FINDINGS INTO THE DEATH OF BENJAMIN WILLIAMS
[2013] ACTCD 1
•17 October 2013
FINDINGS INTO THE DEATH OF X WILLIAMS
[2013] ACTCD 1 (17 October 2013)
CORONERS ACT – death in custody – quality of care, treatment and supervision deceased’s mental condition – death by motor vehicle accident.
Coroners Act 1997 (ACT) ss3C(1)(d), ss13(1)(k), s52, s74
Mental Health Treatment and Care Act 1994 (ACT)
Anderson v Blashki [1993] 2 VR 89
Conway v Jerram, Magistrate and NSW State Coroner [2011] NSWCA 319
Harmsworth v State Coroner [1989] VicRp 87; [1989] VR 989
March v E & M H Stramare Pty Ltd [1991] HCA 12; (1991) 171 CLR 506
Onuma v The Coroner's Court Of South Australia [2011] SASC 218
R v Doogan; Ex parte Lucas-Smith [2005] ACTSC 74; (2005) 193 FLR 239
Re State Coroner; Ex parte Minister for Health [2009] WASCA 165
WRB Transport v Chivell [1998] SASC 7002
X v Deputy State Coroner for New South Wales [2001] NSWSC 46; 51 NSWLR 312
PLEASE NOTE – at the request of the Williams’ family, on 20 February 2020 Chief Coroner Theakston directed the revision of the public version of these findings to redact the first name of the deceased, as well as other potentially identifying information, under s 40(2) of the Coroners Act 1997.
No CD 253 of 2010
Chief Coroner Walker
Coroners Court of the ACT
Date: 17 October 2013
IN THE CORONERS COURT OF THE )
)
) No. CD 253 of 2010
AUSTRALIAN CAPITAL TERRITORY )In the matter of an inquest into the death of X WILLIAMS pursuant to section 74 of the Coroners Act 1997 (ACT)
FINDINGS
Chief Coroner: Lorraine A Walker
Date: 17 October 2013
Place: Canberra
THE COURT FINDS THAT:
The deceased was Mr X Williams, born X 1980.
- Mr Williams died on X 2010 on the Monaro Highway X in the Australian Capital Territory.
- Mr Williams died as the result of multiple injuries sustained in a motor vehicle accident.
- Mr Williams’ death was a suicide.
- No matters of public safety arose in connection with this inquest.
- I make no findings to the effect that the quality of care, treatment and supervision of the deceased contributed to his death.
Background
X Williams was born in 1980. He suffered significant mental health issues. He died in September 2010. At the time of his death he was subject to a psychiatric treatment order (PTO) under the Mental Health (Treatment and Care) Act 1994 (ACT). His matter was referred to the coroner pursuant to section 13(1)(k) of the Coroners Act1997 (ACT) (‘the Act’) because his was a death “in custody” as defined by section 3C(1)(d).
I will respectfully refer to the deceased as X.
The hearing into the circumstances of X’s death was held on 26 to 29 November 2012, 18 December 2012 and 10 to 11 April 2013. Leave to appear was granted to X’s family and the Australian Capital Territory on behalf of ACT Health. Ms Kent of the Office of the ACT Director of Public Prosecutions was appointed as counsel assisting.
In addition to the requirements applicable to all inquests detailed in section 52 of the Act, a coroner conducting an inquest in relation to a death in custody is also required to record any findings made regarding the “quality of care, treatment and supervision of the deceased that, in the opinion of the coroner, contributed to the cause of death” pursuant to section 74.
The scope of the inquest
The concept of contribution involves the application of common sense in identifying causal factors. A narrow approach to this issue is not appropriate, particularly in light of section 74. However that provision is not an imprimatur for the court to conduct an enquiry beyond the scope of what is relevant to the cause of death. There is no clear paradigm for making this assessment; it will depend on the nature and circumstances of each case.
In Conway v Jerram, Magistrate and NSW State Coroner [2011] NSWCA 319, on an appeal against a decision of the New South Wales State Coroner not to hold a hearing as part of an inquest, their Honours Campbell JA and Young JA at [30] referred to the judge at first instance review of the authorities. They were summarised as follows:
Nevertheless, in construing the expression 'manner of death' in a broad way, the court must bear firmly in mind the limits to the coroner's jurisdiction.....
In Harmsworth v State Coroner [1989] VicRp 87; [1989] VR 989 Nathan J was concerned about the limits of the Victorian Coroner’s jurisdiction to consider the circumstances of the death of a number of deceased persons, and particularly how death occurred. There had been a fire at a gaol in Victoria and a number of inmates had died. His Honour said at pages 995-996:
The coroner's source of power of investigation arises from the particular death or fire. A coroner does not have general powers of enquiry or detection (see ss15(1) and 17(1)). The enquiry must be relevant, in the legal sense to the death or fire, this brings into focus the concept of remoteness. ...
In Re State Coroner; Ex parte Minister for Health [2009] WASCA 165, Buss JA said at [46]:
Section 25(1)(c) does not, however, authorise a coroner to undertake a roving Royal Commission for the purpose of inquiring into any possible causal connection, no matter how tenuous, between an act, omission or circumstance on the one hand and the death of the deceased on the other. See R v Doogan; Ex parte Lucas-Smith [2005] ACTSC 74; (2005) 193 FLR 239 [28] (Higgins CJ, Crispin & Bennett JJ).
In R v Doogan; Ex parte Lucas-Smith [2005] ACTSC 74 the Full Court of the Australian Capital Territory Supreme Court said at [29]:
A line must be drawn at some point beyond which, even if relevant, factors which come to light will be considered too remote from the event to be regarded as causative.
10. Young JA agreeing with Campbell JA’s refusal of the appeal in Conway, went on to observe from [47] – [49]:
...It is clear that a coroner has a wide, but not unlimited, mandate to hold or not hold an inquest concerning the death of a person. When an inquest is held, the scope depends on all the circumstances. The inquest may be held to determine who is the deceased, when and how he or she died and this is the primary purpose of the inquest. As Justice O'Keefe said in X v Deputy State Coroner for New South Wales [2001] NSWSC 46, 51 NSWLR 312 at 325 [60]:
The primary duty of the coroner conducting an inquest is to determine and record if a death has occurred and, if so, the identity of the deceased, the date and place of the death and the manner and cause of such death.
It is important that extraneous factors do not get in the way of that primary duty.
48. Just what is the scope of the inquest, is a matter for the coroner; a matter to be exercised using proper discretion and commonsense...
49 In the usual cases of death, a line must be drawn at some point beyond which, even if relevant, factors which come to light will be considered too remote from the event.
11. I refer to the decision of Onuma v The Coroner's Court Of South Australia [2011] SASC 218 citing from WRB Transport v Chivell in which the Court considered the scope of the Coroner’s powers under the Coroner’s Act 2003 (SA) and the meaning of the words “cause and circumstances”, used in s 21 and s 25 of that Act. Lander J (with whom both Prior and Mullighan JJ agreed) said with regard to the meaning of the word “cause” at [9]:
Clearly enough ‘the cause and the circumstances’ must be two different things. If it was otherwise there would be no reason for Parliament to have included both words.
The cause of a person's death may be understood as the legal cause. In determining those events which may be said to give rise to the cause of the death, the Coroner is not limited by concepts such as 'direct cause', 'direct or natural cause', 'proximate cause' or the 'real or effective cause'. Nor is the Coroner limited to a cause which is reasonably foreseeable. The cause of a person's death in respect of the Coroner's jurisdiction is a question of fact which, like causation in the common law must be determined by applying common sense to the facts of each particular case: Mason CJ, March v E & M H Stramare Pty Ltd [1991] HCA 12; (1991) 171 CLR 506 at 515...That is a factual inquiry which only has, as its boundaries, common sense.
12. In determining issues that arise within the scope of an inquest, the standard of proof to be applied is the civil standard, namely the balance of probabilities (Anderson v Blashki [1993] 2 VR 89 per Gobbo J).
13. In this matter, I have been assisted by the sensible conduct of proceedings and the thorough submissions of those represented, and particularly, counsel assisting.
The Issues
14. I have distilled the contentious issues to the following:
Was there anything about the treatment or care of X which contributed to his death?
Two aspects of this issue were considered at the hearing.
a.Firstly, were the drug levels ascertained in X’s post-mortem sample evidence of a lack of adequate or appropriate treatment or care and, if they were, did that contribute to his death?
b.Secondly, did X experience a deteriorating mental state prior to his death which influenced his actions and which was contributed to by inadequate treatment or care?
Factual findings
15. X was fortunate in being born into a supportive and well-educated family. He was one of a sibship of three [redacted]. He was himself towards the top of his year at X College and commenced a science degree at X University.
16. He grew increasingly mentally unwell in his second year of university and ultimately was unable to complete his studies. Whilst there was some prevarication over diagnosis, he was generally treated on the basis that he suffered schizophrenia. During his 20s, his life was somewhat chaotic and stable accommodation proved difficult. Whilst his family were supportive, living at home was often untenable, largely because of his cannabis use.
Proximate Hospitalisations
17. In August 2009, X was staying in a Richmond Fellowship House. In the first few days of the month, X’s parents tried to get in touch with him by telephone but there was no answer. On 6 August they received a telephone call from a worker indicating that X was unwell. They went to the house and found him acutely psychotic.
18. They could not get anyone from the Crisis and Assessment Treatment Team (CATT) to attend for over 24 hours. When someone did attend, because she was alone she would not go into the house. Calling at 9:50 a.m. on 8 August, it took 25 minutes for the phone to be answered and the CATT staff indicated that they would not be attending; rather, they would telephone X.
19. Being told that he did not answer his phone, CATT recommended that X’s parents call the police. X was admitted involuntarily to the Canberra Hospital on 8 August 2009, having been taken by the police. Because there was no bed available at the Psychiatric Services Unit (PSU) at the time, he was taken to the Goulburn Hospital in New South Wales.
20. He was brought back to Canberra and housed at the Calvary Hospital on 21 August 2009. He was returned to the Canberra Hospital on 9 October 2009 because Ward 2N at Calvary Hospital was an open ward and his treating team felt that he need to be cared for in a more restrictive environment.
21. On his admission to the Canberra Hospital, X was acutely unwell, patently psychotic and behaving inappropriately. Although there was some improvement with medication, he could not really be said to have been stabilised during this inpatient admission. He was in the Canberra Hospital until 29 January 2010 as an inpatient of the PSU with some periods out.
22. Dr Bernadette Murphy, his treating psychiatrist at the PSU, was concerned that hospitalisation may in fact have been counter-productive. A decision was made in late November 2009 to give him a trial at Samaritan House, an institution for homeless men run by the Salvation Army. X only stayed a day before he went to his family home. As he was still so unwell, he was readmitted to hospital.
23. A few days later, on 6 December 2009, he absconded. He was formally discharged after leaving. It was left to his family to find him and have him readmitted on 13 December 2009.
24. X’s family, at their request, were involved in a review meeting on 15 December 2009. Housing accommodations were explored, including the possibility of a placement at Brian Hennessy Rehabilitation Unit, a psychiatric unit adjacent to Calvary Hospital. The rationale for this placement was largely an opportunity to trial the antipsychotic drug clozapine. X was very opposed to use of that drug because of its significant health implications.
25. In late December 2009, X was started on depot injections of another antipsychotic, zuclopenthixol. Whilst this appeared to have some benefit, Dr Murphy’s concern was that the ongoing use of cannabis was impacting upon its efficacy.
26. A decision was made to discharge X to Samaritan House after a successful overnight leave placement.
27. X was discharged on 29 January 2010 with an amount of diazepam to be taken as required to assist his anxiety, and with ongoing medication in the form of olanzapine (also known by the trade name Zyprexa) at the rate of 25 mg per day orally and zuclopenthixol decanoate 400 mg to be administered by depot injection fortnightly, both of which are antipsychotic medications. The zuclopenthixol was reduced to 200 mg fortnightly subsequently by an unconfirmed practitioner, given X’s complaint of drowsiness.
28. X stayed at Samaritan House accommodation in the community until he was involved in a motor vehicle incident on 16 February 2010 which led to him being rehospitalised with a broken ankle. Ms Caldwell, who worked with X whilst he was admitted in the PSU and then was subsequently his clinical manager in the community, expressed the opinion that X was not significantly improved at the time of his discharge before the accident.
29. There is a real question about whether the motor vehicle incident was an instance of intentional harm or purely accidental. Some involved with him at the time queried his intent but he denied suicidality at that stage. Whilst it is entirely possible that it was an instance of intentional self harm, in the circumstances that must remain speculative.
30. On 1 April 2010, because of his physical state, X was discharged to his family home. This period was difficult as he was discharged with an Endone dependence, Endone being an opiate-based pain-relieving medication.
31. His parents advocated for accommodation on his behalf, including corresponding with the relevant Minister. X was offered a placement in either Brian Hennessy House or Mimosa House at Ainslie Village. The Brian Hennessy House accommodation was secure and X was not open to that possibility. The Mimosa House option involved negotiating stairs inconsistent with his lack of mobility on crutches.
32. A placement was found for X with the Step Up Stepdown Program (SUSD), a joint venture of the Mental Illness Fellowship of Victoria and ACT Mental Health. This is a specialised accommodation and support program designed to assist those experiencing increasing mental illness or recuperating from an episode. Residence there is limited to three months. The facility is staffed 24 hours a day and offers structured and one-on-one support and a full-time mental health worker with access to ACT Mental Health records via the Mental Health Assessment Generation Information Collection (MHAGIC) system.
33. Ms Eva Seinsche, a psychologist and case worker, said that she was concerned that X was in fact deteriorating whilst at the SUSD program. However, as his time was up, an arrangement was made for X to relocate to The Lodge, a facility managed by Centacare (now CatholicCare).
34. At this time, X’s cannabis use was still a concern as was his mental health. Ms Seinsche considered that a move to The Lodge was suitable as it represented itself as a dual diagnosis facility; that is, a facility able to accommodate men with both mental illness and substance abuse issues. X’s parents thought that The Lodge would be suitable accommodation for the same reason.
35. X therefore relocated again on 3 September 2010 to The Lodge. The Lodge was staffed by people who were not clinically trained and only until 8pm. Residents were free to come and go as they pleased with limited supervision, although they were provided with cooked meals and some psychosocial support and liaison with mental health staff. Staff apparently had no particular clinical expertise. The residence is located at Ainslie Village, an area known for high drug use. Medication assistance was provided rather than controlled. Medication records were poorly kept. Residents’ whereabouts were more loosely monitored.
Treatment
36. Because of his poor mental state and apparent lack of insight into his condition, X had been placed on a PTO in 2009. He remained under such an order for the period following his discharge from the Canberra Hospital in January 2010 until his death. This was administered by ACT Community Mental Health staff on his discharge from PSU.
37. Treatment followed a team model, involving a nominated psychiatrist and a clinical manager, generally a nurse, as the primary point of contact. ACT Health’s ‘Management of Consumers Subject to Psychiatric Treatment Orders Policy’ applied. That policy required a treatment plan to be in place either at the time of making an application for a PTO or within 10 days thereof. A copy of that treatment plan was to be provided to the subject of the order, the general practitioner and, where appropriate, their carers. The policy also required a mandatory review of the person at a minimum of every two weeks.
38. Dr Rodrigo was X’s dedicated psychiatrist from March 2010 to his death, but he was absent for a period during which locum Dr Paull was assigned to X. Dr Rodrigo’s role was review and direction of treatment. Dr Rodrigo first saw X on a visit to his parents’ home on 10 March 2010, an unusual course due to X’s immobility. Dr Rodrigo saw him subsequently on 25 May 2010, 7 June 2010 and 3 August 2010. An appointment planned for 24 August 2010 was cancelled by X. Dr Paull, locum, saw X on 14 July 2010. This pattern indicates psychiatric review on average monthly. There is no evidence that another appointment was outstanding as at X’s death. Dr Rodrigo expressed the view that in 2010 the City Mental Health Team, responsible for X’s care, were understaffed.
39. Clinical managers, that is, the dedicated mental health trained but non-medical staff, worked in partnership with Dr Rodrigo. Their role was one of closer contact and review, with an obligation to ensure administration of prescribed treatment. Ms Caldwell, registered nurse, was X’s clinical manager on his release from the Canberra Hospital with Ms Julia Sullivan, also a registered nurse, filling in during absences. Both Ms Caldwell and Ms Sullivan had had past contact with X at the PSU.
40. Review was at least fortnightly because X was administered his depot injection fortnightly, although not always by the allocated clinical manager. There was some contact on occasions between administration of the injection, although this appears to have come about at the request of others involved in X’s care. Ms Caldwell’s observations of X during the period that she was clinical manager until August 2010 were that he was “slowly improving” although her observations of him over the time fluctuated. She considered him to be one of her most complex patients.
41. Ms Jean Fitzroy, social worker, took over X’s care as clinical manager from 6 September 2010, at the same time as taking responsibility for 15 to 20 patients. The handover was oral and unrecorded. Ms Fitzroy met X for the first time on 22 September 2010 when he attended City Mental Health for his depot injection, although she had spoken to him on the telephone previously to remind him to attend.
42. They discussed his dealings with the Housing and Accommodation Support Initiative (HASI) with whom he was discussing a new living arrangement. She had no concerns about him at that meeting and noted that he appeared bright and conversational albeit somewhat unkempt. Ms Fitzroy gave evidence that taking on a large caseload of new clients at once was difficult. It is surprising against this background that the handovers were all oral rather than recorded although I note that the MHAGIC notes provided a reasonable and centralised history in respect to mental health patients.
Events proximate to X’s death
43. In September 2010, X’s family planned to travel overseas for 13 days. This was to be the first time that there would be no family member in Australia in two years. X’s mother, Mrs Williams, took the trouble to inform ACT Mental Health of this by email as she was concerned about the impact of their absence on X’s mental health. No response was received and it did not provoke communication with X.
44. X’s father, Mr Williams, called X from Singapore on 24 September 2010. He formed the view that X was struggling and made arrangements to collect him from The Lodge on Saturday 25 September when he arrived back in Canberra. Mr Williams informed The Lodge staff that that X would be going home with him. X was troubled by auditory hallucinations at that time. He was having trouble concentrating on conversations with his father.
45. Mr Williams gave him some olanzapine that he had kept at home as X had not brought his medication with him. Mr Williams received a phone call from The Lodge that evening asking if X was with him, despite having earlier said that he was taking him. It was agreed that Mr Williams would return X to The Lodge by 8:30 am on Tuesday morning so that staff could take X to the Canberra Hospital for an appointment regarding his broken ankle. In fact, at X’s request, his father returned him to The Lodge on Sunday but picked him up again when he called asking him to come over. X was clearly highly distressed.
46. At his request, Mr Williams returned X back to The Lodge on Sunday night but again picked him up on Monday morning. X continued to be distracted and distressed. At one point he said to his father, “keep the car keys near you Dad”. Mr Williams took this as an indication that X was concerned about what he might do. Mr Williams hid the car keys [redacted]. Before bed, Mr Williams gave X another dose of olanzapine which he had at the house. Mr Williams was aware of some other tablets and they were not taken by X.
47. Despite his concern, and his knowledge of them as an out of hours service, Mr Williams did not call CATT. His past experience of calling CATT was such that he thought that pointless. He had waited for up to 20 minutes for someone to answer the phone in the past. CATT would only respond to a complaint that the person was at imminent risk of self-harm or harm to others, not X’s situation as Mr Williams then thought.
48. Absent that risk, Mr Williams was aware that he would be advised to take X to hospital for assessment, a process fraught with difficulty and risk. Even if he could be convinced to attend, X was unlikely to remain to be assessed as the inevitable wait increased his anxiety. A request for X to attend hospital, with its risk of being kept involuntarily, threatened his relationship with his family. A past experience of this had damaged the relationship for a period.
49. Mr Williams drove X to The Lodge at 8:30 a.m. on the morning of Tuesday, September 28, 2010. Mr Williams spoke to a worker at The Lodge, Mr Sherab Namgyal, who was unaware of X’s appointment but said that he could take him to the hospital provided X could get back to The Lodge by bus, which had been agreed to. Mr Williams offered to pick him up but X was angry at that suggestion.
50. Mr Williams was extremely concerned and not at all reassured by his conversation with Mr Namgyal. Once he arrived at work, Mr Williams called and left messages for X’s caseworker as well as other workers involved. Mr Williams arranged to meet Ms Fitzroy and hopefully Dr Rodrigo the following day. Sadly, it was too late.
51. At some stage after being dropped at the Canberra Hospital, X left, not having remained for his medical appointment. It is not known whether X took the keys to his father's car before he left the house to return to The Lodge or whether he went back to his parents’ house after being dropped at the Canberra Hospital, however, he then went to the ANU and took his father’s car from there.
52. He drove to the Monaro Highway. At about 11.30 am he was observed to drive into the path of an oncoming truck on the opposite side of the road. The circumstances of a clear view and fine weather conditions, the lack of observation of mechanical failure or evidence of acute physiological disturbance, along with observations of eye witnesses, indicate that this was a controlled action, if not intentional in the ordinary sense of the word. Whilst it is possible that insight into his deteriorating mental state lead to a conscious decision to take his own life, it is likely that X’s deteriorating mental health was such that he was unable to form a rational intent to that effect.
Determination of the issues
Were the drug levels ascertained in X’s post-mortem sample evidence of a lack of adequate or appropriate treatment of care and, if they were, did that contribute to his death?
53. X was found to have potentially toxic levels of olanzapine and zuclopenthixol in his blood, detected on toxicological analysis of a post-mortem sample. Expert evidence was received from Dr Starmer in respect to this issue.
There are 3 possible explanations:
Accumulation, that is, a build up because of the high prescription levels.
a.It is clear that higher than standard doses of both drugs were prescribed to X.
b.Dr Rodrigo gave oral evidence to the effect that such high levels were prescribed on occasion in instances of mental illness which were resistant to treatment.
c.Dr Annita Paull, the locum psychiatrist who reviewed X on 14 July 2010 indicated that at that time X’s olanzapine level should be tested through a blood sample at the time of his next depot injection. That did not take place.
d.The evidence of permanent ACT Health psychiatrists, Drs Murphy and Rodrigo, is that it is not usual practice to carry out such a blood test. I am unable to comment on the basis of the evidence before me whether that is appropriate.
e.It is a matter which ACT Health may consider appropriate to review.
Nonetheless, in the absence of such testing, I am unable to determine whether accumulation would explain the high level of these drugs in X’s system.
Intentional overdose, possibly facilitated by storing prescribed medications.
a.This possibility is unlikely to have any relevance to the zuclopenthixol level. It is highly unlikely that X had access to this drug, taken by depot injection, other than in accordance with its prescribed administration despite some deficiencies in recording.
b.The evidence supports the conclusion that it is possible that X may have stored some of the olanzapine wafers that he had been prescribed. That is because the issue and taking of medication at The Lodge was poorly regulated and recorded.
c.X generally tended towards reluctance to take medications but on occasions had apparently taken more than his prescribed dose.
d.Mr Williams expressed some concern that the mental state he observed in X in the days prior to his death may have been indicative of an overdose of medication.
e.However, Mr William’s observations of X as agitated are not sufficient to conclude that he was suffering the effects of an overdose of olanzapine.
f.He did not display other symptoms which the medical evidence indicates might occur in the context of an overdose of olanzapine, such as delirium, convulsion, respiratory depression or aggression. Whilst agitation is one of the possible features of an overdose, it was also consistent with X being generally unwell.
g.In terms of aggression, apart from being angry at the suggestion by his father that he should collect him after his medical appointment, there was no suggestion of aggression.
h.On post-mortem examination, there was no evidence of any physiological cause for X’s death unrelated to the motor vehicle collision. For example, Dr Jain, the pathologist, did not observe any damage to the heart which might have been related to the effect of the drug.
i.Ultimately, whilst it is possible that X did take an overdose of olanzapine, any conclusion to that effect would be speculative.
Post-mortem redistribution.
a.Post-mortem redistribution refers to a change in the location of the drug within the body after death which occurs when the chemicals leak from tissues and organs into the bloodstream, creating a higher concentration of the drug than would occur ante-mortem.
b.Dr Starmer thought that this was possible but unlikely as an explanation for the high level of both drugs in X’s blood after death. He considered that “individual variation” could account for the high drug levels detected.
54. On the evidence before me, whilst there was evidence of less than ideal recordkeeping in relation to X’s drug administration both in ACT Mental Health records and at The Lodge, I am unable to draw a causative connection between this and X’s death.
Did X experience a deteriorating mental state prior to his death which influenced his actions and which was contributed to by inadequate treatment or care?
55. X had been mentally unwell for about ten years prior to his death. The longitudinal diagnosis was schizophrenia. His condition was difficult to treat and X at times lacked insight in to his need for treatment. His ongoing use of cannabis, confirmed by the presence of cannabinoids in his post-mortem blood test, complicated his treatment.
56. When X was discharged on 29 January 2010 from the PSU, it was not because he was cured or even in remission but because Dr Murphy, his treating psychiatrist at PSU, hoped that discharge would improve X’s mental state, having formed a view that continued involuntary inpatient treatment was potentially counter-productive.
57. Mr Williams’ observations were that on that last weekend that they spent together, X was highly distressed and in need of treatment. Mr Williams was clearly concerned because before finding out about X’s death, he had gone to the extent of making arrangements to meet with X’s treaters as a matter of urgency.
58. I entirely accept that Mr Williams, as X’s father, was as well placed as any expert to assess that X was unwell. Whilst family members lack medical training to interpret and treat mental illness, in most cases they will be best placed to know what is usual behaviour for their loved ones, what is not and to what extent.
59. To that extent, I am satisfied that X was acutely unwell on the weekend of 25 to 27 September 2010.
60. I cannot conclude, however, that X’s mental health had deteriorated considerably in the two to three weeks preceding his death; that is, in the period that he had been relocated to The Lodge. There is no clear basis for that finding. He really had not been well since his discharge from PSU in January 2010.
61. Whilst his presentation fluctuated somewhat between then and his death, there is no clear evidence of a significant and sustained deterioration until the observations of Mr Williams on 25 through to 28 September 2010.
62. As accurate as those observations no doubt were, they were not consistent with the observations of Ms Fitzroy or Mr Namgyal in recently preceding days. Ms Fitzroy did not know X but when she saw him on 22 September, he presented as quite well to her. Mr Namgyal had a positive exchange with X as he drove him to hospital on the morning of his death.
63. It may be that X was better at hiding his distress from those who were less close to him. It may be that he simply became worse on that last weekend for unknown reasons. Whichever is the case, however, the evidence simply does not support a clear path of steadily deteriorating mental health that was “missed” as a result of lack of care by those responsible for X’s care.
64. This finding does not in any way derogate from the observations made by counsel assisting and the Williams family. X was probably not in an ideal environment in the time leading up to his death.
65. Closer supervision and support by clinically trained staff may possibly have provided the prospect of a better outcome for X. Short of a return to hospital, which itself may have been counter-productive in light of his apparent unhappiness in that environment, no such placement was available to him in the ACT in the community. Such an arrangement was also not his expressed preference; rather, he was interested in more independent living, as is evident through his discussions with Mr Anyi of the HASI Organisation.
66. In relation to the unavailability of psychiatric support in the community, and Mr Williams’ decision not to call on the assistance of CATT, I accept that the Williams family’s past experience caused Mr Williams not to try this option. That is entirely understandable. The delay in contacting CATT, the hurdle of the need to establish a risk of harm to self or others before the team is able to respond, the trauma associated with involvement of the police in the absence of CATT attendance and the impact on X’s relationship with his parents as a result of the last experience of involving CATT all go to explain why Mr Williams tried a different approach on this occasion. That being said, however, a causal connection between the lack of support in the community for the mentally ill and X’s death cannot be drawn in the situation where what was available, despite its limitations, was not called upon.
Conclusion
67. In summary, I am unable to conclude that there was anything about the quality of care, treatment or supervision of X that contributed to his death.
68. In coming to that conclusion, I in no way wish to derogate from the validity of the observations made by both counsel assisting and X’s family as to the need for ongoing review and improvement in the ACT Mental Health system. Those observations are intelligent and considered. It would no doubt be beneficial for a representative from ACT Mental Health to consider those submissions, which I would readily make available for that purpose, as part of the continued process of improvement.
69. Before making my formal findings, I wish to take this opportunity to convey my deepest condolences to X’s family for their loss. I have had the privilege of reviewing through the evidence in this matter X’s life and the commitment of his family to his care. X’s untimely death was tragic.
Formal Findings
70. I make the following findings:
1. The deceased was Mr X Williams, born X 1980.
2. Mr Williams died at about 11:30 a.m. on X 2010 on the Monaro Highway X in the Australian Capital Territory.
3. Mr Williams died as the result of multiple injuries sustained in a motor vehicle accident.
4. Mr Williams’ death was a suicide.
5. No matters of public safety arose in connection with this inquest.
6. I make no findings to the effect that the quality of care, treatment and supervision of the deceased contributed to his death.
Lorraine Walker
Chief Coroner
I certify that the preceding 70 numbered paragraphs are a true copy of the Reasons for Judgment herein of Her Honour, Chief Coroner Walker.
Associate:
Date:
Counsel Assisting: M.Kent
Office of the ACT Director of Public Prosecutions
Counsel for the Territory: A.Tonkin
Solicitor for the Territory ACT Government Solicitor
Counsel for the Family: I. Bradfield
Solicitor for the Family: Elrington Law
Date of hearing: 26 to 29 November 2012
18 December 2012
10 and 11 April 2013
Date of findings: 17 October 2013
Date of redaction revisions: 20 February 2020
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