An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 30^th and 31^st days of July, 1^st, 2^nd, 28^th, 29^th and 30^th days of August, 18^th day of October, 1996 and 28^th day of October, 1997, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Nandadevi Chandraratnam.

I have conducted this inquest as part of a series of six inquests in all. These inquests were into the deaths of Nandadevi Chandraratnam, who died on 3 December 1992, Gwenneth Doreen Isobell Hogarth, who died on 23 July 1993, Consiglia Ciampi, who died on 8 October 1994, Matthew Selwyn Proctor, who died on 28 March 1994, Peter James Lewin, who died on 14 May 1994, and Bernard John TenHoopen, who died on 28 July 1994.

This introduction will appear at the commencement of the findings in all six cases. An analysis of the circumstances of each individual case will follow, and I will then attempt to draw together common themes, in order to make recommendations pursuant to Section 25(2) of the Coroners Act. This analysis will also appear in all six findings.

The six inquests can be divided into two groups, and were heard in that way.

The first group involved the deaths of three people (Gwenneth Doreen Isobell Hogarth, Consiglia Ciampi and Nandadevi Chandraratnam) by homicide, and in each case the perpetrator was found not guilty by reason of insanity. In the first two cases, mothers were killed by their sons, and in the third, Dr. Chandra was killed by her patient. In each case the perpetrator was suffering from either schizophrenia or schizo-affective disorder.

The second group also involved the deaths of three people (Matthew Selwyn Proctor, Peter James Lewin and Bernard John TenHoopen) in separate incidents, within the space of four months or so. Each of these people were patients of Glenside Hospital at the time, either as inpatients or recently discharged outpatients, and each suffered fatal injuries from a passing train after laying on or near a railway track. All three of them suffered from either schizophrenia or schizo-affective disorder.

In all six cases, a detailed analysis of the psychiatric treatment provided to the patients was analysed and reported on by Professor R.D. Goldney, Professor of Psychiatry at the University of Adelaide and a consultant psychiatrist at the Adelaide Clinic. Professor Goldney also gave oral evidence in each of these cases, and I am greatly indebted to him for his thoughtful, thorough and helpful analysis in each case.

The families of the deceased were represented by either Mr. P. Charman or Mr. W. Braithwaite. Various hospitals and health services were represented by Mr. J. Homburg, and doctors were represented by Ms. M. Venning. Other counsel appeared for particular people as the inquests proceeded. No objection was taken by any counsel to the grouping of the inquests in the way I have outlined.

In each case, the patient’s history, the progress of his treatment, and the events leading up to the death were analysed. A number of common issues emerged which, in my opinion, carry serious implications for the psychiatric profession and for the providers of mental health services generally.

The following explanations and definitions may be helpful.

Schizophrenia is described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition ("DSM IV") as follows:-

"The essential features of schizophrenia are a mixture of characteristic signs and symptoms (both positive and negative) that have been present for a significant portion of time during a 1-month period (or a shorter time if successfully treated) with some signs of the disorder persisting for at least 6 months. These signs and symptoms are associated with marked social or occupational dysfunction. . . . The characteristic symptoms of schizophrenia involve a range of cognitive and emotional dysfunctions that include perception, inferential thinking, language and communication, behavioural monitoring, affect, fluency and productivity of thought and speech, hedonic capacity, volition and drive, and attention. No single symptom is pathognomonic of schizophrenia; the diagnosis involves the recognition of a constellation of signs and symptoms associated with impaired occupational or social functioning".

(p.274)

 

 

DSM IV describes this condition as follows:-

"The essential feature of schizo-affective is an uninterrupted period of illness during which, at some time, there is a Major Depressive, Manic, or Mixed Episode concurrent with symptoms that meet criterion A for schizophrenia (the "characteristic symptoms"). In addition, during the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. Finally, the mood symptoms are present for a substantial proportion of the total duration of the illness".

(p.242)

 

 

At p.273, DSM IV defines psychosis, in the context of schizophrenia, schizo-affective disorder, and other similar conditions, as delusions, any prominent hallucinations, disorganised speech, or disorganised or catatonic behaviour. The term has other shades of meaning in the context of different illnesses.

Professor Goldney told me that all six patients had a severe form of the illness. He said there is usually a chronic gradual deterioration in such patients, although not all cases take such a "severe malignant course" (T.718). He said that both schizophrenia and schizo-affective disorder are reasonably common in the community, and that ideally the treatment should focus on the schizophrenic component first, usually with anti-psychotic medication as a basic step, which also often helps with the depressive ("affective") symptoms as well. Anti-depressants are also used to deal with the depressive symptoms (T.719).

Professor Goldney said that the prognosis pattern is usually divided into thirds. One third of patients do quite well, a third do very poorly, and a third have relapsing and remitting conditions (T.720). He said:-

"Once you have had a schizophrenic illness, you always retain that propensity to have a further episode, and if you are in that poor prognosis, that third group, you will have essentially an unremitting condition which may be controlled at times to a varying degree, but it can be a very nasty illness which does persist".

(T.720)

 

 

He said that alcohol and drug abuse, both of which were prominent in a number of these cases, makes the illness much more difficult to treat (T.721), and that, although the illness often has a highly unpredictable path, a "longitudinal view", that is a knowledge of the history of the illness and its patterns, "is usually the best predictor of how things are going to happen in the future" (T.730).

This "co-morbidity" between schizophrenic illness and drug abuse should call for a united effort between mental health services and drug and alcohol treatment services. Unfortunately, prior to 1995, there was, in the words of Dr. Harry Hustig, the Director, Extended Care, at Glenside Hospital, a "very clear gap in communication" between them, and that a number of patients were regarded by one agency as the patient of the other, and hence "fell between the gaps" (T.407). He said that the situation hit crisis in 1995 when there was total confusion as to where intoxicated people with a mental illness should be taken, with neither service wanting to be involved with them.

He told me that a working party was established, and a protocol developed whereby the mental health agencies see such patients first, to deal with the issue of "suicidality", and the patient can later be referred on to the other agency. Although this constituted an improvement in the system, there remained a need for cross-education between agencies (T.408).

Dr. Hustig told me that there is a very high risk of suicide in patients with chronic schizophrenia, of the order of 10%. He said that some of the academic literature puts the risk as high as 50%, although South Australian figures are considerably lower than that (T.191).

There is also a higher rate of familial violence involving such patients. Dr. Craig Raeside, a Consultant Forensic Psychiatrist at James Nash House, has done some informal research which shows that 90% of those people who kill a parent have schizophrenia. He said that the violence was usually limited to intra-familial situations, with a pattern of escalation over time, meaning that close family members of people with schizophrenia are more at risk (T.578).

I have already mentioned that anti-psychotic medication is used to treat patients with schizophrenia. Unfortunately, most of the medications have side-effects which are unpleasant and this often leads the patient to be resistant to medication, sometimes against his own best interest. The side-effects are described as extra-pyramidal, or parkinsonian-type (since they mimic the symptoms of Parkinsons disease). They include disorders of muscle tone (dystonia), tremor, and muscle spasms which can be particularly frightening and painful. The longer-term side-effects include tardive dyskinesia (involuntary facial, shoulder and trunk movements), which is difficult and slow to respond to treatment (see the evidence of Professor Goldney at T.723). There are some medications (for example, Benztropine) which can control some of these effects.

This issue is particularly difficult to deal with since the patient often lacks insight into his condition which, when combined with the unpleasantness of the side-effects, makes him resistant to treatment.

Professor Goldney said that it is almost mandatory to change medication when it appears ineffective or is producing side-effects, since people respond to drugs differently. Another drug may be effective without the side-effects.

The main difficulty is in assessment of when a patient is stable, so that the medication can be reduced, and the patient’s quality of life can be improved. Professor Goldney said:-

"It is mandatory to (reduce medication if the illness is in remission) because the risk of long-term side-effects - for example, tardive dyskinesia, the risk increases the longer you are on a higher dose, and so it does behove one to try and reduce it. And then you have to weigh that up against the risk of relapse and the longitudinal history of what has happened when it has relapsed. And, again, it is a matter of trying to weigh up that clinical dilemma of the risk of side-effects against the risk of illness".

(T.726)

 

 

He emphasised that it is "absolutely essential" to monitor the effect of reducing the dose, and to ensure that sufficient time, at least three months, is allowed at each level so that a correct assessment can be made of the affect of the reduction, since the medication (particularly that which is administered intra-muscularly) can be long-lasting in its effectiveness.

For this reason, careful periodic mental state assessments, and appropriate note-taking of both positive and negative symptoms, are essential in order to obtain a "longitudinal view" of the patient’s progress.

Of course, this has been a necessarily brief and superficial analysis of the various aspects of schizophrenic illness. However, it is with these factors in mind that I will now proceed to analyse the particular circumstances of each case.

Dr. Nandadevi Chandraratnam (known widely as "Dr. Chandra") was born in Sri Lanka on 28 April 1945. She was married to Dr. Edward Chandraratnam in 1974 and he came to Australia in 1978, and she joined him in 1979. After working initially in Alice Springs, the couple came to Adelaide and Dr. Nandadevi Chandraratnam commenced work at Hillcrest Hospital as a Career Medical Officer.

David Tzeegankoff was first admitted to Hillcrest Hospital on 27 August 1986. The records indicate that Dr. Chandra had contact with Mr. Tzeegankoff from that time onwards. There were many notations in the casenotes made by her concerning his treatment, and she appears to have initiated several proceedings to the Guardianship Board in relation to him.

At about 8.45a.m. on 3 December 1992 David Tzeegankoff left the family home, telling his parents that he had to attend the Parole Board office at Port Adelaide. His father noted that he was carrying a green bag in his hand, possibly vinyl.

Later that morning he was seen in the Port Admiral Hotel at Port Adelaide, where he had several drinks (see the affidavit of Ms. Westdijk, Exhibit C.11a, p2). He did not appear to speak to anybody in the hotel.

Mr. Tzeegankoff had an appointment to see Dr. Chandra at 11.30a.m. that morning. At about 11.20a.m. he was seen by Ms. Glastonbury, a cleaner at Hillcrest Hospital, in the patients’ waiting area when she was shampooing the carpet. She noted that he was fidgety in the chair and she thought about reporting this fact at the time that Dr. Chandra came out of her office and took him in with her (see her statement, Exhibit C.19a, p3).

Ms. Rees, the receptionist, did not notice that David Tzeegankoff was upset or agitated. Shortly before he went to see Dr. Chandra, Ms. Rees asked him to go outside and finish his cigarette because one of the other patients was complaining. He complied with this request and did not seem angry (see Exhibit C.18a, p3).

Shortly after this, Ms. Alma Lane, a social worker at Hillcrest Hospital, heard noises coming from Dr. Chandra’s room. The door opened inwards, and a male person emerged carrying a bag. She said that he closed the door quickly and crisply and said "It’s alright" (see her statement, Exhibit C.20a, p2). Ms. Lane tried to open the door to check on Dr. Chandra, but her key did not work the lock, as it had a different security classification. She then tried to look in through the window and, after several attempts, found a gap and saw Dr. Chandra lying on the floor. She then raised the alert, the appropriate key was obtained from the receptionist’s drawer and the emergency was then raised (Exhibit C.20a, p4).

Ms. Rees opened the door to Dr. Chandra’s office and found her lying on the floor on her stomach, having suffered terrible knife wounds.

An ambulance was called, and the records at the ambulance service disclose that it was despatched at 11.57a.m. that morning (see the statement of Mr. Hernan, Exhibit C.16a). When the ambulance crew arrived at Mason House they found Dr. Chandra lying face upwards on the floor with resuscitation being attempted. They were unable to find a pulse or cardiac output. Noting arterial bleeding, they found the lacerations to the back of her head and applied a compression bandage and continued CPR.

The ambulance crew left Hillcrest Hospital at 12.11p.m. to Modbury Hospital, arriving there at about 12.20p.m. where Dr. Chandra was seen by Dr. Drew. The staff at Modbury were expecting the arrival of the ambulance and immediately made further attempts at resuscitation but these were unsuccessful, and at 12.30p.m. that day her death was certified (see the statement of Dr. Drew, Exhibit C.2a, p2).

Meanwhile, David Tzeegankoff had gone to the flat of Barry Watts, a fellow patient at Hillcrest Hospital, and told him that he had killed Dr. Chandra. Mr. Watts did not find this particularly remarkable. Tzeegankoff had told him on a couple of earlier occasions that he wanted to kill his doctor at Hillcrest Hospital because he wasn’t happy with his treatment and medication. He said he thought Tzeegankoff was joking, and did not think anything about it (Exhibit C.12a, p1). Tzeegankoff said, "no, I’m serious". Watts told him to telephone the police and give himself up. He said:-

"When I suggested that he phone up the police, he agreed with me and left to do that. . . . David was quite calm all the time he was at my place, he didn’t show any sign of remorse, guilt or anything like that".

(Exhibit C.12a, p2)

 

 

Later that afternoon, a male caller telephoned the switchboard at Hillcrest Hospital and told several staff members where he was, and that he had killed Dr. Chandra. At one stage he mentioned that he did not mean to hurt anybody but that he had told Dr. Chandra he was too sensitive for Modecate and that he was going to kill her and commit suicide, and that he had been telling her that for some time (see the statement of Ms. Marschallek, Exhibit C.22a, p2). Later in the conversation he told Dr. Ash that he felt that he needed to be in hospital and not in the community (Exhibit C.23a).

At about 1.37p.m. that day Detectives Leigh and Busiko attended at the telephone box and arrested Tzeegankoff (Exhibit C.30a, p1). At that time he made admissions about killing Dr. Chandra, as to the location of the knife he had used, and gave them other details of the event.

A post mortem examination was carried out at 3.47p.m. that afternoon by Dr. R.A. James, forensic pathologist. Dr. James found that the cause of death was a left haemothorax complicating a stab wound to the heart. In his report (Exhibit C.3a) Dr. James reported that he noted 28 wounds, representing at least 27 separate blows to Dr. Chandra’s body. 14 of the wounds were inflicted by a knife, mostly to the anterior chest and both arms. The hand and arm wounds were obviously consistent with defence wounds. One wound was in the area of the left breast and penetrated the heart. This was obviously the fatal wound (p.12).

Dr. James also noted eleven blows with a blunt object to the back right side of the head, and evidence of several blows delivered to the left side of the head resulting in comminuted skull fractures. These blows would have rendered the deceased unconscious at the time of infliction, and would probably also have resulted in death in the longer term (p.13). Dr. James suggested that the wound patterns indicated that the knife wounds were inflicted first, and that the blows to the back and side of the head probably occurred with the deceased lying face down (p.13).

At about 7.00p.m. that evening, David Tzeegankoff was admitted to James Nash House at Hillcrest Hospital and was examined by Doctors Hustig and Yellowlees, both consultant psychiatrists. Psychiatric Registrars Dr. Richard Thompkins and Dr. Jarik Hyrniewicki and two psychiatric nurses were also present. According to the report of Dr. Yellowlees (Exhibit C.24a). It would appear that Tzeegankoff was completely frank about his role in the death of Dr. Chandra earlier that day and, although he mentioned a history of symptoms compatible with schizophrenia, he denied that he had suffered from any psychotic symptoms for several months (p.5). Dr. Yellowlees concluded by saying:-

"Dr. Hustig and I examined David Tzeegankoff in great detail to see if he had any symptoms of psychosis. We were unable to find any such symptoms during the examination. I could not find any symptoms of psychiatric illness as to why he would kill Dr. Chandra. He certainly did not appear to be clinically depressed and was cognitively intact. From this examination I can only say that he was suffering a personality disorder, and not a major psychiatric illness"

(p.5).

 

 

On 7 October 1993, David Tzeegankoff was interviewed by Dr. W.E. Lucas, forensic psychiatrist, at the request of Mr. Tzeegankoff’s solicitors. Dr. Lucas’ report is Exhibit C.63a. Several significant comments in Dr. Lucas’ report include the following:-

• "at that time I formed the opinion that Mr. Tzeegankoff was acutely psychotic and required urgent transfer to James Nash House for treatment (p2);

 

• during the interview it became evident that he was suffering from thought blocking, auditory hallucinations and at times his affect was inappropriate in that he smiled or laughed in response to hallucinations (p2);

 

• he went on to spontaneously mention the killing of Dr. Chandra and when he did this his conversation increased in speed and he spoke more loudly. He said ‘that’s why I think that Dr. Chandra was a vampire. That she was a vampire and I thought I was doing something good by killing her. Each time I had a blood test done I thought it was a vampire act" (p.3).

 

 

Having found Mr. Tzeegankoff to be acutely psychotic and requiring of urgent treatment, Dr. Lucas arranged for him to be transferred back to James Nash House later that same day. Dr. Lucas noted that Mr. Tzeegankoff had been due to receive a dose of Modecate two days prior to the interview, although he does not suggest in his report that the onset of Mr. Tzeegankoff’s psychotic symptoms corresponded with this missed dose.

Dr. Lucas interviewed Mr. Tzeegankoff again on 10 December 1993, and noted that his medication had been changed and that he was feeling better. He said that he was happy being off Modecate, which had given him excessive side-effects. Dr. Lucas found that he was no longer acutely psychotic and was more able to communicate. During that interview, Tzeegankoff told Dr. Lucas that he had been feeling paranoid during the interview with Doctors Yellowlees and Hustig on 3 December 1992 (in the interview with Dr. Lucas on 7 October, he had said that he did not remember the interview at all (p.5) ). Dr. Lucas’ report is as follows:-

"He said he was paranoid as he was ‘afraid that they would change my medication’ and that this would be detrimental to his mental health. He was also worried that they were ‘all going to chop me into pieces’ when he was taken to a cell. This was because of what he had done. He interposed the remark that his thinking was clearer now that he was off Modecate. He could not tell me any more about how he felt during the interview and he denied being hallucinated at the time.

He volunteered that ‘the reason why I didn’t tell them I had voices and hallucinations was that they would put me on a bad drug’."

(p.6)

On 9 March 1994 David Tzeegankoff appeared in the Supreme Court of South Australia on a charge of murdering Dr. Chandra. After a trial, the jury found him not guilty of murder by reason of insanity by unanimous verdict. On 17 March 1994 the Honourable Justice Cox directed, pursuant to Section 292(2) of the Criminal and Consolidation Act that he be detained in a secure psychiatric institution until further order of the court.

David Tzeegankoff was born on 24 July 1962. He showed some signs of unusual behaviour in his early teenage years, according to his brother Alex (see his evidence at T.26). This culminated in a crisis in about August of 1986. He had accompanied Alex to theological college and had developed some rather bizarre ideas based upon religious delusions, and appeared to have some sort of "nervous breakdown" at the college. As a result of that, he was initially hospitalised at the Queen Elizabeth Hospital and then at Hillcrest Hospital between 27 August 1986 and 30 April 1987. Professor Goldney has noted from the casenotes that his psychotic condition was severe, and was slow to respond to medication. Mr. Tzeegankoff had several further admissions to Hillcrest Hospital from time to time.

Mr. Tzeegankoff was admitted to Hillcrest Hospital again on 10 April 1991 and stayed there until 1 August 1991. In the discharge summary for that admission he was described a "markedly psychotic", even though he was on a medication regime of Fluphenazine (Modecate) in a dose of 50mg every two weeks. He was suffering from delusions, for example that the television could influence him, that he was Lucifer, and that his brother Tony was possessed by the devil. His medication was increased by adding a further anti-psychotic medication, Pimozide, with good effect. Professor Goldney remarked:-

"This is a clear indication of the fact that even with a reasonable dose of Fluphenazine of 50mg every two weeks, without the additional Pimozide Mr. Tzeegankoff was markedly psychotic. . . . It is an indication of the severity of his psychotic condition".

(Exhibit C.81a, p4)

 

 

No doubt for this reason, Dr. Chandra applied for and was granted orders for guardianship and treatment by the Guardianship Board.

On 23 October 1991, Mr. Tzeegankoff presented at the outpatients clinic showing increasing signs of psychosis, including persecutory ideas and increased agitation. He expressed the fear that he may commit another offence (he had committed an offence of assault on 7 July 1988, and complained of hearing voices at that time - see the casenotes, Exhibit C.66). Notwithstanding this apparent increase in the severity of his symptoms, his dosage of Modecate was reduced from 50mg every two weeks to 37½mg every two weeks by Dr. Chandra. The casenotes record that he was complaining of the side-effects of Modecate to Dr. Chandra, explaining that there was a lady travelling to Australia from Russia with a view to marriage, and he did not wish to be suffering such side-effects when she arrived.

Professor Goldney was critical of this reduction in dosage of Modecate, particularly since there was evidence that Mr. Tzeegankoff had also been non-compliant with his oral dose of Pimozide since his discharge from hospital (T.735).

Even after the dosage was reduced, Mr. Tzeegankoff continued to complain of the side-effects of medication, which led to the prescription of Benztropine to control them. This occurred in a casualty attendance on 15 January 1992.

On 23 January 1992 the Modecate dosage was reduced again to 25mg every three weeks. This further reduction was ordered by Dr. Chandra as, when she saw him in the outpatients department, he was agitated and restless and showing signs of rigidity (see the casenotes, Exhibit C.66). Dr. Chandra also prescribed Procycladine, an alternative side-effect medication.

Mr. Tzeegankoff’s mother confirmed that he was complaining about his medication. Her statement records that in April of 1992, even after the second reduction in the dosage, he was complaining that the medication was too strong, that the injections made him feel like he was dying, and that he would try and avoid them (see Exhibit C.8a, p3).

On 11 April 1992 Mr. Tzeegankoff presented at the casualty department complaining that he was hearing voices which were telling him to throw himself in front of a car. It is also recorded in the casenotes that, prior to this presentation, he had been engaging in some violent behaviour, involving smashing shop windows, for no apparent reason. He was admitted to Mason House at Hillcrest Hospital that day, and settled down with medication, including Pimozide.

The casenotes reveal that on 15 April 1992 Dr. Chandra saw Mr. Tzeegankoff. She recorded that she noted no evidence of overt psychosis. Professor Goldney expressed some surprise at this conclusion, saying that (with reference to the reports of violent behaviour and hearing voices) "if that’s not psychotic behaviour I don’t know what is" (T.733).

Professor Goldney also expressed surprise that Mr. Tzeegankoff’s medication was not increased when he was admitted to hospital, noting that the increase in the severity of his psychotic symptoms followed the progressive reduction in his Modecate dosage level since December 1991 (Exhibit C.81a, p3).

On 5 September 1992 Mr. Tzeegankoff presented at the Queen Elizabeth Hospital complaining of restlessness and asking for a reduction in his Modecate dose. He was given Diazepam instead. On 1 October 1992 he attended the Modecate Clinic, where he was seen by Registered Nurse Janeen McKenzie. In her statement (Exhibit C.26a, p2) Ms. McKenzie said that he seemed very guarded, wore dark glasses and spoke very little. This was a change from previous presentations.

Professor Goldney said that this information should have been conveyed to the treating team if it constituted an observable deterioration in his condition (T.755). In particular, he suggested that the information should have been recorded (T.766).

Ms. L.M. Fawcett, who, at that time was the Acting Assistant Director of Nursing at Hillcrest Hospital, agreed with Professor Goldney, saying that an appropriate entry should have been made in the casenotes consistent with the duty of care of a Registered Psychiatric Nurse to her patient (T.80). Ms. McKenzie responded that she only saw Mr. Tzeegankoff for between five and ten minutes that day, and did not conduct a full mental state assessment of him. She did not believe that she was observing an emerging illness at that time, and said that had she been concerned about his condition she would have taken him directly to the doctor for an assessment (see Exhibit C.26c).

On 8 and 22 October 1992 Mr. Tzeegankoff failed to attend at Hillcrest Hospital, the first for an outpatient appointment and the second for a Modecate injection.

On 1 November 1992 a community nurse was despatched to his home to administer the Modecate injection (see the statement of Ms. McKenzie, C.26a, p2). It is not clear whether the injection was administered at home or at the hospital, since the casenotes also record that Mr. Tzeegankoff attended at the emergency section that day, complaining of violent aggressive thoughts. At that time, Mr. Tzeegankoff was seen by Dr. C. Fraser. His notes record that he said "I am ill, I am having violent thoughts two to three times a day".

Professor Goldney was critical of Dr. Fraser because she failed to increase his medication level in view of the clarity of his presenting symptoms (T.749). Dr. Fraser responded that although he was having violent and aggressive thoughts, he was not behaving violently and was able to control his thoughts easily. She said that he was cooperative, although a little animated and had no thought disorder. She said that he indicated that he would contact Dr. Chandra to arrange follow-up appointments. Dr. Fraser said that she noted her findings in the emergency record but did not separately attempt to contact Dr. Chandra because she did not feel any need to present the information to Dr. Chandra apart from making the comments in the notes. She said:-

"Had I been concerned about the patient’s mental state I would have arranged for his admission and contacted Dr. Chandra".

(Exhibit C.44d)

 

 

This attendance by Dr. Fraser upon Mr. Tzeegankoff on 1 November 1992 was the last occasion on which Hillcrest Hospital staff had the opportunity to carry out an appropriate mental state examination on Mr. Tzeegankoff prior to the day on which Dr. Chandra died. Professor Goldney said:-

"Bearing in mind there were no hallucinations and he felt he could control his symptoms, I don’t believe I would have admitted him but I would have been increasing his Modecate, giving him a sedating major tranquilliser like Largactil, and ensuring that he came back for his next outpatient appointment within a few days (T.749)

 

 

Professor Goldney agreed that Mr. Tzeegankoff did not seem to have been detainable pursuant to the Mental Health Act at that time (T.751). There had been no trouble in the past having him admitted to hospital on a voluntary basis.

In the time between 1 November 1992 and 3 December 1992 David Tzeegankoff’s mother noted a deterioration in his condition, observing that he began drinking alcohol, and had become verbally aggressive. His brother Alex had been so concerned for the safety of his parents that he moved back into the family home about a fortnight before Dr. Chandra died. He said:-

"About a week and a half ago I noticed that David was looking withdrawn and his behaviour was changing. He wouldn’t eat, he wouldn’t dress properly, he was smoking a lot, things like that. I said to him ‘David you don’t look well. If you keep on going you’re going to end up where you don’t want to be’ (he was referring to the hospital)."

 

 

He said that on 25 November 1992 he saw his brother with a knife from the kitchen which was used to cut the lawn edges. Alex Tzeegankoff said that he challenged his brother about his possession of the knife because "I always had a mistrust of David because of his mental illness" (Exhibit C.64, p4-5).

Professor Goldney reviewed the four volumes of casenotes from Hillcrest Hospital, as well as the Guardianship Board file, and the statements of Mr. Tzeegankoff’s mother, father and brother Alex, together with the reports of Dr. Lucas and others.

I will refer to various aspects of Mr. Tzeegankoff’s treatment under the following headings:-

1. Diagnosis of schizophrenia

Professor Goldney summarised the nature of Mr. Tzeegankoff’s condition as follows:-

"There is no doubt that Mr. Tzeegankoff has a history of impulsive behaviour with violence which ante-dates the onset of his psychotic illness in the mid 1980’s. The psychotic illness has at times been difficult to delineate, but on balance it would appear that he has a paranoid schizophrenic illness, although the alternative diagnosis of a schizo-affective disorder has been utilised. Whatever the precise diagnosis, it is important to note that he had a relapsing condition, with a minimal degree of insight, and he has also reported side-effects from long-acting Depot medication (Modecate), which has led him to make repeated requests to reduce such medication".

(C.81, p1)

2. Basic treatment approach

Since, tragically, the medical practitioner who had the most input into Mr. Tzeegankoff’s treatment is now deceased, there is little evidence before me about whether there was a specific treatment plan formulated in relation to his illness.

A perusal of the Hillcrest Hospital casenotes does not disclose that a particular treatment plan was devised for Mr. Tzeegankoff. The best that can be gleaned from the records is a letter to the Guardianship Board from Dr. Rob Moyle dated 13 December 1988, when he said:-

"David as you may recall has a schizo-affective illness that is treated with Pimozide 60mg nocte and Lithium Carbonate 500mg mane and 750mg nocte.

 

He is a young man who usually presents in a self-induced crisis wanting rescue. When unwell he suffered a prolonged and very difficult to treat psychosis but he has, by and large, recently complied with treatment and any exacerbations have been brief and induced by various chemicals, self-induced.

 

Attempts to encourage David into various rehabilitation programs have failed. David is an appealing young man who presents psychotic after ingesting various substances often in a social situation. While he assures us this will not recur, it does. The same applies for the legal problems. When well he shows no signs of illness affecting his judgment.

 

It is my belief that David requires as much structure as is possible and he complies with this treatment order. The treatment I believe has protected David from a longer lasting more severe psychosis given the risks he chooses to take, and the order should remain. David will be seen at my outpatient clinic".

 

 

Professor Goldney was not critical of the basic treatment approach taken at Hillcrest Hospital, although it must be emphasised that he was particularly critical of the approach taken to medication, and to the fact that although the names of several psychiatrists are mentioned in the casenotes, there is no information about whether or not they had any input into his treatment, and they made no notes. I will deal with these specific issues under separate headings.

3. Medication

I have already described how David Tzeegankoff’s Modecate dose was reduced twice, on 5 December 1991 and 23 January 1992, in accordance with the following table:-

Dr. Peter Yellowlees, then the Chief Psychiatrist for the South Australian Mental Health Service, said in his statement (Exhibit C.24a):-

"It would appear from the casenotes that David Tzeegankoff was being well-managed and was not presenting any major problems with his treatment (p.6). . . . In the last twelve months the Modecate prescribed has been reduced from 37.5mg per fortnight to 25mg every three weeks. His last injection of Modecate was on 23/11/92 with his next due on 14/12/92. . . . In my opinion the medications that were prescribed to David Tzeegankoff were appropriate (p.7). . . . If I had been the treating doctor it is quite possible that I would have prescribed the same medication. There appears to be nothing abnormal in his treatment, and I have no problems with Dr. Chandra’s refusal to prescribe Valium and I would consider that appropriate (p.8)"

 

Dr. Yellowlees was there referring to an occasion on 7 September 1992 when Dr. Chandra refused to continue the prescription of Diazepam (Valium), after he had been prescribed with that drug at the Queen Elizabeth Hospital two days earlier.

Dr. W.E. Lucas did not take the same sanguine view of Mr. Tzeegankoff’s treatment. He pointed out that even when Mr. Tzeegankoff was receiving a relatively high dose of Modecate at 50mg every two weeks, when he was assessed on 1 August 1991 prior to discharge, a psychiatrist had noted psychotic symptoms, including blunting of mood, incongruous behaviour, thought disorder, auditory and tactile hallucinations, delusional beliefs with ideas of reference. He pointed out:-

"These symptoms were present despite the fact that he was receiving Modecate 50mg every two weeks, a dose considerably more than 25mg three weekly he was receiving in the year prior to the offence (in a six week period he would have been receiving 150mg at the time he saw Dr. Shaw as against 50mg over the same period prior to his killing of Dr. Chandra)".

(see Exhibit C.63a, p11)

 

 

I have already mentioned the fact that Professor Goldney was also critical of these reductions in medication. There is no doubt that Mr. Tzeegankoff complained bitterly from time to time about the side-effects from Modecate. This obviously put pressure on the medical practitioner to reduce the medication to the lowest level which is appropriate. Professor Goldney pointed out that it is mandatory to attempt to reduce medication when a patient is stable because of the risk of long-term side-effects, and it behoves the medical practitioner to try and reduce it, weighing up against that the risk of relapse and the longitudinal history of what has happened when it has relapsed (T.726). He added:-

"I think it is absolutely essential to monitor the effect of reducing the dose and also it is very important to make sure that you have quite a long period at each level, probably at least three months, when you are going down because it takes a while for a steady state to occur at the lower dose. So it is no good reducing the dose from one three week visit to the next, to the next. So one has to reduce slowly and over a long period of time because you are dealing with a longitudinal illness, you are not dealing with something that is going to change quickly".

(T.726)

It is very difficult to assess what monitoring (if any) of the effect of reducing the dose took place in Mr. Tzeegankoff’s case because of the paucity of clinical notes in the casenotes. I have already referred to the fact that Professor Goldney pointed out that both reductions occurred in the face of recent history of increasing psychotic symptoms, whereas the reduction should only have occurred if the reverse was the case. Professor Goldney said:-

"If you are reducing a dose of a drug like Modecate you really need to have a record of was there any thought disorder, are there hallucinations, if there are hallucinations are they more intense than they were before, has there been any impulsive behaviour? . . . Because it’s analogous really to a patient with diabetes, you know you monitor their blood/sugar level or a patient with hypertension, you monitor their blood pressure".

(T.744-5)

 

Professor Goldney also suggested that other medications than Modecate could have been tried if Modecate was proving ineffective or the side-effects are too severe. He said:-

"If one doesn’t work it is mandatory to try another one because sometimes people will respond to one drug rather than another. So if drugs are available I think it behoves one to use them".

 

 

4. Qualifications of staff

I have already mentioned that Dr. Chandra had been working at Hillcrest Hospital since she arrived in Adelaide. Professor Goldney said in his report that he had checked in a medical directory, and that her qualifications were given as "MB BS Ceylon 1971" (Exhibit C.81, p2). This was confirmed by her ex-husband (Exhibit C.1a, p2). Although Professor Goldney accepted that Dr. Chandra was an experienced medical officer, she was not a qualified psychiatrist.

Ms. Lisa Fawcett, who was then the Acting Assistant Director of Nursing, said that the management of patients at Hillcrest Hospital prior to Dr. Chandra’s death was divided into teams consisting of a consultant, trainee psychiatrist or career medical officer, nurses, social worker, and sometimes an occupational therapist or psychologist (T.59). She said that Dr. Chandra ought to have had a line of supervision whereby she would review the patient’s mental state and medication regularly, and then would be subject to supervision (T.61).

Professor Goldney noted that in the year to 3 December 1992 two psychiatrists are mentioned in the casenotes, Dr. Kuruvilla and Dr. vandenBoss, although to what extent they were involved with Mr. Tzeegankoff is not clear. He was critical of the fact that Mr. Tzeegankoff was not seen by a qualified psychiatrist on a more regular basis. Certainly all of the casenotes which recorded his attendances at Hillcrest Hospital were made by Dr. Chandra or another career medical officer. He said:-

"I think it unfair for people without specialist training to be put in a situation of making decisions, unless there is very careful supervision, and I also think patients with severe illnesses warrant the best treatment, which is from a person with a specialist degree, because that’s what happens in physical medicine. I see no reason why it shouldn’t happen in psychiatric medicine".

(T.731)

 

 

Professor Goldney suggested that a career medical officer should receive at least one hour of supervision per fortnight, depending on the case load. He said:-

"However, it is of concern that a man with a severe psychotic illness, who is under the care of the Guardianship Board, did not appear to have ongoing assessment by a qualified psychiatrist. It is not clear that there were recommended guidelines in terms of adequate doses of medication, or what should have been done if Mr. Tzeegankoff had not been compliant".

(Exhibit C.81, p6)

 

He pointed out that, in his opinion, the push towards de-institutionalisation for the provision of mental health services towards community treatment models had resulted in a dilution of expertise in psychiatric medicine. He said:-

". . . one of the dilemmas about the community push is that there is a dilution of a critical mass of expertise in one or two centres, when you get that dilution of expertise with people being distributed all over the place. In the one sense that is good because treatment is made closer to people’s homes, but the trade-off is that you don’t have that critical mass of expertise and everything gets reduced to the lowest common denominator, rather than having centres of real excellence. That’s one of the dangers that I think we have run into in South Australia, with the breaking down of good institutions, that that critical mass of people has been lost. I think it is one of the reasons why psychiatrists have been leaving the system as well, because it is seen that that body of expertise is being diluted".

(T.761-2)

These concerns should also be seen in the light of the fact that David Tzeegankoff’s family had been under the impression that Dr. Chandra was a qualified psychiatrist throughout the time she had been in charge of his treatment. His brother said that he did not become aware that she was not a psychiatrist until he read Professor Goldney’s report (T.36). I do not suggest that there was any policy of deliberately concealing the fact that Dr. Chandra was not a qualified psychiatrist. However, it would appear that David Tzeegankoff’s family drew the very understandable conclusion that, because he was being treated in a hospital for people with mental illness, the person in charge of his treatment would be appropriately qualified. In my opinion, this merely emphasises the fact that the family expected, and were entitled to expect, that, as Professor Goldney suggested, a person with a serious mental illness deserved to be treated by an appropriately qualified specialist.

5. Quality of record keeping

Mr. Tzeegankoff was seen on a number of occasions at Hillcrest Hospital in the last few months of 1992. Professor Goldney remarked:-

"There is a paucity of clinical notes regarding the presence or absence of psychotic symptoms during the last few months of 1992".

(see Exhibit C.81, p6)

 

 

He expanded upon this comment in oral evidence. I have already referred to this issue in the context of discussing Mr. Tzeegankoff’s medication levels. Professor Goldney drew analogies with a patient with a physical illness, such as diabetes, where it is necessary to monitor the blood/sugar level, and with a patient with hypertension where the blood pressure needs to be monitored. In order to obtain a longitudinal view of the progress of the patient’s illness, it is virtually impossible to monitor the patient’s progress unless the presence or absence of symptoms is noted in the case record. Professor Goldney agreed that this is particularly important in the public health system, where the patient might be seen by a variety of doctors, and it is virtually impossible for one doctor to know what has happened before. It is inappropriate for a doctor to assume, because of an absence of casenotes, that symptoms were absent on any previous occasion when the patient had been seen (T.746).

From the state of the casenotes in relation to Mr. Tzeegankoff’s treatment, I think it is possible to infer that Dr. Chandra was not receiving the degree of professional supervision and support which she required and deserved. Since the fact that the importance of maintaining a case record does not appear to have been brought home to her, a lack of appropriate specialist input into the patient’s treatment can be inferred.

6. Liaison with the patient’s family

David Tzeegankoff’s brother Alex was critical of the amount of information the family received about David’s illness and treatment at Hillcrest, and the lack of attention that was paid to information they provided about their brother’s condition. I have already referred to the fact that Alex Tzeegankoff was under the impression that Dr. Chandra was a qualified psychiatrist. He said that he had made a number of attempts to speak to her about his brother’s condition but that this achieved little. He said:-

"I tried to speak - I wasn’t making any progress with Dr. Chandra so I attempted to go higher up the ladder and speak to somebody else but the door was just shut in my face and they referred me back to Dr. Chandra and that was the end of it".

(T.35)

 

 

Mr. Tzeegankoff was also critical of the fact that he received little information about the medication his brother was receiving at the hospital. He said that Dr. Chandra referred to the patient’s privacy in that regard (T.44). Mr. Tzeegankoff’s attitude, on the other hand, was that:-

"We had to keep the pulse on him. If he had a nervous breakdown, we’re the ones who had to deal with it. If he was showing odd behaviour, we’re the ones who would have to take him to hospital or contact somebody to come and get him . . . so I wanted to make sure he wasn’t going to be psychotic and do anything stupid at home. He could have killed somebody at home".

(T.45)

 

Mr. Tzeegankoff also said that he could not remember a visit to the home by a social worker, a probation officer or any other professional person at any stage while David was living at home with his parents (T.48).

Ms. Fawcett told me that at the time of Dr. Chandra’s death there was a multi-disciplinary team operating from Port Adelaide. Its role was to provide outpatient clinics, medication, patient review and family support and education to patients with mental illness who were in the community. Unfortunately, it seems that no-one referred David Tzeegankoff’s case to the team. Ms. Fawcett said that she was not surprised that no-one from Hillcrest Hospital had discussed the illness with the family, and that the family were not aware of the existence of the community team. She said that the community teams were not very well publicised, and that there was no protocol in place to ensure the families availed themselves of their services (T.94).

Professor Goldney agreed that there was a need for more support for patients’ families, and although he recognised a need for patient confidentiality and privacy, he suggested that an appropriate step would have been to refer the family on to community organisations and other support networks. He suggested that the management of the patient could be split, so that a social worker attached to the hospital could have the specific task of supporting the family and providing such information as was appropriate concerning the patient’s illness without breaching privacy or confidentiality provisions. Such a worker would also be in a position to pass information back from the relatives to the treating doctors. This is a variant of the system used at Carramar Clinic, as described by Dr. Rose in the Ciampi inquest.

Of course, where a patient is paranoid, doctors must be careful about passing information to other family members, as allegations of a breach of confidentiality can easily be made in such situations. Professor Goldney suggested that it is sometimes appropriate to speak to the family over the telephone while the patient is in the consulting room so that the patient is aware of what information is being divulged (T.742).

7. Staff security

A number of issues were identified following Dr. Chandra’s death which relate to the physical security of staff employed at hospitals and clinics where people with psychiatric illness are treated. In particular, it is noted that her death occurred in an office at Hillcrest Hospital which only had one door, so that her egress could be easily blocked. Further, it was not easy to see into the office when staff became concerned for her safety, and the key to the office was not readily available and had to be fetched from the receptionist.

Ms. Fawcett told me that institutions are now more acutely aware of these safety concerns. In particular, she told me that although she was not aware of the precise details, practices had now developed whereby patients are now interviewed in interview rooms rather than in the doctor’s office, such interview rooms always have two exits, they have glass panels in a door or window so that people can see into the room, the rooms are not remote from other staff, alarm and personal duress systems have been installed, and sometimes periodic telephone checks on staff seeing violent patients are made.

While I accept the accuracy of Ms. Fawcett’s evidence in this regard, the evidence given by practitioners in other cases before me (particularly in the matter of Ciampi) indicates that things are still not ideal in relation to staff security, and much remains to be done.

I find that Nandadevi Chandraratnam, late of 15 Martinique Court, West Lakes, aged 47 years, died at Hillcrest Hospital, Fosters Road, Oakden on 3 December 1992 as a result of left haemothorax complicating stab wound to the heart.

Section 25(2) of the Coroners Act provides:-

"A coroner may add to his or her finding any recommendation that might, in his or her opinion, prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the inquest".

 

 

Having regard to the similarity of the circumstances of the deaths in this series of inquests, and in particular, to the similarity of the issues relating to psychiatric treatment arising in these cases, I will take into account evidence in each case and draw together a series of recommendations. Before doing so, however, I will discuss the issues under the same series of headings, as follows:-

In two cases, the diagnosis of schizophrenic illness was made at a much later time than it need have been. In the case of Matthew Proctor, Professor Goldney told me that the opportunity for early intervention in this illness is an advantage to treatment. In that case, however, schizophrenia was not diagnosed during his first admission to Glenside. Peter Lewin’s illness was not diagnosed until his third admission to Glenside in 1979. No criticism was levelled in relation to the timing of the diagnosis in the other four cases.

In case those charged with the heavy responsibility of making a diagnosis of schizophrenia are reluctant to do so because, as Professor Goldney suggested, "it’s almost like a death sentence", I consider that it is necessary to remind those people, and particularly trainee psychiatrists and career medical officers, that an early and clear diagnosis of schizophrenia will be particularly advantageous to the patient’s treatment. Once made, such a diagnosis should of course be revisited. But due regard should be paid to the diagnosis throughout the treatment period. This did not occur in the case of Bernard TenHoopen, until he was seen by Dr. Gill, who remembered an earlier stay at James Nash House and put his treatment back on track.

There is clear evidence before me that in all six of these cases, there were serious defects in the psychiatric treatment provided. In Matthew Proctor’s case, staff at Glenside did not come to grips with his psychiatric illness at all, instead concentrating on socio-economic factors, an approach which was doomed to failure in view of the severity of his illness. In Peter Lewin’s case, the difficulties associated with his treatment were largely attributable to a failure to obtain appropriate treatment orders from the Guardianship Board, although Professor Goldney acknowledged the complicating factor of Mr. Lewin’s abuse of anti-parkinsonian medication. In Bernard TenHoopen’s case, Professor Goldney said that he should have been treated in a much more aggressive way. A detailed analysis of the treatment given to David Tzeegankoff was not possible since, tragically, the person who was most responsible for such treatment (Dr. Chandra) is deceased and the casenotes are largely uninformative. In the case of Geoffrey Hogarth, Professor Goldney was critical of a transfer of the responsibility for the treatment of his serious and chronic schizophrenic illness by Glenside Hospital to a general practitioner, thereby placing him in an "invidious position". In the case of Frank Ciampi, the revocation of a treatment order by the Guardianship Board, and his subsequent refusal to receive Modecate in appropriate doses, had a seriously deleterious effect upon his treatment. A lack of communication between the Ciampi family and Carramar Clinic staff was probably the most important factor which led to this situation, and which led in turn to a failure to provide adequate information to the Guardianship Board.

Frank Ciampi’s case is an example of a problem encountered in several of these cases where staff at psychiatric institutions were either reluctant to approach the Guardianship Board for coercive orders, even when the condition of the patient called for such action, or provided inadequate information to the Board, thereby preventing an appropriate decision being made. This problem was also evident in the cases of Matthew Proctor and Bernard TenHoopen.

A common factor in all of the cases in this series was the fact that the levels of anti-psychotic medication prescribed for these patients was inadequate to control their psychosis. In the introduction, I referred to the fact that it is often difficult to achieve a satisfactory balance between, on the one hand, providing an adequate level of medication, and on the other hand ensuring that the level is not so high as to needlessly produce unpleasant side-effects. In Matthew Proctor’s case, Professor Goldney was critical of the fact that on a number of occasions when he presented with psychotic symptoms, his medication levels were not adjusted, and other medications were not considered which may have been more successful. When levels were changed, they were given an inadequate trial before being changed again so that monitoring of the effects of such changes was ineffective.

In Peter Lewin’s case, although his treatment was complicated by his abuse of anti-parkinsonian medication, Professor Goldney was critical of the low dose of anti-psychotic medication he was receiving, and the failure of Glenside staff to increase it after signs of psychosis began re-emerging. Professor Goldney told me that Bernard TenHoopen did not have a satisfactory trial of anti-psychotic/major tranquilliser medication at Glenside Hospital, and the dosages were inadequate. This was particularly apparent in the last few days of his life. This is to be contrasted with the successful course of medication achieved when Mr. TenHoopen was at James Nash House, which should have led to optimism that his condition was treatable. David Tzeegankoff’s medication was also criticised as inadequate, no doubt because he often complained bitterly about the side-effects, thereby putting pressure on his medical practitioners to reduce it. However, Professor Goldney criticised the fact that his mental state was not monitored adequately after reductions took place in the face of recent history of increasing psychotic symptoms. If the medications were unsatisfactory, alternatives should have been tried. Geoffrey Hogarth’s medication was reduced by his general practitioner, and on one occasion by a psychiatry registrar at Glenside, to a level which was completely inadequate for a person with a condition as severe as his, to the extent that Dr. Raeside described it as "like giving him nothing at all". Plainly, Glenside Hospital gave Dr. Beckoff inadequate guidance as to medication levels, nor did they consider medication to control the side-effects as an alternative. Finally, Frank Ciampi’s medication levels were also criticised as inadequate, and again Mr. Ciampi placed great pressure on his treating practitioners, complaining about the severity of the side-effects. Decisions were being made about Mr. Ciampi’s medication levels while his practitioners at Carramar Clinic were ignorant of his violent behaviour, particularly towards his family, when he was not at the hospital.

In my opinion, although it is not possible to conclude that these six tragic deaths would not have occurred had these patients been treated adequately with anti-psychotic medication, the conclusion is inescapable that such deaths would have been less likely to have occurred. In my opinion, this is particularly evident in the cases of the deaths of Dr. Chandra, Mrs. Hogarth and Mrs. Ciampi, as in each of these cases the medication levels were minimal and were demonstrably inadequate to control psychosis in the patient.

Professor Goldney made it clear to me that, in his opinion, each of these six patients, all of whom had severe schizophrenic illnesses, should have been treated by qualified psychiatrists, or at the very least, by doctors who were being supervised on a regular and effective basis by a qualified psychiatrist. Matthew Proctor did not see a qualified psychiatrist in the fourteen months before he died. At the time of Peter Lewin’s death, Dr. Hustig told me that Glenside Hospital was suffering from an acute shortage of qualified consultant psychiatrists, although Mr. Lewin had seen a number of consultants in the last six months of his life. Bernard TenHoopen received treatment which could only be described as poorly-focussed and ineffective until such time as Dr. Gill reminded staff at Glenside that the fundamental diagnosis was one of schizophrenia, but even that failed to ensure that his treatment was adequately resumed. David Tzeegankoff had been treated by Dr. Chandra, who was a Career Medical Officer and not a psychiatrist, virtually since his first admission to Hillcrest Hospital in 1986. Professor Goldney was critical of the fact that he was not seen by a qualified psychiatrist on a more regular basis, a situation which he described as unfair on the non-specialist, and unfair on the patient who, with a severe illness, warranted the best treatment. He pointed to the fact that this problem was likely to increase in the push towards de-institutionalisation of psychiatric service towards community treatment models, thereby relating in a "dilution of a critical mass of expertise". In the case of Geoffrey Hogarth, I have already referred to the fact that Professor Goldney criticised the referral of responsibility by Glenside Hospital for Mr. Hogarth’s treatment to a general practitioner who was untrained in psychiatry. Frank Ciampi was also treated by a general practitioner, Dr. McKenna, in the last few months before the death of his mother, a fact which caused Professor Goldney "very serious concerns", concerns which were also held by Dr. McKenna herself.

In my opinion, the fact that many of the practitioners treating these patients were inadequately qualified should not result in a criticism of the practitioners themselves. As Professor Goldney commented, they were placed in an "invidious position" by a system which was unable to provide a sufficient number of qualified psychiatrists to cope with the caseloads involved. In my opinion, unless the situation can be addressed and improved considerably, such patients will continue to receive what Professor Goldney has described as inadequate treatment.

Perhaps as a concomitant to the inadequacies of the basic treatment approach taken in these cases, of the inadequacy of medications prescribed, and the lack of qualifications of treating personnel, Professor Goldney was also highly critical of the standard of record-keeping in relation to all of these cases, a criticism which was accepted by Dr. Hustig. In each of these cases, a mental state examination was not recorded with sufficient regularity, or at all, in order that a "longitudinal view" of the patient’s illness could be obtained by reading the casenotes. This has resulted in confusion about the basic diagnosis and inadequate regard being paid to the patient’s clinical history. He rejected any suggestion that such information was a counsel of perfection, describing it as "standard medical practice". In each case, the inadequacy of the record-keeping may also be a reflection of the inadequacy of the training and professional qualifications held by treating practitioners.

In particular, in my opinion the views expressed by Dr. Jha in the case of Geoffrey Hogarth about record-keeping are to be rejected, and Professor Goldney’s approach should be preferred, particularly in the case where the treating practitioner is not a qualified psychiatrist. In such a case, provided adequate notes are taken, it might be possible for a qualified psychiatrist who is supervising a practitioner to provide adequate guidance in the treatment of the patient, but not otherwise.

It is heartening to note the comments of both Dr. Rafalowicz and Dr. Hustig to the effect that this issue has been addressed. Hopefully, the issue has been addressed along with the other concerns I have outlined, which may have brought the problem about, namely lack of training, lack of experience, understaffing, and lack of supervision.

I also consider that Dr. Raeside’s evidence about the advantages which might flow from the computerisation of psychiatric casenotes should receive earnest consideration.

It is clear that there was insufficient communication between the family of the patient and their treating teams. In particular, David Tzeegankoff’s brother Alex was critical of the lack of such communication with Hillcrest Hospital, and the fact that, although he and his family were forced to deal with David while he was living at home, they were doing so without any information about his condition, whether his treatment had been changed in some way, whether to look out for particular symptoms, or whatever. It is also apparent that facilities which were available, namely the multi-disciplinary team operating from Port Adelaide, were not brought to the attention of the family. Similar concerns were raised by the family of Frank Ciampi.

It should be recognised that the families of people afflicted with these terrible illnesses need considerably more support than they were receiving in these cases. As Mrs. Hogarth’s daughter pointed out, families may feel a considerable degree of embarrassment and even guilt for the behaviour of such patients. On many occasions there is a reluctance to discuss such issues with health professionals, particularly when there is no confidence that any such concerns will be acted upon. Indeed, (name suppressed) made a number of very sensible recommendations which I adopt and repeat pursuant to Section 25(2) of the Coroners Act. Professor Goldney recognised that families are in a position to provide highly useful information to therapists about the behaviour of patients, and suggested that it ought to be possible to set up a scheme whereby a social worker, or other health professional, could be allocated the task of liaising with the patient’s family, and providing such information as is appropriate without breaching privacy or confidentiality provisions, while at the same time passing useful information back from the relatives to the treating doctors. Dr. Rose outlined a system adopted at Carramar Clinic, whereby families are given a contact point for any concerns they may wish to communicate, and that when a new patient is taken on, two people are nominated, one to see the patient and the other to liaise with the family, so that there is no breach of confidentiality or conflict of interest. I will recommend that such a scheme should be adopted more widely.

A number of issues concerning the security of staff in psychiatric institutions arose, particularly in the context of the deaths of Dr. Chandra and Mrs. Ciampi. While Dr. Rafalowicz told me that steps had been taken to remedy a number of security defects, and that such efforts were ongoing, I will make a recommendation that such issues should continue to receive close attention in view of the evidence of Dr. Rose that there are a number of outstanding issues to be addressed.

I have already referred to the fact that Professor Goldney told me that one of the results of de-institutionalisation of psychiatric services is the loss of a "critical mass of expertise" at major treatment centres in South Australia. Professor Goldney described this as a "dilemma" in that, on the one hand, resources are available to the patient in the local area, but that, on the other hand, this may result in loss of centres of real excellence. He said:-

"That’s one of the dangers that I think that we have run into in South Australia, with the breaking down of good institutions, that that critical mass of people has been lost. I think it is one of the reasons why psychiatrists have been leaving the system as well, because it is seen that that body of expertise is being diluted".

(T.761)

 

In another passage, he described how people with chronic illnesses become dependent upon institutions. Again, this constitutes a dilemma. He said:-

"The double-edged sword is that on one hand dependence is fostered, and all the bad parts of an institution can be invoked. The good thing is that people can view the institution as an asylum, a good old-fashioned asylum, as an area of expertise. If one person is not there, another will be available; if two people are not available there will be a third; there is a body of people who can take up the slack, whereas if you are in the community you might have four or five people in one centre, and if one or two are away you are really stretched".

(T.800)

He further explained his concept of a "good old-fashioned asylum":-

"And that gets back to the old idea of asylum, that when people are distressed there is a place for them to go. One of the dilemmas is now that there is a push to keep people out of hospital at all costs, and so the basic humanity of offering asylum to people has been lost".

(T.801)

 

Dr. Hustig agreed, explaining that at the time when Peter Lewin died, Glenside Hospital had lost such a large amount of expertise that they were unable to pursue accreditation as a psychiatric teaching hospital. He said that they did not pursue such accreditation because "we wouldn’t have achieved it". He explained that the situation has now improved somewhat, with support from the pharmaceutical industry, in that Glenside Hospital had become a centre of expertise in clozapine therapy (T.363).

Another effect of de-institutionalisation is the loss of availability of appropriately humane closed wards for the accommodation of psychotic patients. Kurrajong Ward at Glenside was described as "fairly spartan and prison-like", and more appropriate for a prisoner than a patient (T.366). Having regard to its design and staffing levels, staff were unable to keep illegal drugs out of Kurrajong. Accordingly, a facility for the placement of psychotic patients so that they could be free of illicit drugs, and so that their illnesses could be treated appropriately, was not available.

Since that time, Dr. Hustig explained that the situation has taken a turn for the worse, forcing the administration at Glenside to set up another temporary closed ward, which is "quite unsuitable" (T.367).

There can be no doubt that the lack of an appropriate closed ward facility has led to breakdowns in appropriate treatment for psychotic patients. There was a reluctance to utilise a closed ward environment when the condition of the patient clearly called for it. This also seems to have led to a reluctance to approach the Guardianship Board for detention orders in relation to psychotic patients, on the basis that closed wards really only "punish" the patient, in the words of Dr. Hustig (T.185).

Closed wards should, although secure, constitute a benign environment where treatment, and not punishment, is the priority. If such facilities were available, perhaps psychiatrists would be less reluctant to use them. Professor Goldney explained that with the decentralisation of mental health services, he was not sure that it was going to be possible to have secure areas in all community treatment centres. This emphasises the need for at least one excellent service where such a facility is available. He explained that "unless action is taken to make sure there is a secure area there, I think we could be in for further problems" (T.469).

I have already analysed the specific deficiencies in the psychiatric treatment provided to all six of the patients suffering severe mental illness in the cases before me. Each of those areas of deficiency should not be seen in isolation. They should be seen in the general context of the mental health system as a whole.

Each of these factors is, in my view, a symptom of a syndrome which Professor Goldney, quoting an English commentator, described as "malignant alienation" (T.444). He explained that this was a sense of hopelessness, as sometimes happens in a hospital when the morale goes down, when staff feel that they are powerless. This feeling then is transferred to the patients and, as with all malignancies, it grows. In Professor Goldney’s words:-

"Patients die, I think, because of it".

(T.444)

 

Clearly, such a syndrome is exacerbated by difficulties such as understaffing, underfunding, lack of training, and lack of cohesion in the organisation in which people work. This results in the staff, again to use Professor Goldney’s words, "losing sight of the ball". He said:-

"Then what can happen is that people tend to lose sight of the ball so to speak, tend to blame social factors, blame the administration without keeping your eyes on the ball, with the ball being the illness that these people have got".

(T.454)

 

Taking all the matters I have just described into account, I make the following recommendations pursuant to Section 25(2) of the Coroners Act, namely that the Minister of Health, those in charge of psychiatric institutions, the psychiatric profession, and those involved in provision of treatment and assistance to patients suffering from schizophrenia and related disorders, should be educated about, and reminded of the importance of the following factors:-

(1) the benefits of early diagnosis and treatment;

 

(2) the need to remain focussed upon the primary illness, and to provide effective treatment for it, rather than becoming preoccupied with the symptoms and effects of the illness, such as socio-economic factors;

 

(3) where coercive orders by the Guardianship Board are called for, the need for clear, accurate, up-to-date and helpful information to be provided to the Board;

 

(4) there should not be a reluctance to approach the Guardianship Board for such orders where the patient’s condition requires them, and that such action should be seen as therapy rather than punishment;

 

(5) where it can be reasonably anticipated that specialist opinion will assist in such an application, the services of a qualified psychiatrist should be available to assist in presentation of the case to the Guardianship Board;

 

(6) where the treatment of such a patient is to be in the hands of a general medical practitioner or Career Medical Officer, such a practitioner should receive supervision and assistance from a consultant psychiatrist so that strategic decisions concerning such issues as changes in medication, orders by the Guardianship Board, the need for detention, transfers between institutions, and the like are not made without specialist psychiatric input. The limits of the non-specialist practitioner’s role should be clearly defined and mutually understood;

 

(7) the level of medication used in the treatment of such patients should primarily be determined by the minimum levels required to control the patient’s symptoms, particularly psychosis. Of course, the side-effects of such medication should also be considered , and treated where possible, but should not deter aggressive attempts to treat the patient’s illness;

 

(8) medication should be given an adequate trial before being changed. During the trial, careful monitoring and accurate recording of the patient’s mental state should occur. Changes in medication dosages should only occur after a full analysis of these factors over an adequate period of time;

 

(9) the adequacy or appropriateness of particular types of medication should also be analysed carefully. If one form of medication does not prove effective, resort should be had to the other medications available, and an adequate trial should be undertaken before any conclusion is reached that the patient’s condition is not amenable to medication;

 

 

(10) the role of family members in the monitoring of a patient’s mental state for the purposes of paragraphs (8) and (9) should not be underestimated. They are often in a position to provide information which the patient is unable or unwilling to disclose, but which is highly relevant to a diagnosis or, for example, re-emerging psychosis;

 

(11) the standard of record-keeping should be sufficient to enable the assessments referred to in these recommendations to take place. In particular, regular and accurate recording of the patient’s mental state, including a note of the presence or absence of both positive and negative symptoms, should occur;

 

(12) consideration should be given to the computerisation of psychiatric casenotes to assist in this process;

 

(13) (name suppressed)’s recommendations, which I quoted in the findings in relation to Mrs. Gwenneth Hogarth, referred to the need for better communication between therapists and families, more support for families, better community education about mental illness, and better and more flexible and suitable non-institutional accommodation for patients. These are all extremely sensible and appropriate suggestions, and I adopt them for these purposes;

 

(14) the practice now adopted at Carramar Clinic, as described by Dr. Rose in the matter of Mrs. Consiglia Ciampi, whereby one member of the treatment team is specifically allocated the task of liaison with the family and supporters of the patient, should be considered for general application;

 

(15) the security of staff in psychiatric institutions should continue to receive close attention;

 

 

(16) the future planning of psychiatric services should take into account Professor Goldney’s views that at least one "centre of excellence" for the provision of psychiatric treatment should be retained, and that a facility should continue to exist where patients may seek asylum in such a centre in appropriate cases;

 

(17) the condition and ambience of closed words should be improved so that the detention of a patient in an appropriate case can be seen as humane and therapeutic, rather than as a punitive measure. At the same time, the security of such wards needs to be improved so that patients are prevented from having access to illicit drugs, thereby complicating their psychiatric condition;

 

(18) the fact that under-staffing, high staff turnover, lack of cohesive management, and under-funding can all result in the death of patients, when staff morale drops to the extent that a sense of hopelessness develops, described by Professor Goldney as "malignant alienation", should be recognised and addressed.

 

 

 

 

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