mg tramadol tablets and four 5mg diazepam tablets daily, as well as 12.5-25mg of prednisolone daily for his chest.  He was known to drink alcohol excessively, and described chronic right ankle pain for which he was awaiting an orthopaedic assessment in Hobart.

Management over the next six months [from August 2012] essentially consisted of reducing his requirement for medication, particularly diazepam, and managing his chronic ankle pain…

My last contact with Mr Scott was on 22 March 2013, a week or so after he had discharged himself against medical advice from the Launceston General Hospital where he was being treated for pneumonia.  He remained dyspnoeic…

In my opinion, Mr Scott was in poor general health.  He was dependent upon codeine-containing analgesia, as well as tramadol.  He drank excessively and regularly would arrive at the surgery intoxicated…He appeared to be far older than his actual age, and his pulmonary function was poor due to years of smoking heavily.”

In March 2013 things had become difficult with Mr Scott living at Ms Bannister’s residence due to there not being enough room for the family.  As a result of this, accommodation was identified and obtained for him in a room at Cosy Hometead at Youngtown.

On the evening of 31 March 2013, at approximately 8:00pm, Ms Bannister attended at Mr Scott’s room to take him his dinner she had prepared at her home.  She found him to be asleep and when woken he did not seem interested in having the meal.  He was noted as being very tired and “chesty”.  Mr Scott stated he was in pain in relation to his ankle and he requested painkillers; Ms Bannister placed two Panadeine Forte on the bedside table for him.  Ms Bannister was concerned as to his condition and requested that Mr Scott go with her to hospital but he declined.  Ms Bannister stayed with Mr Scott until he fell asleep and she left at approximately 8:30pm.

On 1 April 2013, Ms Bannister made several attempts to contact Mr Scott but was unsuccessful.  There had also been no contact between them on the previous evening (after she left his at approximately 8:30pm) which was unusual.  Ms Bannister requested her mother, Carol Bannister and step-father, Damien Maynard, to call into Mr Scott’s room and check on his wellbeing.  At 12:00pm, Mr Maynard entered Mr Scott’s room and found him on the bed not breathing.  The Ambulance service were notified, paramedics attended, but no resuscitation endeavours were commenced as he was obviously deceased.  Police were notified, attended and a site examination together with subsequent investigation identified no suspicious circumstances in relation to Mr Scott’s death. 

The result of the post-mortem conducted upon Mr Scott identified from toxicology of post-mortem blood a range of prescription and illicit drugs in his system.  It was noted that Mr Scott was suffering with pneumonia and this means that his respiratory system was compromised and was more susceptible to respiratory depression with the use of multiple opioids, for example tramadol and codeine.  The findings of the actual post-mortem are as follows:

“The autopsy revealed a well developed, well nourished adult man with an enlarged heart (cardiomegaly) and thickening of the main heart chamber in a pattern suggestive of long-standing high blood pressure.  There was consolidation of the lower lung lobes that microscopically had acute inflammation (pneumonia).  There was evidence of chronic intravenous drug use including microcrystalline cellulose deposited within the lung interstitium and chronic hepatitis C with scarring of the liver.”

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 Mr Scott, the date, place, cause of death, relevant circumstances concerning how his death occurred and the particulars needed to register his 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 significant information further to that disclosed by the investigations conducted by me. 

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

This matter is now concluded.


DATED:   8 September 2014 at Hobart in the state of Tasmania.


Stephen Raymond Carey