An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 10^th, 11^th, 12^th, 13^th, 14^th and 24^th days of November 2003 and the 19^th day of December 2003, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of AB.

1. Introduction

1.1. On 10 November 2003, on the application of Mr Edwardson, counsel for the deceased’s sister, I made an order suppressing the names of the deceased and his sister from publication pursuant to Section 69a of the Evidence Act. Accordingly, I will refer to the deceased as AB throughout this finding.

1.2. At the time of his death on 3 November 2000 AB was aged 26 years. He was born on 28 June 1974.

1.3. AB had a very extensive psychiatric history which I will detail in due course.

1.4. At the time of his death AB was a voluntary inpatient at Glenside Hospital, South Australia’s major psychiatric teaching hospital. He was accommodated in a ward known as ‘the Glen’. The purpose of his admission to Glenside Hospital was that he was to commence a program of treatment for his mental illness with a drug known as Clozaril (Clozapine).

1.5. In addition to being an inpatient, AB had also recently entered the Methadone program at Warinilla, a drug treatment and rehabilitation centre operated by the Drug and Alcohol Services Council at Norwood. He received his first dose of Methadone on 31 October 2000, and received further doses on 1 and 2 November 2000. His last dose was administered at about 9:30am on 2 November 2000.

1.6. At about 7:40am on 3 November 2000 Registered Mental Health Nurse Bronte Mackereth was in the process of checking the patients in the east wing of the Glen when she found AB on the floor of his room. In her statement Ms Mackereth said:

'I couldn’t see AB and I dropped my eyes and saw AB on the floor. He was faced to the floor with his legs not quite under his chest. He was dressed, he had on jeans and a grey sweatshirt. I could only see a small part of his face. I called his name twice very loudly and there was no verbal response from him. I stepped one step closer to him. I then observed a dark pool of fluid and the foot of his bed. His head was at the foot of the bed next to the fluid.'

(Exhibit C22a, p1)

1.7. Ms Mackereth raised the alarm and other nursing staff rushed to assist. An ambulance was called, and in the meantime nursing staff commenced cardio-pulmonary resuscitation (CPR) and administered oxygen.

1.8. Dr Rhett Bosnich attended the room at about 7:45am and noted that resuscitation was continuing. A Guedel airway was inserted and attempts were made to defibrillate AB without success. At about 8:05am that morning, Dr Bosnich examined AB again and due to the absence of breath sounds, palpable or audible heart sounds, and the fact that his pupils were fixed and dilated and that he was completely non-responsive, Dr Bosnich pronounced his life extinct (see Exhibit C2).

2. Background

2.1. As I have already mentioned, AB had an extensive history of psychiatric illness, going back to 1985 when he was 10 years old. It is recorded that he began using illicit substances at 13.

2.2. AB’s first admission to hospital was in June 1996 when he presented with psychosis with grandiose and paranoid delusions in the context of marijuana and intravenous drug abuse. There were further admissions in October 1996, March 1997, April 1998, February 1999, October 1999, February 2000, April 2000, June 2000 and October 2000.

2.3. AB had also been admitted to Warinilla Clinic in May 2000 for drug detoxification and rehabilitation.

2.4. The diagnoses made during these admissions usually involved a psychosis associated with illicit drug abuse but also involved symptoms of depression and paranoid schizophrenia, non-compliance with medication, borderline personality disorder and anti-social traits.

2.5. When he was not an inpatient, AB was managed by the Eastern and later the Southern Mobile Assertive Care Service (MACS).

2.6. AB had been receiving medication in the form of Flupenthixol, an antipsychotic, on a fortnightly basis since at least January 1999. He was subject to a Community Treatment Order, pursuant to the Mental Health Act, 1993 to take this medication. He was also receiving Olanzapine, another antipsychotic medication and Sertraline, an antidepressant.

2.7. On a number of the abovementioned admissions, AB was found to be acutely psychotic and on several occasions suicidal. It is recorded on many occasions that his general behaviour was reckless and that he placed himself at risk. In the report prepared by Associate Professor Tim Lambert and Ms Joy Monkley (Exhibit C24b), which I will discuss in more detail later, AB’s behaviour is recorded as follows:

'At Risk Behaviour

· Illicit and prescribed substance abuse from the age of 13 years. (Snort, smoke, ingest or Intravenous routes) Marijuana, alcohol, amphetamines, benzodiazepines, heroin regulated only by available funds).

· Known to share or exchange his prescribed medication and sexual favours for accommodation / illicit substances.

· Suicide attempts and accidental overdoses:

- 1997 2 alleged heroin overdoses

- 1998 Jumped of 2^nd story balcony c/- delusional beliefs

- 1999 Walked in front of a car (minor injuries)

- 2000 (15.4.00) Heroin Overdose

(29.9.00) Heroin Overdose (2/52 before last admission)

· Absconding while an in-patient – occurred frequently on all admissions unless within a closed ward.

· Poor Insight and compliance with medication (required weekly dispensing, dept route, and active monitoring and follow up by MHS).

· Itinerancy.

· Impulsivity.'

(Exhibit C24b, p11)

2.8. Court appearances
On 16 August 2000 AB attended the Adelaide Magistrates Court accompanied by his keyworker, Mr Dennis Stevens. AB was charged with a number of offences of dishonesty including receiving stolen property, making a false statement to a secondhand dealer, providing a false address to a police officer, and unlawful possession. His case was referred to the Magistrates Court Diversion Program and he appeared again before Mr Iuliano SM on 27 September 2000. The court records reveal that this was the second time he had been referred to the Diversion Program. He informed the Clinical Adviser during his assessment on 2 August 2000 that he had ‘sought treatment at Warinilla and has not used heroin or other substances since receiving treatment’. In view of evidence from other sources, these statements would appear to have been untrue.

2.9. AB was assessed as being suitable for involvement with the Court Diversion Program. The assessor commented:

'In view of AB’s past involvement in the Court Diversion Program it is essential that AB be monitored carefully and compliance with the program plan be strictly adhered to. AB will need to be easily available for mental health treatment and other appointments at all times. In addition it is recommended that he refrain from substance abuse and engage in treatment for this issue as advised by the mental health team.'

(Exhibit C14)

2.10. Having entered into the Court Diversion Program, AB was brought before the court again on 27 September 2000, when it was ordered that he appear again on 8 November 2000 for review. The ‘program plan’ prepared as a result of his assessment was endorsed with the following comments:

'That AB be required to strictly attend and be available for treatment through the mental health services. In addition AB will be required to abstain from all substance abuse and engage in treatment for substance abuse as advised by his mental health team. If AB fails to comply in this manner he will be brought back to the normal court process.'

(Exhibit C14)

2.11. It is interesting that two days later, on 29 September 2000, it is recorded that AB took an overdose of heroin, as a result of which he was admitted to the Royal Adelaide Hospital with complications including aspiration pneumonia. He was detained pursuant to the Mental Health Act 1993 on that occasion.

2.12. AB’s progress was not reviewed until contact was made with Mr Stevens later in October 2000, by which time he had been detained in a closed ward. The review report reads:

'AB’s diagnosis as well as his treatment remains under review. AB is due for final determination on 17/1/2001 at which time a full report of his progress will be made to the court.'

(Exhibit C14)

Unfortunately, AB died in the meantime.

2.13. Final admission to Glenside Hospital
As part of the Magistrates Court Diversion Program AB commenced a course of treatment on Clozapine, a highly effective antipsychotic medication. Unfortunately, Clozapine also can have very significant side effects, some of which can be life-threatening. For this reason, the patient’s condition, in particular observations to monitor vital signs and the extent of sedation, as well as monitoring of his white cell count were required on a regular basis. After discussion between Dr Rene Pols, his treating Psychiatrist at Southern MACS, AB and his mother Mrs Margaret O’Donnell, it was agreed that AB would be admitted to Glenside Hospital as a voluntary patient so that the Clozapine could be administered under controlled conditions.

2.14. AB was admitted to Glenside Hospital on 9 October 2000 as a voluntary patient. He was placed in the Glen. The first ten days or so of his hospitalisation were characterised by absenteeism and non-compliance. For example, Dr Marion Drennan, the Career Medical Officer with responsibility for the Glen, was unable to assess him on admission because he could not be located. When she saw him on 10 October, she gave him a full examination and found him hostile, uncooperative and angry. Because of his lack of cooperation, she was unable to perform a full mental state assessment (T55).

2.15. AB continued to be absent from the ward during the day time, to the extent that the Clozapine therapy was not commenced until 20 October 2000. Although there is a clear protocol to be adopted when patients are commenced on Clozapine (see Exhibit C15b), this did not occur because the nurse who administered the first dose was not aware that this was the case (see the evidence of RN Padget, T310). This was a serious omission, although the deceased suffered no apparent ill effects.

2.16. Detention order, 23 October 2000
On 23 October 2000, AB was seen by Dr Drennan. He was described in the clinical record as having ‘returned from absconding by keyworker’. Dr Drennan detained him pursuant to Section 12(1) of the Mental Health Act 1993. The grounds upon which she made this order are as follows:

'AB is psychotic, with persecutory delusions - he repeatedly uses heroin to gain relief - has overdosed (says accidentally) recently with 2° (secondary) aspiration pneumonia. Repeatedly leaves the ward for heroin. Needs closed ward management.'

(Exhibit C15)

2.17. The reference by Dr Drennan to ‘closed ward management’ is significant. Some patients are detained pursuant to the Mental Health Act 1993, but are not placed in closed, or locked, wards. However AB was placed in Kurrajong Ward. Kurrajong was a locked ward, which was intended to provide a secure therapeutic environment for seriously ill patients. Unfortunately, it was also austere, crowded and counter-therapeutic. It has since been closed.

2.18. On 24 October 2000, AB was reviewed by Dr Harry Hustig, the Director, Extended Care, at Glenside Hospital. Dr Hustig confirmed the initial detention order pursuant to Section 12(4) of the Mental Health Act 1993. Dr Hustig made the following entry in the clinical record at the time that he made this order:

'AB presents an interesting dilemma in management. His use of illicit drugs certainly complicates his diagnosis and poses a serious risk to his own safety. At present I have elected to confirm his order so that he can be more comprehensively assessed.'

(Exhibit C15)

2.19. Following this order, AB was not assessed, comprehensively or otherwise, by any psychiatrist until 26 October 2000 when he was reviewed by Dr Mark Scurrah, a Consultant Psychiatrist, pursuant to Section 12(5) of the Mental Health Act 1993. In the meantime, there is a nursing note on 25 October 2000 at 1900 hours to the effect that AB was irritable, he was showing a memory deficit, and that he ‘believes he is the only sane patient in Kurrajong’. The later nursing note at 0600 hours on 26 October 2000 merely recorded that he retired to bed at 2130 hours and slept well overnight.

2.20. It is clear on the face of the record, and on the basis of the evidence before me, that no further assessment of the complicated nature of AB’s condition was carried out during that period. Indeed it was noted that one of the reasons why he was irritable was because of the non-attendance of the doctor (see the note for 25 October 2000 at 1900hrs).

2.21. Lapse of detention order
As I mentioned, AB was seen by Dr Mark Scurrah on 26 October 2000 for what he described in the clinical record as a ‘detention review’. Dr Scurrah’s note of his consultation reads as follows:

'Denial of recent psychotic symptoms, major mood symptoms or thoughts of self-harm/aggression.

MSE (Mental State Examination) Calm, cooperative, organised speech, suspicious – angry in affect (at being detained)

Insight – "I need to go to Narcotics Anonymous meetings"

Assess (Assessment) No acute safety issues (related to) an Axis I disorder)

Plan detention to lapse.'

(Exhibit C15)

2.22. As a result of Dr Scurrah’s decision not to detain AB for a further period, the detention order made by Dr Drennan and extended by Dr Hustig lapsed at midnight on 26 October 2000.

 

2.23. Even though the order had not yet lapsed, AB was transferred back to the Glen from Kurrajong at 11:30am. Dr Drennan examined him later that day and made the following entry in the clinical record:

'AB has made a commitment to stay on the ward and to not use heroin. Is adamant that he only uses heroin for its antipsychotic effects. Has agreed to ask for PRN (as required) medication if needed.'

(Exhibit C15)

2.24. At 7pm that evening AB was given 10mg of Diazepam as he was ‘feeling agitated’. He was given further Diazepam at 8:00pm as he ‘could not wait until medication round at 2030’ (8:30pm). The following day, on 27 October 2000, he absconded at some time after 6:30am and his absence was reported to the police. He returned to the ward at 1:50pm that afternoon.

2.25. The Methadone program
When AB returned to the Glen at 1:50pm on 27 October 2000, it was noted that he was ‘very sedated’. Dr Drennan saw him shortly afterwards and noted as follows:

'AB has returned to the Glen. Reminded of his promise to stay on the ward. Re-negotiated agreement from him to stay here. Pin-point pupils, sedated, grandiose delusions re chess. Later came to me saying that he was interested in the Methadone program – agreed to go to DASC (Drug and Alcohol Services Council) for assessment. Letter typed to accompany him.'

(Exhibit C15)

2.26. Dr Drennan then typed a letter referring AB to Warinilla. The letter includes the following information:

'As you know, AB has a problem of Heroin addiction. He states that he uses heroin for its antipsychotic properties. We have commenced him on Clozapine since he was admitted to the Glen. His current dose is 25mg mane, 50mg nocte. He is also on Sertraline 50mg for depression. His Olanzapine 10mg nocte has not yet been ceased – it will be tapered as his Clozapine increases.

Initially AB said that he could stop Heroin without any help, but he is now expressing an interest in the Methadone program. I would value your assessment and plans for treatment.'

(Exhibit C19a)

2.27. Although it is not totally clear, it would appear that AB was given a cabcharge voucher to transport him to Warinilla. He attended there, and he was seen by Dr Susan Caton at 3:30pm that afternoon. Dr Caton’s note of her attendance reads as follows:

'AB presented stoned requesting Methadone as soon as possible. Heroin $100/day even when in Glenside. Used $100 today 12:00 noon.

…

Plan – to present Monday am for assessment

SOBER.'

(Exhibit C19a)

2.28. There was no entry in the Glenside Hospital clinical record for 28 October 2000.

2.29. On Sunday 29 October 2000 AB absconded again. He returned at 1pm but was absent again at the ward handover at around 7pm. He returned at 9:20pm requesting Diazepam for ‘withdrawals from heroin’. He was given two doses of Diazepam that evening, of 5mg each.

2.30. On Monday 30 October 2000 AB attended Warinilla again, and he was seen by RN Walsh. She conducted a duty counselling session with him, during which he told her that he was using $50 to $100 of heroin per day in three doses. He told her that he had last used it at 10am that morning and had used $50 worth. He told her that he used Valium, Sertraline, Olanzapine and ‘Clonazapine’, although I think that last drug should have been Clozapine. He was told to present the next day ‘not intoxicated’ for an appointment with the medical officer. He was also seen briefly by Dr Margaret Moody that day. Dr Moody reinforced the instruction not to use heroin, and provided him with various information booklets (Exhibits C10b, C10c and C10d).

2.31. On Tuesday 31 October 2000 AB presented again at Warinilla where he was seen by Dr Moody. Her note of the consultation is as follows:

'Using heroin since age 14. Regular use from age 20. Has had several I/P (inpatient) detoxes and spent a few days in the Woolshed in 11/96. Recent use $100/day injecting x 2/day using clean fits (needles). Dropped (overdosed) once or twice but not recently. No other substance abuse. Occasional alcohol.

Schizophrenia diagnosed 1997. Current treatment being changed over from Olanzapine to Clozapine. Staying in longterm program at the Glen.'

(Exhibit C19a)

2.32. After a full examination, Dr Moody assessed AB as being suitable to enter the Methadone maintenance program. She directed that he commence on a dose of 25mg to be increased 5mg to 10mg per day prn (as required) to maximum 40mg. On 1 November 2000 he received 35mg, and on 2 November 2000 he received 40mg.

2.33. On 1 November 2000 Dr Drennan saw AB at 3:15pm. Her note of this consultation is as follows:

'AB was given 25mg of Methadone yesterday and ? 35mg today. Is quite sedated this pm. Wants to see a dietician to assist him to not gain eight on Clozapine. ü

Wants to do some art work – this is available.'

(Exhibit C15)

2.34. On 1 and 2 November 2000, AB’s behaviour continued to be difficult to manage. He was described as ‘defiant’, ‘overtly familiar’, ‘continues to lie and manipulate, splitting staff and being over familiar and syrupy in order to get needs met’, ‘disruptive and push(es) limits’, and ‘disruptive to other patients’.

3. Events of 2-3 November 2000

3.1. As I have already mentioned, AB received 40mg of Methadone at about 9:30am on 2 November 2000 at Warinilla (see Exhibit C10e).

3.2. At 4:10pm, the following Glenside Hospital nursing note appears:

'AB attended Warinilla this morning to receive Methadone. Upon return looked sedated, however was more settled in mood. Conversation was more pleasant and cheerful where as prior to leaving ward was belligerent, hostile and difficult to motivate and comply with reasonable requests. Given $10 with which he purchased cigarettes. Did not attend music this afternoon. Several cigarette butts were found in bedroom drawers along with cigarette ash. Informed again that smoking indoors is prohibited and extremely dangerous. Has required some limit setting for intrusiveness today.'

(Exhibit C15)

3.3. Mr Danny Bradley, AB’s room-mate at the Glen, said that he saw AB at about 5pm that afternoon in bed, snoring (T371).

3.4. At 5:40pm AB telephoned his mother, Mrs Margaret O’Donnell, and asked her to come and see him. She said:

'I knew that from the tone of his voice that he was very heavily medicated. I said, you’re on the Methadone program and he said yes, he said, but I think they’re giving me too much Mum. I remarked that it sounds like you are really out of it AB and he said yes. I said, look, it would be best for me to come and see you when you are okay. So we will leave it tonight and we will catch up tomorrow, and he agreed to this and told me that he loved me.'

(Exhibit C1b, p1)

 

3.5. Mrs O’Donnell said that after this conversation with her son she telephoned Dr Drennan and expressed concern to her about the level of AB’s sedation. She said that Dr Drennan seemed to share this concern, and undertook to look into it the following day. Dr Drennan could not recall any such conversation (T71). As I have already stated, Dr Drennan noted the same thing about AB the previous day. She took no further action to follow it up with Warinilla.

3.6. At about 8pm, Mr Bradley saw AB again in the TV room walking backwards and forwards listening to his radio (T372). Mr Bradley did not speak to him then, and could offer no opinion as to his mental state at the time.

3.7. At 8:20pm, AB was seen by RN Angela Padget. She said:

'I was speaking to another patient at the time when I saw AB skipping along the path towards the front door. He greeted me and I acknowledged AB. He appeared quite happy, but I didn’t speak to him further at that stage…'

(Exhibit C20, p1)

3.8. RN Padget saw AB again at around 9pm when she gave him his medication for the evening, including Olanzapine (10mg), Clozapine (50mg) and Diazepam (10mg). The Diazepam (Valium) was given at his insistence, despite RN Padget’s attempt to dissuade him from taking it (Exhibit C20, p2).

3.9. After taking the medication, RN Padget said that AB said 'Goodnight Sweetheart'. She said that he did not appear sedated at that time (T321). In fact, he pointed out that he had not had his observations taken that day, as required by the Clozapine protocol. As a result of this, RN Padget directed Enrolled Nurse Manhire to take his observations, which she did shortly afterwards. EN Manhire said that his temperature and respiration rate were normal, but his pulse was slightly high at 100 beats per minute (T336). She also said that he did not seem sedated or ‘high’ (T338).

3.10. RN Padget said that she checked the patients in the Glen at regular intervals during the night. She said that these checks took place at 12:30am, 2:30am and 4:45am. She said that she checked each patient with a torch, and that on each occasion he was ‘snoring loudly’ (T306).

 

3.11. RN Padget said that EN Manhire carried out the 6:15am check of the residents. She said:

'Carolyn reported to me that on her 6:15am round she went in to AB’ room, but she did not see him in the room. She said that she heard someone in the toilet and assumed that it was AB.'

(Exhibit C20, p2-3)

EN Manhire had no recollection of this, and told me that all she could remember was that all the patients were accounted for (T339-340).

4. Issues arising at inquest

4.1. Cause of death
A post-mortem examination of the body of the deceased was performed by Dr R A James, who was the Chief Forensic Pathologist, at the Forensic Science Centre on 5 November 2000. A toxicological analysis of blood taken at autopsy was performed by Mrs Janice Gardiner, Forensic Scientist, and disclosed the following:

'RESULTS'

1. The blood contained:

(1) approximately 1.0 mg Methadone per L. (toxic/lethal concentration)

(2) 0.27 mg olanzapine per L. toxic concentration)

(3) 0.78 mg clozapine per L. (toxic concentration)

(4) approximately 0.1 mg codeine per L. (therapeutic concentration)

(5) approximately 0.1 mg presumptive diazepam per L. (therapeutic concentration)

(6) approximately 0.1 mg presumptive nordiazepam per L. (therapeutic concentration).

2. Neither alcohol nor sertraline was detected in the blood. '

(Exhibit C4a)

4.2. An additional toxicological analysis, performed at the request of Ms Hodder, Counsel Assisting me, resulted in a further report from Mrs Gardiner advising that the blood also contained 0.26mg (presumptive) Sertraline per litre.

4.3. Mrs Gardiner also advised that morphine was not detected in the blood with the limit of detection being 0.01mg per litre (Exhibit C4b).

4.4. A further report from Mrs Gardiner advised that Flupenthixol was not detected in the blood, with the limit of detection being 0.010mg per litre (see Exhibit C4c).

 

4.5. Dr James commented as follows:

'1. Death was due to mixed drug toxicity. The Methadone level was reportedly approximately 1mg/L and he had toxic levels of two benzodiazepine-class drugs, clozapine and olanzapine.

Fatal levels of Methadone vary between 0.4-1.8mg/L, with the average fatal level being 1.0mg/L. In a patient on long-term maintenance on the Methadone programme, a level of 1mg/L would be compatible with survival. However, the clinical information suggests that the deceased in this case had only very recently commenced treatment with Methadone, and therefore would not yet have acquired full tolerance to the drug. In this case the reported level of 1mg/L of Methadone is relevant to the cause of death, and in conjunction with toxic levels of two benzodiazepine-class drugs, death appears to have been due to a combination of these drugs.

It is recommended that this case be reviewed by Dr Robert Ali of the Drug and Alcohol Unit.

2. There were no injuries or other markings on the body to indicate the involvement of another person in the death.

3. No natural disease that could have caused or contributed to the death was identified at autopsy.'

(Exhibit C3a, p1)

4.6. Having regard to the fact that treatment given to AB at Warinilla forms part of the circumstances of his death, I did not consider it appropriate to seek Dr Ali’s opinion in this case.

4.7. I have received a report detailing the expert opinion of Associate Professor Nick Buckley who is the Director of Clinical Pharmacology and Toxicology at Canberra Hospital as well as being an Associate Professor at the University of Sydney. Associate Professor Buckley is a Consultant Physician as well as a Pharmacologist and Toxicologist, and he has very wide experience and a high degree of expertise in the analysis of drug concentrations in the body and the interpretation thereof.

4.8. Associate Professor Buckley analysed the toxicology results obtained by Mrs Gardiner on the basis of the history of the medication provided to AB in the last few days before he died. In particular, he proceeded on the basis that AB had received 25mg of Methadone on 31 October, the 35mg on 1 November and 40mg on 2 November 2000, and he received 10mg of Diazepam at about 9pm on 2 November as well as 10mg of Olanzapine and 50mg of Clozapine. He also received 50mg of Sertraline in the morning.

4.9. By way of initial comments, Associate Professor Buckley reported:

'9. Methadone maintenance treatment is commonly used as a treatment for opiate dependence. Recommended starting doses are 20 to 30 mg daily. It is recommended that doses are not increased by more than 5mg/day. The majority of Methadone related deaths occur in the first few weeks of therapy (typically on the third or fourth night as in this case) and are related to higher doses given to non-tolerant or opioid naïve individuals. Much higher doses may be used after induction over the first few weeks. The doses prescribed in this case (25 to 40 mg /day) are within the general recommended doses for starting Methadone. It is clear from the records that there is objective evidence that AB was a regular user of heroin (based on repeated observations of him being intoxicated with small pupils)'

10. The volume of distribution of Methadone is 3 to 6 L/kg (ie 210 to 420L in AB). The clearance of Methadone in the average person would generally be between 70 and 250 mls/min. Using these values and the doses administered, this would predict that his concentration at the earliest possible time of death (say 10pm) would have been between 0.1 and 0.3 mg/L (see figure).

 

 

 

 

 

 

 

 

 

 

 

11. In support of this prediction, in studies of fatalities within the first few days of Methadone induction, concentrations were between 0.1 and 1.1 mg/L. However the higher concentrations were only found in those being given much higher doses and/or greater duration of Methadone.

12. Similar to other opioids, fatal blood concentrations of Methadone overlap with ‘therapeutic’ concentrations. This is because of the development of ‘tolerance’ to the sedative effects. The concentration of Methadone post-mortem in this case (1 mg/L) is at the top of the range reported in deaths occurring during Methadone induction (0.1 to 1.1 mg/L). It is more than sufficient to be a sole explanation for death, as a high degree of tolerance would not have been expected.

13. There are some complicating factors that confound post-mortem Methadone concentrations. Methadone may redistribute post-mortem, leading to higher concentrations that existed at the time of death, but this occurs in an unpredictable manner. This effect is not large but has been reported to increase concentrations by up to 40%.

14. Methadone has a long half-life and concentrations do not fluctuate to a great extent over the course of the day – peak concentrations occurring 2 to 4 hours after ingestion are generally only 1.6 fold greater than the trough concentration just prior to dosing. Concentrations are at ‘steady state’ about a week after any change in dose. Thus AB would not have been at steady state – meaning his Methadone concentration would have been increasing each day he was dosed – see figure, (and would have continued to increase for another week or so, if he had continued on 40 mg/day).

(Exhibit C25, pp2-3)

4.10. Associate Professor Buckley’s conclusions were as follows:

'24 Deaths occurring within the first few weeks of Methadone use are relatively common and easily explained on the basis of a dose in excess of that which the person could tolerate. Profound respiratory depression during sleep is the usual mode of death. It is difficult to reconcile this with his posture at the time of death – but it is possible that he got out of bed to vomit and then lapsed into a coma kneeling beside his bed, dying of respiratory depression and/or hypothermia. No explanation other than Methadone toxicity is apparent or required.

25 The methadone concentration measured post-mortem is several times higher than expected. This cannot be reasonably attributed to an interaction with Sertraline or post-mortem redistribution. Thus it seems probable that a dose higher than that prescribed at Warinilla was ingested. If this was ingested orally, then 100mg or greater would be required to explain the post-mortem result. There have been many reports of overdoses from supplementation of Methadone from illicit or diverted sources and it seems most likely that this is the cause of his fatal Methadone overdose and higher than expected concentration.

26 The concentration reported is vague ‘approximately 1 mg/L’, and raises the question does this reflect a less than complete toxicological evaluation? Also, why was no Sertraline or its metabolite detected? The laboratory should be asked to confirm its report prior to further investigation as to a source of non-prescribed Methadone. They should also be asked to look for Morphine if that has not been done. They should also examine the stomach contents for Methadone (no Methadone would be expected to be remaining from his morning dose).

27 The doses of Methadone prescribed were quite reasonable in someone who was a regular heroin user beginning Methadone maintenance treatment. The only concern related to the prescription was that the interaction with Sertraline may not have been recognised. This might have lead to a more conservative approach to dose escalation (ie doses might have remained at 20 to 30 mg/day during induction). However this does not explain the very high concentrations found post-mortem.

28 While cardiac deaths from therapeutic use of Clozapine occur at about this time after commencement, these are not common and there is no supporting evidence (such as myocarditis on autopsy or ECG changes).

29 The slightly high concentrations of Clozapine and Olanzapine are most likely explained simply by post-mortem redistribution. These drugs and the Diazepam and Codeine would have contributed to the sedation and respiratory depression but clearly the major drug responsible for death in this man was Methadone.'

(Exhibit C25, p5)

4.11. As to Associate Professor Buckley’s concern, expressed in paragraph 26 of the report, about the accuracy of the toxicological results, Ms Hodder requested further reports prepared by Mrs Gardiner to which I have already referred. On the basis of those results, Associate Professor Buckley ruled out morphine or codeine playing a part in AB’s death (T451). As to Flupenthixol, Associate Professor Buckley said that because the therapeutic range of this medication extends below the limit of detection available to Mrs Gardiner, it is possible that there was still a therapeutic concentration of Flupenthixol in AB’s blood which was not detected (T452).

4.12. Even if AB’s blood concentrations of Methadone had been as low as between 0.1 and 0.3 mgs per litre, which could have been totally explained by the Methadone dispensed at Warinilla as depicted on the graph, Associate Professor Buckley conceded that this would have been within the range of concentrations which have proved fatal in the past (T455).

4.13. When questioned by Mr Bonig, Counsel for Glenside Hospital, Associate Professor Buckley pointed out that this did not explain the concentrations that were actually found at post-mortem. Having regard to AB’s weight, a concentration at post-mortem of 1mg per litre would indicate that AB has received 210mgs of Methadone in total. He only received 95mg from Warinilla, leaving a deficit of more than 100mgs of Methadone which cannot be accounted for (T455).

4.14. As to post-mortem redistribution, Associate Professor Buckley pointed out that this is more likely to be an issue where the patient has been receiving the drug over a long period. He said:

'As I pointed out in my earlier statement, post-mortem redistribution is mainly an issue for people who are chronically on a drug and therefore have a high body burden of the drug which then redistributes back into the circulation on death. It is more difficult to explain a situation like this where the Methadone has been recently started.' (T458)

4.15. Even if redistribution took place in AB’s body after death at the maximum rate ever reported in the literature, namely 40%, this would still only have raised his post-mortem levels (assuming that he had only ever received the doses at Warinilla) to between 0.12 and 0.34 or thereabouts, which is still nowhere near 1.0 as was found in AB’s body at post-mortem (T459).

4.16. The only drug found in AB’s blood which could have complicated this picture was the presence of Sertraline, found at a presumptive concentration of 0.26mgs per litre, as reported in Mrs Gardiner’s second report (Exhibit C4b). Associate Professor Buckley said that this would have had a ‘fairly minor effect’ on his calculations (T443).

4.17. As to the other antipsychotic medications found in AB’s blood at autopsy, Associate Professor Buckley commented:

'All antipsychotic drugs and benzodiazepines are sedative and may have additive sedating effects when combined with Methadone.'

(Exhibit C25a, p1)

4.18. In my opinion, an analysis of this rather complex evidence leads to the following conclusions:

· The concentration of Methadone in AB’s blood found at autopsy is more than sufficient to explain his death;

· The other antipsychotic medications found in AB’s blood at autopsy would have had a sedating effect additional to that of the Methadone and as such they are relevant in the legal sense, although not necessarily relevant to a medical analysis of the case (T442). I note that Mrs O’Donnell has made a written submission supporting this conclusion;

· Accordingly, I find that AB died as a result of mixed drug toxicity;

· The concentration of Methadone found in AB’s blood at autopsy cannot be explained by the doses of Methadone dispensed to him on 31 October, 1 November and 2 November 2000;

· The only reasonable explanation for the concentration of Methadone found in the blood at autopsy, having made an excessive allowance for post-mortem redistribution after death, is that AB obtained an extra supply of Methadone illicitly and administered it to himself;

· The evidence of AB’s clinical condition during 2 November 2000 is contradictory and unclear. He was noted by nursing staff to have appeared sedated in the afternoon. Mr Bradley said that he was in bed snoring loudly at 5pm. Mrs O’Donnell thought her son sounded sedated at around 5:40pm. On the other hand, RN Padget and EN Manhire thought that he appeared normal at between 8pm and 10:30pm before he retired to bed. After he went to bed he was noted to be snoring loudly which can be a sign of sedation (T446);

· It is not possible to draw conclusions about when AB consumed the extra Methadone, whether it was during the daylight hours of 2 November or later in the evening. Associate Professor Buckley said:

'Basically, the concentration doesn't change that much with time because the clearance is very slow of the drug, so it could be a few hours before, it could be one hour before, it could be - one would expect the peak effect fairly rapidly. As I said, if you overdose on the drug you might still die during your sleep rather than wakefulness, so it is, for example, possible that sometime that afternoon he might have got an extra dose of Methadone and that he still would have died during the night.' (T448)

4.19. Standard of psychiatric treatment
I received a report from Professor R D Goldney who is a Professor of Psychiatry at the University of Adelaide and has extensive experience in academic, general and hospital psychiatry as well as the medico-legal aspects of psychiatry.

4.20. Professor Goldney examined the materials which form the evidence in this matter. His initial comments were as follows:

'It is pertinent to note at the outset that AB presented a particularly challenging clinical situation, having a chronic psychotic illness with associated substance abuse. I find Dr Hustig’s reservations about the presence of a psychotic disorder to be somewhat unexpected, particularly in view of the fact that AB was commencing Clozapine in Dr Hustig’s unit at the time of his death. I appreciate that there can always be doubt about diagnoses, but there appears to have been, certainly in my view, adequate documentation of psychotic symptoms which are typical of a severe schizophrenic or schizo-affective disorder.'

(Exhibit C26, p6)

4.21. Firstly, Professor Goldney said that the extent of AB’s antipsychotic medication was reduced upon admission to Glenside Hospital, no doubt as part of the ‘weaning’ process before the introduction of Clozapine. For example, his dosage of Olanzapine was reduced from 20mg at night to 10mg, and the Sertraline was reduced from 200mg to 50mg, and was only substituted by a low dose of Clozapine at 12.5mg. These changes occurred in the context that the regular injections of Flupenthixol had been ceased altogether. Professor Goldney expressed concern that, overall, AB’s level of antipsychotic medication had been reduced considerably during his stay at Glenside (T463-464).

4.22. Professor Goldney also expressed concern that the detention order made initially by Dr Drennan, and extended by Dr Hustig, was not extended further by Dr Scurrah on 26 October 2000. Indeed Professor Goldney was somewhat critical of the thoroughness of Dr Scurrah’s assessment. For example, he said that Dr Scurrah appeared to pay little attention to AB’s history, and concentrated almost entirely on his presentation that day. He was dubious about the proposition that because AB indicated that he needed to go to Narcotics Anonymous, he was displaying ‘insight’ as Dr Scurrah suggested.

4.23. Professor Goldney said that the criteria for detention under the Mental Health Act 1993 continued to exist, and that the detention order should have been continued. He said:

'We have a man here who has got a chronic schizophrenic or schizo-affective disorder, is on far reduced doses of antipsychotic medication, he has been established on a new antipsychotic drug, he has got a past history of suicidal behaviour and I understand that some of that suicidal behaviour he was acting in response to delusional beliefs when he jumped, and there is a past history, a relatively recent history of him having risked his life with an overdose which he said was accidental. Now I think he was still at acute risk … there is the history of him absconding frequently from the ward, not being available for the introduction of the Clozapine. The only way in which he could be adequately managed would be by having that external control to try and introduce appropriate treatment.' (T471-472)

4.24. Dr Scurrah rejected Professor Goldney’s criticisms of his assessment. He pointed out that there was a good deal more in his interview with the patient which he did not note in the clinical record. He gave an elaborate explanation and interpretation of the rather scant material which he did record (see his evidence at T141-147).

4.25. I am not in a position to reject Dr Scurrah’s evidence about what transpired between him and AB on that day. However, I have considerable scepticism that his assessment of AB was as thorough as he now suggests, having regard to the content and tone of the entry he made in the clinical record. It seems to me that if a practitioner expects his assessment to have any therapeutic value for the patient, in the longitudinal sense, he should put a lot more information arising from his mental state assessment, assuming he performed one, in the clinical record for the benefit of subsequent therapists. It seems to me that the entry Dr Scurrah put in the clinical record simply addressed the issue before him, namely, was AB detainable or was he not? Dr Scurrah does not appear to me to have addressed the issues of ongoing management or treatment at all.

4.26. Introduction of Clozapine therapy
There is general agreement among the clinicians who gave evidence in this matter that it was appropriate to introduce Clozapine therapy. Other antipsychotic medications had been tried in the past without success, and AB’s condition was not improving. Professor Goldney said:

'I think it is a very appropriate medication to have used.' (T466)

4.27. Professor Goldney also supported the idea of admitting AB to hospital in order to introduce the Clozapine therapy on a managed and controlled basis. However, as I have already mentioned, he was concerned that AB was continually absconding from the hospital, thereby delaying the introduction of the Clozapine therapy for eleven days until it was eventually introduced on 20 October 2000. Even after the Clozapine therapy was commenced, he continued to abscond and, according to his own statements to therapists, continued to abuse heroin throughout that time. It was no doubt Dr Drennan’s frustration at her inability to manage this behaviour which led to her decision to detain him on 23 October 2000, and which led to her subsequent frustration when Dr Scurrah failed to confirm the order (T63), a feeling with which I can readily sympathise.

4.28. The Methadone program
Professor Goldney told me, and I accept, that it was surprising that AB was allowed to commence Methadone therapy in the circumstances. He said:

'It surprises me a little that he was, because if in fact it (the heroin abuse) was very much related to his psychotic illness, let's see what result we get from the Clozaril. Really, what is happening is two quite major steps in this person are being undertaken at the one time and it's possible that if Clozaril was going to work, if that could have been introduced successfully, his need for narcotics may have reduced. It may not have, but one is doing two quite major interventions at the same time here. There's no absolute reason why you can't do that but I would prefer to do one at a time.' (T474)

4.29. Indeed the whole manner in which AB commenced on the Methadone program seemed adhoc and opportunistic. Dr Drennan wrote the letter of referral to Warinilla on 27 October 2000, but it would appear that he had already been to Warinilla, and had already made an appointment for later that afternoon, when she wrote the letter. In any event, it seems to me that the staff at Glenside were behind the play the whole time on this issue. The clinical records reveal, for example, a telephone call from RN Gifford on 1 November 2000 seeking information from Warinilla about Methadone and AB’s treatment regime. It would have been much more appropriate if all of these details had been discussed between the clinicians at Warinilla and Glenside before AB ever commenced on the Methadone program.

4.30. The situation may have been complicated by the fact that Drs Hustig and Drennan were undertaking training at Warinilla in order to receive accreditation to prescribe Methadone at the time these events occurred. Dr Hustig was at Warinilla on 30 October, and gave AB a lift back to Glenside after he was seen by Dr Moody that day. Dr Moody had written in the Warinilla clinical record:

'Glenside can dose AB but probably best to do early stabilisation here and Dr Hustig will take over after the weekend.'

(Exhibit C19a)

4.31. If there were more detailed discussions between Dr Hustig and Dr Moody on that occasion, it is regrettable that Dr Hustig did not make an entry in the clinical record of his understanding of AB’s proposed treatment regime.

4.32. I was told that since AB’s death, the proposal that medical practitioners at Glenside should also administer Methadone has been abandoned. I was told that no Glenside inpatient has entered the Methadone program since that time, although some patients, who are already stabilised on Methadone, have been admitted to Glenside and the Methadone treatment has been continued (see the evidence of Ms Malone T399).

4.33. Having regard to the evidence of Ms Malone who has, since AB’s death, been appointed the Director of the Glenside Hospital campus, I am confident that these issues would now be approached on a different basis. For example, Ms Malone told me that a Clinical Director, Associate Professor Norman James, a Director of Nursing Care Services, Mr Des Graham and a Director of Corporate Services have since been appointed and together with Ms Malone form the executive of the organisation. As a result, there is a much clearer and more focussed management structure for the organisation. In addition, a number of clear protocols have been developed which deal with a number of the issues before me. For example:

· Protocol MHCLPR-0900 deals with a ‘risk assessment’ which must be completed in relation to all patients prior to admission, and at regular intervals thereafter. Once the assessment has been carried out, the management plan must specifically address the risks which have been identified. I am sure that if this process had been performed in relation to AB, a number of very clear risks would have been identified and, hopefully, a plan would have been developed to deal with them;

· Protocol MHCLPR-0901 deals with ‘nursing observations’ and clearly sets out the requirements placed upon nursing staff to observe patients with regard to the risk factors which have been identified, and contains a specific direction that the regular visual sighting of a patient is to be recorded in the client record. This is to be contrasted with AB’s case, where the observations of RN Padget were not recorded;

· Protocol MHCLPR-0902 deals with ‘missing persons’, and sets out a clear action plan when patients are missing from the campus, and requires a risk assessment to be performed on the return of a patient from an unapproved absence;

· Protocol MHCLPR-0903 deals with ‘escorting patients to external agencies’, and again requires a risk assessment to be carried out and a management strategy to protect the patient from harm. In particular, the decisions about the level of supervision to be given to a patient are to be made by the clinical nurse consultant or the senior nurse on duty within the ward so that a degree of consistency and management skill is brought to the task.

4.34. Dr Hustig told me that Glenside no longer accepts patients purely for the initiation of Clozapine therapy, and that if Clozapine therapy is to be embarked upon, it is more likely that this will be done in the context of an acute hospital setting rather than a psychiatric hospital setting (T131-132).

4.35. In particular, Dr Hustig said that the psychiatrists were more aware of the difficulties involved in operating parallel therapies, namely both Clozapine and Methadone:

'Certainly since the event with AB, we've deliberately taken the line that of not running the two drugs concurrently. The reality is I've since had more options on atypicals and certainly, AB would have been tried on a few more drugs before we would have ventured on this combination, even in 2003. But in 2000 he'd already been tried on all of the drugs that we had.' (T132)

4.36. Ms Malone also told me that there have been discussions with Warinilla, and that she would expect that there would be a great deal more consultation between Glenside and Warinilla if a patient approached Warinilla whilst still a patient at Glenside. She said:

'A: Given the different relationship we have with Warinilla today, I don’t believe that they would be accepted without some consultation with us. Having said that, if they don’t actually indicate that they are actually at Glenside, it would be most difficult. It depends on personal responsibility of the individual making that information available.

Q: So you think that that process would be managed more closely than it was?

A: I think there has been a heightened acknowledgement of those issues since AB’s death.' (T403)

5. Conclusions

5.1. I have already indicated that I accept Associate Professor Buckley’s evidence that the most likely explanation for the concentration of Methadone in AB’s blood at autopsy, namely 1.0mg per litre, is that he obtained illicit Methadone in addition to the Methadone prescribed and supplied to him at Warinilla on 31 October, 1 November and 2 November 2000. There is no evidence that he deliberately overdosed himself with Methadone, however. He had a history of reckless behaviour in relation to drug abuse, and the facts are more consistent with an accidental overdose.

5.2. Although this inquest has illustrated that there are several causes for serious concern about the quality of psychiatric treatment AB received at Glenside Hospital in the period leading up to his death, the acceptance of Associate Professor Buckley’s evidence on this point requires the conclusion that none of these deficiencies were causative of AB’s death. In particular, the medication which had been prescribed to him prior to his commencement on the Methadone program cannot be seen to have been causative. As Associate Professor Buckley said:

'I think they are a distraction from the main issue in this case which is surreptitious use of illicitly obtained opioids. Methadone toxicity from an overdose was the probable cause of AB’s death. It is a sufficient explanation and no contributing factors (such as the combination with the other drugs or starting Methadone only ten days after Clozapine) need to be identified. It is unfortunately true that in the real world most people on Methadone are on other psychotropic drugs, despite the known increase in sedative effects. Thus the major clinical question is whether he was an appropriate candidate for Methadone – not whether he was an appropriate candidate for Clozapine. Would an alternative approach to his heroin dependence (such as Clonidine, abstinence (‘going cold turkey’) or Buprenorphine) have been preferable or would have he been equally likely to obtain illicit opioids and overdose (as he had on heroin only a few weeks previously)?'

(Exhibit C25a, p1)

5.3. On the basis of the evidence before me, it can be readily concluded that AB was not an appropriate candidate for Methadone therapy, and that it was inappropriate that he should have entered upon the Methadone program. However, once again, this cannot be said to have directly resulted in his death, since the Methadone prescribed by Warinilla was unlikely to have resulted in his death, although it may have put his blood concentrations in the range from which deaths have been reported in the past.

5.4. Thus, it cannot be said that AB’s participation in the Methadone program was directly causative of his death. The most that can be said is that it may have provided him with the opportunity to obtain illicit Methadone, perhaps from one of the other patients at Warinilla. However, it could be argued to the contrary that he had never experienced difficulty in obtaining illicit drugs in the past, and there is reason to think that, if he wanted Methadone on the illicit market, he would have been capable of getting it whether he had been at Warinilla or not.

6. Recommendations

6.1. I have heard evidence that no Glenside patient has entered the Methadone program as a treatment for heroin dependence since AB’s death.

6.2. If one accepts that Methadone is an appropriate and effective treatment regime for heroin dependence, and if it is accepted that such treatment could be administered at the same time as appropriate psychiatric treatment is being provided to a patient, it seems to me that this treatment should be available.

6.3. However, if the two forms of treatment are to be administered at the same time, a very clear management plan must be developed between the two agencies involved in the treatment, if two agencies must necessarily be involved. It is not clear to me why the therapists at Glenside discontinued their training to become accredited Methadone prescribers. It is to be hoped that this does not signify a retreat into highly compartmentalised areas of treatment, whereby the psychiatrists at Glenside will not deal with drug issues, and the therapists at Warinilla will not deal with psychiatric issues. In patients with multiple diagnoses, this is an entirely inappropriate response.

6.4. I therefore recommend that Glenside Hospital management develop clear protocols with the Drug and Alcohol Services Council concerning the optimum way in which Methadone therapy can be made available to Glenside patients.