An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 16^th, 17^th, 18^th, 20^th, 23^rd, 24^th and 25^th of June 2008, the 17^th day of July 2008 and the 3^rd day of December 2008, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Rowan Scott Wheaton.

The said Court finds that Rowan Scott Wheaton aged 18 years, late of 3 Fletcher Drive, Christies Beach, South Australia died at Christies Beach, South Australia on the 21^st day of April 2006 as a result of neck compression due to hanging.  The said Court finds that the circumstances of his death were as follows:

1.                  Introduction and reason for Inquest

1.1.           Rowan Wheaton hanged himself using a sock suspended from a door handle on 21 April 2006.  He was at that time detained pursuant to an order of the Guardianship Board relating to his place of residence.  Accordingly, his was a death in custody within the meaning of the Coroners Act 2003 and this Inquest was held pursuant to section 21(1)(a) of that Act.

2.                  Aspergers Syndrome

2.1.           Aspergers Syndrome is a neuro-developmental disorder.  It is sometimes considered to be part of what is called the Autistic Spectrum.  Sufferers often appear to have normal intelligence and normal development up to around the age of 5.  They then find it difficult to manage social interactions and they may have odd and eccentric mannerisms.  They may suffer from anxiety and appear to have stereotyped or restricted interests in particular circumscribed fields.  They struggle, particularly in their teenage years with relationships with others[1].

3.                  Rowan is diagnosed with Aspergers Syndrome

3.1.           Rowan’s father, Simon Wheaton, gave evidence.  He said that when Rowan was 4 years of age he was diagnosed with Aspergers Syndrome[2].  His parents noted that he would rock, engage in repetitive behaviours and ‘zone out’ in the sense of not being as aware of his environment as he should have been[3].  Rowan’s diagnosis had a significant effect on the Wheaton family.  Mrs Wheaton is an Enrolled Nurse and she would have returned to work after Rowan’s birth were it not for his condition[4].

3.2.           Mr Wheaton said that for most of his life Rowan was a pleasant and agreeable young man[5].  Vanessa Alexander who is a lecturer in disability studies and has worked with sufferers of Aspergers Syndrome during her career had a considerable amount of contact with Rowan over his life.  She said that as an 8 year old boy Rowan was a delight and was very easy to work with[6].  She said that he was socially very immature but compliant.  He was interested in Egyptology and the Titanic.  She worked with him until he was about the age of 11 when her work circumstances changed and she lost contact with Rowan.

3.3.           Ms Alexander’s next contact with Rowan was when he was approximately 13 years of age.  She said he was still a very happy and delightful child.  However, she next encountered Rowan when he was a student at Woodcroft College and Ms Alexander was engaged there as a counsellor.  Rowan was then 14 or 15 years of age and Ms Alexander noted a marked difference in Rowan’s behaviour.  She said that he was very worried and eager to please everyone.  He was always polite but concerned that he would be a disappointment to his teachers and parents[7].  According to Ms Alexander, Rowan had a very negative view of himself and she was worried about his level of anxiety[8].

3.4.           Simon Wheaton said that although Rowan was able to attend mainstream school for most of his school life, problems started to develop in his teenage years.  Mr Wheaton said that Rowan would retreat from the classroom situation and engage in rocking backwards and forwards while seated outside the classroom[9].  Mr Wheaton said that Rowan developed a level of literacy and numeracy that was quite reasonable[10].

3.5.           When Rowan was in Year 11 at Woodcroft College he was required to attend religious instruction classes.  During these classes he became agitated and violent, to the extent that he would throw chairs.  Rowan had gradually developed a fear of religious groups which seemed to be associated with this behaviour.  In the end, Rowan left school in Year 11 and stayed with his parents at home.  Mr Wheaton said that they tried to teach him to live as independently as possible but that Rowan did not have an understanding of money or paperwork.  Mr Wheaton said that Rowan was something of a ‘fly in a bottle’ at home[11], becoming frustrated but unable to cope with the outside world.  Rowan tended to stay up all night.  From time to time Rowan would light small fires in his room[12].  At about this time he called Mr Wheaton into his room and explained that when he was 18 he wanted to be taken to America to obtain weapons and that he wished to take action against religious groups whom he regarded as a great threat[13].  When Mr Wheaton attempted to dissuade Rowan from these notions, Rowan would react violently[14]. 

4.                  Rowan’s behaviour escalates

4.1.           In the period leading up to his 18^th birthday in November 2005, Rowan would regularly behave violently in the Wheaton’s home.  He would smash items in his room and kick holes in the wall.  He would hurl himself against the furniture[15].  Mr Wheaton said that on three or four occasions Rowan would run from the Wheaton house to the nearby Lonsdale Road[16] dodging in amongst traffic.  The Wheatons interpreted this as a method of attempting to kill or otherwise harm himself[17].  These events usually occurred at night and Mrs Wheaton would telephone the police while Mr Wheaton ran after Rowan where he would have to drag him off the road and take him home.  Mr Wheaton would have to use physical force.  On one occasion Rowan tried to attack Mr Wheaton when Mr Wheaton refused to support his views and tried to persuade him to moderate his violent attitudes[18].

4.2.           On another occasion Rowan grabbed a knife from the kitchen drawers and tried to stab himself in the stomach but Mr Wheaton was able to restrain him from doing that because he spotted Rowan in the act[19].

5.                  The Wheatons attempt to obtain assistance from the hospital system

5.1.           During this period Mr Wheaton said that the family made a number of attempts to obtain assistance for Rowan through the hospital system.  Mr Wheaton commented that services for persons suffering from Aspergers Syndrome disappear after the initial early intervention[20] and although Autism SA runs social groups and other services, the Aspergers sufferer has to get by in the community[21].  Mr Wheaton said that the Intellectual Disability Services Council – now known as Disability SA – provided lists of private organisations and places where the Wheaton family might be able to obtain help.  However, they were unable to obtain assistance from any of these places because Rowan, with an IQ above 70, was not regarded as suffering from a mental disability and also because he did not have a caseworker[22].

5.2.           Mr Wheaton gave a harrowing account of a number of Emergency Department visits in which Rowan would be discharged shortly after his arrival because the clinicians in the Emergency Departments would say that there was nothing they could do for Rowan.  Mr Wheaton said that Rowan attended at either the Flinders Medical Centre[23], the Noarlunga Hospital or the Women’s and Children’s Hospital, and he attended each of these institutions on a number of occasions, sometimes accompanied by the police and the ambulance service[24].  Mr Wheaton said that when Rowan was presented with a novel situation such as the Emergency Department, he would calm down.  Because he was not behaving irrationally, the clinicians would say that he appeared to be well and could leave[25].  Another witness, Joanna Zeitz, who has worked extensively in the area of Autism Spectrum Disorder (ASD) said that a person with ASD who arrives in a very agitated state at an Emergency Department and who is met with the response of being held in the hospital or medicated if their behaviour continues ‘can remarkably pull the behaviour into line’.  She pointed out that a person with a mental illness or a psychosis simply would not be able to do that[26].  Accordingly, busy Emergency Departments could respond by discharging Rowan almost as soon as he had been brought in the door.

5.3.           Mr Wheaton gave a lengthy account of his numerous attempts to obtain treatment for Rowan at the hospitals mentioned above.  His strategies included refusing to leave until Rowan was treated and producing a tape recorder to record his conversations with staff.  Clearly he was extremely frustrated with the hospital system and his perception that he was unable to obtain treatment for Rowan that was sorely needed.

6.                  August 2005 - Crisis meeting in Boylan Ward

6.1.           This period culminated in an admission to Boylan Ward in the Women’s and Children’s Hospital.

6.2.           Rowan’s Women’s and Children’s Hospital notes were admitted as Exhibit C27 in these proceedings.  They show that on 2 August 2005 Rowan was admitted to Boylan Ward, the psychiatric unit at the Women’s and Children’s Hospital.  On that occasion he was kept at the hospital overnight and discharged the following day.  The final separation summary for that admission says that Rowan presented following an argument with his father over Rowan’s views that all terrorists should be killed culminating in Rowan slapping his father in transit to the Flinders Medical Centre.  Rowan denied suicidal or homicidal ideation and was settled in behaviour and affect during the stay.  There was no evidence of pervasive mood or psychotic disturbance.  The summary records that he was discharged to his father’s home and a list of private psychiatrists was provided.  Following this admission, Rowan was next seen at the Women’s and Children’s Hospital in Boylan Ward on 7 August 2005.  The final separation summary for that admission records that he was admitted on 7 August 2005 and discharged on 12 August 2005.  The summary refers to the previous admission and records that ‘subsequent altercations with father resulted in this readmission 4 days later, where again settled behaviour was seen’.  Rowan was psychiatrically assessed and according to the summary:

'Saliently, Rowan has received multiple recent psychiatric assessments concurring that inpatient admissions have gained little other than respite.  He has no treatable psychiatric illness affecting his mental state, and has an understanding of law and personal responsibility.  Outpatient management is the option of choice.  A management protocol was formulated (12.08.05) detailing if Rowan presents to an Emergency Department MSE should be evaluated.  If no change from baseline – discharge to parents.  If they refuse – telephone Crisis Care for placement.  If Rowan displays threatening behaviour, consider pressing chares (sic).  Further information can be gained from the AHMHN/Boylan Ward at the Women’s and Children’s Hospital.'

6.3.           A copy of the management protocol is also contained on Exhibit C27.  It refers to the two admissions, provides a diagnosis of high functioning autism disorder and obsessive compulsive traits/disorder and contains the following in bold print:

'In the event of presentation to an Emergency Department to a hospital the following need to be considered:

­          Rowan’s mental state needs to be reviewed.  If there is no change in his baseline mental state, he needs to be discharged home to the care of his parents.

­          If Rowan’s parents refuse to take him home, Crisis Care need to be contacted for placement.

­          If Rowan displays threatening behaviour, consideration needs to be given to press charges against him.

­          No benefit can be gained through inpatient hospitalisation.

­          For further information please contact AHMHN/Boylan Ward at Women’s and Children’s Hospital.'

6.4.           The plan is endorsed by Dr Peyman Bakhtiarian, Consultant Psychiatrist, Paula Redpath, Social Worker and Susan Bailey, AHMHN, all of the Women’s and Children’s Hospital. 

6.5.           It appears that Rowan was discharged home on 12 August 2005 but that a further crisis ensued the same day.  The notes reveal that he was brought to Flinders Medical Centre Emergency Department at approximately 11pm that day having been detained by the police under section 23 of the Mental Health Act 1993.  The Emergency Department doctor records a conversation with Simon Wheaton describing the events leading to the admission.  Rowan had run into traffic on Lonsdale Road and Mr Wheaton had needed to run into the traffic to prevent him from being hurt.  A struggle ensued resulting in Rowan being pinned down by his father.  Rowan then began talking about self-harm and killing himself and the police were called with Rowan being conveyed by them to the Flinders Medical Centre Emergency Department.  Rowan told the Emergency Department doctor that he wanted to kill himself and said that he would do this by drinking the eucalyptus oil in his bathroom.  The doctor records that the management plan from the Women’s and Children’s Hospital, to which I have referred above, had been faxed to Flinders Medical Centre.  The doctor spoke to Dr Ken Hooper, a Psychiatric Registrar at Boylan Ward, who was aware of Rowan’s recent admission there.  The Flinders Medical Centre Emergency Department doctor records that Dr Hooper:

'Would prefer that detention be avoided as he doesn’t feel it will be beneficial.  However he agrees that if he attempts to leave tonight he should be detained.  Currently Rowan is cooperating and willing to stay.  Ken will come in at 0800 to see patient and facilitate the ongoing care.'

6.6.           The Flinders Medical Centre notes show that Dr Hooper did attend at the Emergency Department to see Rowan at 0800 hours on 13 August 2005.  He noted that Rowan told him that after going home Rowan had felt disempowered and weak.  His frustration generated suicidal ideation and this resulted in Rowan walking into the traffic.  Rowan was now apologetic and wanted to return home.  He denied ideas of harm to others or himself and denied ideas of walking into traffic or plans to self-harm.  Interestingly, the note says that Rowan:

'Reports eucalyptus oil has been an “option” he has considered briefly at points of frustration over last two years, but denies courage to enact this.'

6.7.           The notes record that at 9am on 13 August 2005 Dr Hooper contacted Mr Wheaton to discuss the situation.  It appears that Dr Hooper proposed that Rowan be discharged home but at that point Mr Wheaton expressed frustration and concern and Mrs Wheaton could be heard in the background requesting complete assurances for Rowan’s safety.  Mr Wheaton requested confirmation that the hospital would assume legal responsibility for Rowan’s safety after discharge.  At that point Dr Hooper was interrupted and the call had to be terminated.  Dr Hooper was unable to contact the Wheaton home again at that time and at 10:30am a decision was made for Rowan to be transferred to the Women’s and Children’s Hospital.  Thus the clinicians involved at Boylan Ward appear to have accepted that Rowan should be admitted to Boylan Ward despite the terms of the management protocol referred to above.

6.8.           Mr Wheaton gave evidence of his frustration with the hospital system and his feeling that Rowan was being ‘churned’ through that system.  This is reflected in the following passages of his evidence:

'The hospitals have become very adept at pushing people out because they know, because there's no facilities out there, they're going to be stuck with an ASD person for weeks, if not months while a facility is created from scratch.' [27]

'Well once he started running out the road 20 minutes after he was discharged, it became apparent that it was hopeless.  We couldn't stay awake 24 hours a day to watch him, the house was not designed to stop someone from self-harm.' [28]

6.9.           It appears that the clinicians at Boylan Ward brought matters to a head by requesting a case conference be convened involving Disability SA and all other relevant agencies.  Mr Wheaton described the meeting in the following way:

'We attended that meeting at Women's and Children's.  That had about six different agencies and numerous members from the different agencies attending, including the hospital representatives and the objective was to actually find some longer term solution because Boylan Ward was placing a lot of pressure on us.  They were ringing us up and telling us that Rowan was going to be thrown out on the street if we didn't come and get him and by that stage we knew that this was just more of the same ping pong that was going to go on and Rowan would try and kill himself again and we'd have him back there.' [29]

6.10.       Minutes of the case conference were taken and they appear in Exhibit C27.  They record that the case conference meeting was held at the Women’s and Children’s Hospital on Tuesday, 23 August 2005.  Mr and Mrs Wheaton were present.  The other attendees were:

·          Dale Hassam - Director, Disability SA

·          Cheryl Merritt - Senior Practitioner, CYFS

·          Rex Nicholson - Youth Worker

·          Bron Warren - CYFS

·          Adrian Miller - CAMHS

·          Jessica McDeed - Options Coordinator, Disability SA

·          John Martin - CEO of Autism SA

·          Dr Peyman Bakhtiarian - Consultant Psychiatrist, Boylan Ward

·          Dr Ken Hooper - Psychiatric Registrar, Boylan Ward

·          Paula Redpath - Senior Social Worker, Boylan Ward

·          Gigetta Salamone-Violi - Senior Clinical Psychologist, Boylan Ward). 

The minutes occupy five pages and are quite detailed.  They record the various points of view.  They state that the following possible options for ongoing management were discussed:

'1)    Immediate – Disability SA would make an immediate referral to the Exceptional Needs Unit for a longer terms solution.

2)    Discharge home with IDSC intensive support.  Disability SA expressed concern at that suggestion as intensive support would not be available.

3)    Remain on Boylan Ward.  Limited option?'

The meeting adjourned to Boylan Ward with the Wheatons, IDSC allocated case manager, Dr Ken Hooper, Paula Redpath and Gigetta Salamone-Violi where this option was discussed with the family.  It was decided that Rowan would remain on Boylan Ward until Friday, 26 August 2005 during which time Disability SA would be looking for alternative accommodation options for Rowan and working with the family to determine the same while the application to the Exceptional Needs Unit proceeded.  The note said that the Boylan Ward would liaise with Disability SA again at the end of the week.  The meeting went for 2.5 hours.

6.11.       It will be recalled that Rowan was readmitted to Boylan Ward following transfer from Flinders Medical Centre on 13 August 2005.  The case conference occurred on 23 August 2005.  The notes, Exhibit C27, record the following entry by Dr Brock, Psychiatric Registrar, on 31 August 2005:

'Telephone call to Richard Bruggemann, Head IDSC[30].

­      Informed him that Rowan did not suffer from an overt psychiatric disorder and had to be discharged immediately from Boylan.

­      Richard stated he would discuss situation with Dale and Sue and get back to us.'

While the Boylan Ward notes do not reveal any similar sentiment being expressed to Mr and Mrs Wheaton, it is alarming that a clinician would be expressing himself in such peremptory language.  This is consistent with Mr Wheaton’s claims that similar pressure was placed upon Mr and Mrs Wheaton by staff at Boylan Ward. 

6.12.       Undoubtedly the staff at Boylan Ward would have been under pressure to make Rowan’s bed available for other children.  Perhaps the staff would have regarded Rowan as inappropriately admitted to Boylan Ward, as he had no treatable psychiatric condition.  Perhaps other children with psychiatric conditions that may have been amenable to treatment were requiring admission.  This may have resulted in the need for staff at Boylan Ward to press for Rowan’s immediate discharge.  The note to which I have referred by Dr Brock is dated 31 August 2005, which is 8 days after the case conference already mentioned.  It is clear that efforts were being made to find suitable alternative accommodation for Rowan at this time and the Boylan Ward notes refer to the involvement of SJCS[31], the organisation that eventually provided accommodation for Rowan on 30 August 2005.  It is very unfortunate that the hospital system felt such a need to remove Rowan from its care at that time when other alternatives were being actively explored.

6.13.       A further note from Dr Brock on 31 August 2005 reveals that Mr Bruggemann from Disability SA contacted him later that day and assured him that a placement would be available with SJCS on 12 September 2005.  Mr Bruggemann suggested that Rowan could be discharged home and supported there until the placement was available.  The note records that this would be discussed at the ward round the following day and a decision advised to Mr Bruggemann.  The ward round of the following day records as follows:

'Progress discussed.  Remains settled.  Accommodation available 12/09/05.  Option of return to parents in interim discussed – in view of level of family distress/dysfunction and potential destabilising influence on Rowan which may adversely affect transition to community housing, consensus reached that staying at Boylan until 12/9 will be in Rowan’s best interests.  Continue other management.'

6.14.       This unfortunate interlude at Boylan Ward culminated in Rowan’s discharge on 12 September 2005 into the care of his mother and Disability SA Case Manager, Jessica McDeed[32]. 

6.15.       Before I deal with Rowan’s subsequent care, I make one further observation about the stay in Boylan Ward.  It is significant that according to a note of the psychiatric registrar on 29 August 2005 Rowan described ‘loosely formed’ ideas that if he were to perpetrate some wrong doing in the future that suicide may be a preferable option.  The note goes on to say that Rowan had no current active plans or intent and that Rowan appeared to be making some longer term future plans.  However, in view of what later happened, this note takes on greater significance.

7.                  Accommodation is provided for Rowan by Southern Junction Community Services

7.1.           Disability SA came to an arrangement with an entity known as Southern Junction Community Services (SJCS).  Graham Brown, the Chief Executive Officer of SJCS, gave evidence.  He said that the arrangement with Disability SA evolved over time.  There were several ‘contracts’ between SJCS and Disability SA for Rowan’s accommodation and care.  The first contract went from mid September 2005 to mid December 2005.  It was then extended to the end of December 2005 and in early January 2006 it was extended until the end of June 2006.  Mr Brown said that when the arrangement was first contemplated SJCS was to provide emergency accommodation while Disability SA explored other options[33].  Initially, SJCS found accommodation at Finbar Crescent, Christie Downs.  This was temporary only as it was not entirely suitable.  Subsequently, SJCS arranged for a more suitable house which was called the Beach House.  It was situated at 3 Fletcher Drive, Christies Beach.  SJCS had a number of other houses which it provided for youth support and accommodation services[34].  This arrangement was rather novel for SJCS. 

7.2.           Mr Brown said that as the arrangement became firmer in the sense that it was extended and would be running for a reasonable length of time, training for the youth workers engaged at the Beach House was arranged.  In fact, in January 2006, Ms Alexander provided four, half day sessions[35].  These were specific ASD training sessions[36]. 

7.3.           In October 2005 Ms Alexander resumed her association with Rowan.  She said that she had been overseas immediately prior to this and while she was away Rowan had sent her a letter.  In that letter he had said that he would try not to harm himself but that he could not guarantee it[37].  She confirmed that she provided training to the SJCS staff in December 2005 and January 2006 running sessions to alert them about how to deal with people with autism.  Ms Alexander said that she was concerned at the idea of putting Rowan into the house with inexperienced people.  However, it was her opinion that they did the best they could in the circumstances and that there was no other option[38].

8.                  Rowan harms himself - 27 November 2005

8.1.           In late November 2005 Rowan was taken from the SJCS accommodation for a family barbecue.  Peter Rankine gave evidence of the preparations that were required in order that this occasion might go smoothly.  He was a psychologist who was engaged by Disability SA in late 2005 to work with Rowan at SJCS.  He met with staff from SJCS and provided them with strategies in dealing with Rowan.  For example, he advised them not to argue with Rowan about his beliefs about religion, fundamentalists and terrorists.  Some of the workers with SJCS were Christians and were rather affronted by Rowan’s opinions.  Mr Rankine had to advise them not to argue with Rowan about any of these things.  Prior to the family barbecue Mr Rankine gave the staff strategies for dealing with Rowan’s separation from the family after the barbecue was over.  This was all carefully rehearsed and indeed, the staff rehearsed the issues with Rowan himself.

8.2.           However, things did not go well at the barbecue.  Rowan gained access to a small knife and stabbed himself in the abdomen.  As a result of this he was transported by ambulance to the Noarlunga Health Service and then to the Flinders Medical Centre Emergency Department.  He had a laceration to the left side of his abdomen that was approximately 1.5cm long.  As a result of this he underwent exploratory surgery at which the stab wound was extended medially and laterally to allow examination of the abdomen wall.  At surgery, a decision was made to perform a laparotomy on the view that Rowan’s Aspergers Syndrome would not allow adequate conservative management.  Accordingly, a midline laparotomy was performed and he was returned to a ward in the early hours of the morning of 28 November 2005. 

8.3.           On 28 November 2005 he was formally detained under the Mental Health Act 1993 and on 1 December 2005 a longer term detention order for a period of 21 days was made.

8.4.           Rowan remained in Flinders Medical Centre.  A second order for detention for 21 days was made on 21 December 2005 under the Mental Health Act.  He was discharged form Flinders Medical Centre on 12 January 2006.  His discharge summary states that he presented with an exacerbation of obsessive compulsive disorder and major depression with psychotic features with ongoing suicidal ideation and plans as well as strong ideas of self-harm.  He required a nurse 1:1 special for the majority of his inpatient stay.  During his stay he made repeated attempts to conceal knives and reopen his laparotomy wound.  He was discharged on citalopram and olanzapine to which he was said to respond well.  His suicidal ideation gradually became less intense but despite this he was regarded as an ongoing risk upon discharge.  The discharge note refers to the supported accommodation arrangements at SJCS.  It refers to a multidisciplinary meeting having been held at the Exceptional Needs Unit at the Julia Farr Centre.  It refers to the fact that there would be a further meeting of that group in February 2006.  According to the note, intense discharge planning occurred through which it was decided that a 6 day transition period to Rowan’s Beach House accommodation would be appropriate for Rowan.  This occurred successfully and Rowan was without a nurse 1:1 special for 5 days prior to his discharge.  He was discharged to the Beach House under the care of the SJCS staff with the long-term management to be coordinated by Disability SA and psychologist Peter Rankine.  That discharge summary provides a useful picture of the arrangements that were made for Rowan’s transition to care in the Beach House following this prolonged stay at Flinders Medical Centre.

9.                  The various administrative arrangements put in place by Disability SA

9.1.           As will be apparent from what I have just said, a Special Needs Unit regular meeting was taking place for Rowan at the Julia Farr Centre on a monthly basis.  The various materials which were tendered at the Inquest include extensive notes from the various institutions that were involved with Rowan’s care.  These extensive records demonstrate that a great deal of effort was being put into planning for Rowan’s care during the period of approximately 8 months leading up to his death.  The relevant documents appear as Exhibits C23 through to Exhibit C34.  A perusal of these exhibits demonstrates that a great deal of attention was being paid to Rowan’s case during this period.  In particular, treatment management guidelines were prepared under the supervision of Peter Rankine for use by SJCS staff in the management of Rowan. 

10.             Application is made to Guardianship Board

10.1.       On 22 December 2005 Sue Deeprose, Regional Manager for the Southern Suburbs with Disability SA made an application to the Guardianship Board seeking certain orders under the Guardianship and Administration Act 1993.  On 29 December 2005 the Board appointed the Public Advocate as the limited guardian of Rowan.  It ordered that the role and duties of the Public Advocate would be limited to those concerning accommodation for Rowan.  The order directed that Rowan reside in a place to be determined by the Public Advocate and authorised his detention in such places as the Public Advocate should determine.  Condition 7 of the order of the Board required that Simon and Debbie Wheaton be appointed liaison persons.  The Guardianship Board notes were admitted as Exhibit C28 in these proceedings.  The notes of the Public Advocate were admitted as Exhibit C31.  A copy of the order of 29 December 2005 is to be found as Exhibit C14c.

11.             January 2006 - Rowan returns to the Beach House

11.1.       Lynette Ziedler is a Director at Disability SA and was involved in the establishment of the accommodation arrangements for Rowan.  She explained that the arrangement was dynamic, that it was developing around the circumstances and around Rowan as knowledge of what his requirements were increased[39].  She acknowledged that there were some areas of concern.  She was aware that there was a reluctance by some of the workers employed by Southern Junction to engage in the training about the therapeutic role that the workers needed to play for Rowan.  She said that in these services it is hard to get a stable base of support workers and there was change of personnel[40].  She also said that there were some concerns in relation to the level of communication from Southern Junction to Disability SA.  She said that the role of the Disability SA case manager was to keep abreast of the whole situation and that there were instances where Rowan was taken to hospital following particular incidents and the case manager was not informed for some time about the admission[41].  She said that fortnightly meetings were intended to gradually iron these problems out[42].  Ms Ziedler said that from Disability SA’s perspective they were concerned about Rowan’s ‘level of despair’[43] but their overall view was that this was not actually escalating[44].

11.2.       Ms Ziedler gave evidence of the circumstances in which Disability SA introduced a second Aspergers sufferer, a boy by the name of Alex, into the Beach House[45].

12.             The introduction of Alex to the Beach House

12.1.       The evidence of all witnesses was that Alex and Rowan did not get along very well.  Ms Zeitz gave evidence that after Alex came to share the house Rowan deteriorated quite significantly from that point on[46].  Veronica Nagathota was another of the support workers employed in the beach house.  She gave evidence at the Inquest.  She commented that Rowan and Alex were not a good mix and this was a cause of stress for Rowan.  She described them as ‘opposites’.  She said that Alex was an attention seeker who did not like Rowan getting attention.  It seemed that Rowan had met Alex on a previous occasion when they had been at a camp together and that they actually did not like each other.  Overall it was Ms Nagathota’s view that Rowan’s behaviour and condition deteriorated after Alex’s arrival[47].  Other witnesses gave similar evidence.

13.             Further attempts at self-harm

13.1.       Ms Ziedler made reference to hospital admissions that took place which were not notified to the case manager from Disability SA.  These admissions followed episodes of self-harm by Rowan during the period February and March 2006 at the Beach House.  Evidence of them can be found in the Flinders Medical Centre casenotes[48].  On 25 February 2006 Rowan was brought into the Noarlunga Health Service by ambulance with three stab wounds that he had inflicted upon himself with a knife.  Staff at Noarlunga Health Service were informed that Rowan had become angry when his parents had come to visit on that occasion and he had stabbed himself with a 5cm long pointed knife in his bedroom at the Beach House.  The wound was 1.5cm in length and penetrated subcutaneous tissue.  It was found to be superficial.  The clinicians noted scarring from the old injury which Rowan had inflicted in November of the previous year.  The notes record a further admission to the Noarlunga Health Service on 26 March 2006.  On that occasion Rowan had asked for a knife to cut some cake and the worker on duty at the Beach House had asked him for it back.  Rowan refused and started stabbing cupboards, containers and then pointed to his stomach and said he was going to kill himself.  The support worker called the ambulance and Rowan was admitted to the Noarlunga Health Service.  The support worker informed the clinicians that Rowan had been refusing his medications for the last five or six days.  Rowan settled and was discharged.

13.2.       These are but two of the numerous references to Rowan’s thoughts or actions of self-harm during this period.

14.             Rowan’s admission to Flinders Medical Centre in late March 2006

14.1.       Rowan was an inpatient at the Flinders Medical Centre in late March 2006.  His Flinders Medical Centre notes show that he was being ‘specialled 1:1’ or given special one to one nursing during that stay.  Professor Kalucy gave evidence at the Inquest and explained that the special nursing that was occurring on that occasion was not because Rowan was considered to be suicidal for the whole of the stay, but to manage the fact that he was being kept in the Emergency Department which is an environment that is not peaceful for a young patient such as Rowan to be kept in.  He was a very demanding and restless patient and the decision was made that he would get intensive nursing to manage him because of the type of patient he was and the setting he was being kept in.  However, it was not Professor Kalucy’s view that Rowan remained at a high risk of suicide throughout that stay and the nursing special was not implemented for that purpose.  Having said that, Professor Kalucy conceded in his evidence that Rowan was at chronic risk of suicide.

14.2.       Rowan was discharged from Flinders Medical Centre on 3 April 2006.  On that day Professor Kalucy had a discussion with Dr Silfverskiold, the psychiatrist who had been treating Rowan during regular appointments at the Noarlunga Health Service over the past two or three months.  Professor Kalucy gave evidence that there was a debate as to whether Rowan had a psychosis or not.  Professor Kalucy’s view was that Rowan did have a psychosis but Dr Silfverskiold disagreed[49].  Because Dr Silfverskiold had been more involved in the case and Professor Kalucy had only seen Rowan in what he described as a rather narrow setting, Professor Kalucy deferred to the opinion of Dr Silfverskiold[50].  I should also note that Professor Kalucy acknowledged the difficulties in making mental health diagnoses in a person suffering from Aspergers Syndrome.  This occasion may have offered an opportunity for a change in Rowan’s treatment if it was considered that he was psychotic.  For example, it may have been possible to introduce different drugs with the chance that events may have taken a different course.  However, it seems to me that it was reasonable for Professor Kalucy to defer to Dr Silfverskiold in these circumstances, and I am unable to reach any conclusion to the effect that Dr Silfverskiold’s conclusion about Rowan was wrong.  Certainly, Professor Kalucy was not prepared in his evidence to assert that Dr Silfverskiold made an incorrect decision.

15.             April 2006

15.1.       On 4 April 2006 Rowan went with Ms Alexander to a Thai cooking class that they were doing through WEA together.  Ms Alexander said that Rowan participated in the cooking but was very stressed.  He was sweating and he was chopping food ingredients very quickly and appeared very worked up.  Ms Alexander suggested that they leave the group early, which they did.  They returned to the Beach House and Rowan said that he was going to bed which was also very unusual given the time.  Ms Alexander remained in the house for a time, and just before she was about to leave, Rowan came out of his room saying her name and then hugging her which was unusual.  He kept on saying ‘I’m sorry, I’m sorry’ and although Ms Alexander tried to ask him what he was sorry for he was unable to articulate anything.  He behaved in a very childlike fashion on that occasion[51].

15.2.       Then, on 10 April 2006, Rowan had a session with Joanna Zeitz.  He was self-abusing when she saw him in that he was biting his lips and pulling skin off the inside of his lips.  At the end of the session she suggested that they have a hot chocolate from a café.  She said that she hoped to distract him from his self-abuse.  However, when they went to the café Rowan drank his hot chocolate without stopping at all, even though it was extremely hot.  Ms Zeitz said that he showed no pain or discomfort in doing this.  Ms Zeitz was extremely concerned for him and his wellbeing[52]. 

15.3.       The following day, 11 April 2006, Ms Alexander had a further session with Rowan.  On that occasion, Rowan was again acting out of character.  He said to her that one day she would get married and not have enough time to spend with him as she did now.  He also referred to his hope that he never disappointed her and that he wished he was still 8 years old and coming to her special classes as he used to at that time in his life.  In retrospect, Ms Alexander thought that he was saying goodbye[53].

15.4.       On reflection, and with the benefit of hindsight, Ms Alexander thought that Rowan probably needed to be hospitalised at that time[54].  She recalled that she was aware at the time that he had not been compliant with his medications and she speculated whether a period of hospitalisation might have assisted.

15.5.       Ms Alexander saw Rowan for the last time on 18 April 2006[55].  She said that Rowan was particularly agitated on that occasion and was talking in circles[56].  They went for a drive in the car and had lunch.  After lunch they returned to the Beach House at Christies Beach and Ms Alexander suggested that they go for a walk on the beach.  When they got to the esplanade above the beach Rowan jumped up onto the railing which bordered the footpath.  On the other side of the railing there was a sharp drop with rocks below leading to the beach.  Ms Alexander was very concerned about this behaviour for obvious reasons.  Rowan was not responding to the usual strategies she would employ for a situation such as that.  In the end she said to him words to the effect that if he were to jump off the rails she would get into a lot of trouble and that if he cared about her he would get off the railing now.  With that, Rowan did jump off the railing onto the footpath and was then very apologetic and said that he would never do anything to get her into trouble[57].  Ms Alexander said that she was very anxious for Rowan at this stage and decided that they should return to the house.  When they returned to the house she got Rowan to lie down and attempt to relax doing some relaxation exercises she had taught him in the past.  She decided to stay for a little while to make sure Rowan was alright.  At this point Rowan was lying on his back and he placed his fingers on his windpipe, started to press quite firmly, and made a gagging sound[58].  This caused further distress for Ms Alexander and then Rowan opened his eyes and said ‘don’t worry Vanessa, I’m just messing with you’[59].  Ms Alexander reported all of this to the support staff at the Beach House, contacted Peter Rankine, and sent an email to Rowan’s parents.

15.6.       It was Ms Alexander’s opinion that Rowan did understand the consequences of his actions on 21 April 2006.  In other words, that he deliberately took his own life[60].

16.             Rowan is seen by Dr Fry, Psychiatrist, 19 April 2006

16.1.       On 19 April 2006 Rowan was due to have a regular appointment with the dieticians at the Noarlunga Health Service.  The carers who were with him that day were concerned that Rowan had been chewing the skin on the tips of his fingers and they requested that a psychiatrist review him.  Dr Fry had just taken over from Dr Peter Silfverskiold in the Mobile Assertive Care team at the Noarlunga Health Service.  Dr Fry had 10 minutes free and was able to see Rowan briefly.  Dr Fry had some background information about Rowan from a peer review group he participated in with Dr Silfverskiold.  The two support workers were present for the session and Dr Fry said that he introduced himself to Rowan.  Dr Fry looked for symptoms or signs of a psychosis or depression but did not find any.  He said that in a patient with Aspergers it is often difficult to get the patient to participate.  Rowan repeatedly asked for the session to terminate so that he could see the dietician.  Dr Fry asked Rowan if he had thoughts of suicide and Rowan just nodded.  Dr Fry commented that it was difficult to know what to make of a nod, as this could have been a normal part of Rowan’s Aspergers condition.  He said that he took the nod at face value and was aware of Rowan’s previous attempts to take his own life.  Dr Fry said that he took some comfort from the fact that Rowan was in 24-hour care.  He said that finger biting can be a symptom of increased anxiety which can happen with Aspergers sufferers and he felt at the time that his interview with Rowan was probably adding to the problem.  Dr Fry concluded that there was no evidence of a marked change in Rowan’s mental state that was symptomatic of psychosis or depression.  He decided that there was no cause for any change to Rowan’s treatment and that it was sufficient for him to continue with his existing regime.  Dr Fry commented that he did not believe that Rowan’s mental state required his admission to hospital[61].

17.             The early hours of 21 April 2006

17.1.       Samuel Dunn is a support worker in youth work.  He had Certificates 3 and 4 in Community Services, Youth Work, from Onkaparinga TAFE and was working for SJCS in 2006.  On the night of 20 April and the early morning of 21 April 2006 he was present in the Beach House performing a night shift which he described as a passive shift.  By this he meant that the practice of SJCS for a night shift was that the support worker would be present on the premises but was not required to be awake while the young men in the house were asleep.  All of the doors of the house were alarmed and the alarm would sound an audible warning when the doors were opened.  So if either Rowan or Alex had attempted to leave the house in the middle of the night the intention was that the alarm would sound and the support worker would be alerted.  Although the doors to the house were locked at night, they were not deadlocked.  Therefore it was possible to unlock them from inside and leave the house.  In my opinion, this was a sensible approach because in the event of fire it was necessary for the occupants to be able to leave without having to find a key to unlock the doors.  The protection of the alarm system catered for the situation in which either Alex or Rowan attempted to abscond from the premises.  The alarm was activated from within the office occupied by the support worker.  The support worker also slept adjacent to the office in their own quarters.  The office was locked so the young men were unable to come in and deactivate the alarm in order to exit from the house without alerting the support worker.

17.2.       Mr Dunn gave evidence that he was awakened at 4:50am on 21 April 2006 when the alarm went off.  He got up and saw Rowan near the front door[62].  He told Rowan to go back to bed.  Mr Dunn went back to bed himself but the alarm went off again at 5am.  Mr Dunn got up and found Rowan wrapped in a blanket by the front door.  He told him to go to bed and watched while Rowan walked back towards his room wearing the blanket[63].  Mr Dunn did not reset the alarm after having deactivated the siren.  He said that he left the alarm turned off because Rowan kept walking through the front door and activating the siren.  In effect, he admitted that he was sick of being woken up and wanted to have undisturbed sleep[64]. 

17.3.       Clearly this does not reflect at all well on Mr Dunn.

17.4.       Mr Dunn said that he attempted to wake Rowan up at approximately 8:40am but there was no answer.  He tried to gain access to Rowan’s room with his key but was unable to.  At approximately 9am Anthony Bernhart, a day shift support worker, arrived for duty.  Mr Dunn told Mr Bernhart that he was unable to unlock Rowan’s door to gain access and was getting no response.  Mr Dunn then went for a drive around the streets to see if he could find Rowan.  He conceded in his evidence that the reason he did this was because he was uncertain Rowan was still in the house, the alarm having been deactivated at 5am.

17.5.       Eventually the bedroom door was forcibly opened at approximately 9:15am.  Mr Dunn gained entry to the room and saw Rowan leaning against the inside of the door with a sock tied around his neck and secured to the door handle.  Anthony Bernhart was also present.  Neither Mr Dunn nor Mr Bernhard attempted cardio-pulmonary resuscitation or any form of first aid on Rowan.  He was pale, his tongue was protruding from his mouth and his lips were blue.  They formed the view that he was deceased[65].

18.             The protocols and policies governing the Beach House

18.1.       Mr Dunn said that the support workers at the Beach House had team meetings every week.  There were house rules as well and written guidelines were provided by SJCS.  A journal was also available.  During the team meetings the support workers would discuss issues relating to the house and the young men with their supervisor, Mr Philip Dunkley.

18.2.       Mr Dunn referred to Ms Alexander and the fact that the support workers had quite a lot of contact with her.  He was aware that Rowan had admissions to hospital for suicide attempts and other self-harming.

18.3.       Mr Dunn said that the support workers would encourage Rowan to take his medication but that if he was not prepared to do so there was nothing they could do other than to inform Rowan’s treating doctors and Mr Dunkley[66].  Mr Dunn did not consider that the Beach House, or that support workers such as him, were adequately equipped to deal with a person such as Rowan.  He said that he reported to his supervisor ‘many times, that I didn’t think that this was the right place for Rowan’[67].  He said that he believed that Rowan needed to be in a psychiatric facility with mental health professionals[68].

18.4.       Veronica Nagathota was another support worker and also had a Certificate 4 in Youth Work.  She said that initially the staff were under instructions that Rowan was not allowed to leave the property, however that changed later on with the result that Rowan was allowed to leave the property but that he was supposed to be kept in view by one of the staff members following.  She said that a number of different sources of information would feed instructions into the support workers at the Beach House and that it was extremely confusing[69].  She said that there were ‘too many chiefs’[70].  Ms Nagathota said that it was her opinion that training was lacking and that the workers needed to be more skilled to deal with the situation they found themselves in[71]. 

18.5.       Cindy Eggington was another of the support workers who gave evidence.  She has a diploma in Youth Work and in Community Youth Work.  She was of the opinion that a number of the other staff did not want to work with Rowan[72].  She said that she felt that a number of the other staff simply did not want to be there[73].  She had reservations about Rowan returning to the model of accommodation provided by SJCS which she expressed fairly broadly.  She thought that Rowan was in danger[74].  She explained this to one of her supervisors and had a disagreement with management about the situation.  She was very critical of the culture within SJCS.  She was critical of other staff and said that some of them did not regard the work as a real job but merely as a form of babysitting[75].  Ms Eggington was aware that other staff did not ensure that Rowan took his medication[76] and was extremely critical of what she described as the lack of training[77].

19.             Rowan’s non-compliance with medication

19.1.       There was a strong body of evidence that Rowan was not taking medication that was prescribed to him while in the Beach House in 2006.  There was no lawful means to enforce compliance - his guardianship order extended only to residence.  Professor Kalucy commented that it would be difficult to obtain a Community Treatment Order for a boy like Rowan with whom it is difficult to ‘nail the diagnosis down satisfactorily’[78]. 

20.             Conclusions

20.1.       The Beach House model of accommodation for Rowan came too late in his life to make a real difference.  The model had many flaws.  For example, the staff were not adequately trained.  The policies and procedures were less than ideal.  The behaviour of Mr Dunn in turning off the alarm on the morning of Rowan’s death was extremely poor, but the fact of the matter was that Rowan was safely inside the house and did not come to any harm from Mr Dunn’s reprehensible decision to turn off the alarm and leave it off so that he could be left undisturbed.  While that may not have been causative of Rowan’s death, it is a strong indicator of a cultural deficiency in at least one member of the staff of the Beach House.

20.2.       The decision to introduce another person suffering from Aspergers Syndrome was clearly not well thought out.  It did not have a happy result.  There may have been an assumption that because the other young man had Aspergers Syndrome, it would be suitable to place him in the same house as Rowan.  That assumption was flawed in the same way that it is not safe to make such an assumption about any two persons who do not happen to suffer from Aspergers Syndrome.  They were not well matched and the introduction of the other young man clearly increased Rowan’s already high levels of anxiety.

20.3.       On the other hand, the decision to provide supported accommodation for Rowan was a significant concession by Disability SA.  The cost of establishing the house and providing the level of support that was in fact provided would have been extremely high.  Professor Kalucy regarded the arrangement as something of a luxury[79].  This assessment by Professor Kalucy reflects his experience of the mental health sector and the fact that he has become accustomed to a lack or resources in that sector.  Compared to what he has become accustomed to in that respect, he regarded the facility that was established to accommodate Rowan as being out of the ordinary, and more generous than the norm.

20.4.       The Wheatons had been trying to obtain assistance in caring for Rowan for nearly 18 years before Disability SA provided this assistance.  Clearly, there were many interventions during Rowan’s life; however, they were far from sufficient to maximise whatever potential Rowan might have had, and to reduce the trauma suffered by his parents and family in supporting Rowan through his childhood and adolescence.

20.5.       Professor Kalucy made a statement which was admitted as Exhibit C46 in which he said that one of the problems with our society is that the help available, especially for parents of children with autism or ASD sufferers, is a ‘good deal short or desirable’.  In his oral evidence, Professor Kalucy elaborated on this theme:

'The parents are often beside themselves and distraught.  Its not uncommon for those marriages to break up because its a huge stress, its - and, you know, would be time and again you’d be talking to mothers, particularly in the situation who are just sobbing their way through the whole interview because they’re so distressed and that goes on month after month, year after year, right through to late adolescence and then they face the whole other set of problems like; what kind of future does my child have in any sense of work.  So every step of the way is really hard work and we, as a society, are not well set up to deal with that particular problem.' [80]

20.6.       It is very clear that early intervention in Aspergers and ASD sufferers is far more effective than an intensive intervention in the late teenage years such as the Beach House for Rowan.  This seems to be the universally accepted position of all of the expert witnesses.  It appears that it has gained some acceptance in Government as well and I note that The Australian newspaper reported on 26 June 2008 that the Commonwealth Parliamentary Secretary for Disabilities, Bill Shorten, said:

'We do know that early intervention makes a quantum difference in the quality of life of a child with autism and of course, their families.'

That quote appeared in a report entitled ‘Autistic children to see $190m in support’[81].  Whether the package announced by Mr Shorten will be sufficient to cover the needs of all Aspergers sufferers across Australia, and in particular South Australia, remains to be seen.

21.             Recommendations

21.1.       In her evidence Ms Zeitz referred to a model for intervention that she prepared in conjunction with Dr Jenny Curran of Disability SA[82].  A document setting out the model, and prepared by Dr Curran and Ms Zeitz, entitled ‘Asperger Youth: Pathways to Better Outcomes’ was admitted as Exhibit C37a[83].  According to Ms Zeitz, the document has been provided to a number of South Australian Government agencies and Ministers, including the Minister for Disability, the Minister for Health, the Minister for Mental Health Services and the Minister for Education.  I recommend that the Minister for Disability considers the implementation of the model set out in Exhibit C37a, or a similar model, in South Australia.

21.2.       The experience with Rowan has shown that an ad hoc arrangement such as the Beach House was expensive and unsuccessful.  It is impossible with an ad hoc arrangement such as the Beach House to build up long term experience amongst staff.  There is a need for a permanent solution with permanent staff and permanent accommodation.  This would surely be far more effective and efficient as a method of dealing with the situation where early intervention fails.  Ms Zeitz in her evidence said that a number of children with Aspergers Syndrome are being handed to the State because families are unable to support them effectively.  She estimated between 70 to 100 such children[84].  In that passage of evidence she was referring to the circumstance in which a family relinquishes responsibility for a child, with the result that the child must be accepted under the Guardianship of the Minister for Families and Communities.  If it is the case that under the current ad hoc arrangements the State is to assume responsibility for these children one way or another, it seems only sensible that a carefully planned arrangement be established for dealing with them in an appropriate setting with properly trained staff.

21.3.       I recommend that a copy of this Finding be forwarded to the Commonwealth Parliamentary Secretary for Disabilities, Mr Bill Shorten, for his consideration.  I direct that, if requested, Mr Shorten be provided with access to any of the materials tendered at this Inquest for his assistance.