An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 25^th, 26^th and 27^th days of February, 11^th, 12^th and 19^th days of June, and 28^th day of October, 1997, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Peter James Lewin.

I, the said Coroner, do find that Peter James Lewin, late of 1a Arnold Street, Underdale, aged 38 years, died at the Queen Elizabeth Hospital, Woodville on the 19^th day of May, 1994 as a result of anoxic encephalopathy due to cardiac arrest due to severe closed head injury.

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.

At about 10.30a.m. on 14 May 1994 Peter Lewin went into a delicatessen at 33a Fussell Place, Alberton and spoke to the proprietor, Mr. Agius. Mr. Agius said that he appeared "quite happy with life", that they talked for a while and that he left "contented and cheerful" (Exhibit C.14a, p2).

At about 8.15p.m. that evening Mr. Lewin went into the delicatessen again, but this time told Mr. Agius that he was going to commit suicide. He said, "I don’t want to go back to Hillcrest and be stuck in the same room as three or four other guys". Mr. Agius noted that he appeared sombre, remorseful and glassy-eyed, and "on a mission". Mr. Agius spoke to him and tried to lift his spirits, reminding him of their positive conversation that morning. He said:-

"Don’t do anything stupid, just have a good night’s sleep".

(Exhibit C.14a, p1)

Five minutes after that, an STA train was travelling from Outer Harbour towards Adelaide. It had just left the Alberton Railway Station heading east when, about 300 metres east of the station, and when it was travelling at about 60 kilometres per hour, the driver saw what he thought was a pile of rags on the track. When the train was only 15 metres or so away, he realised that it was a male person lying across the track with his head against the northern rail and his feet against the southern rail. The driver applied the emergency brakes but was unable to avoid him. Mr. Lewin sustained very severe head injuries. He was transferred by ambulance to the Queen Elizabeth Hospital, where he survived for several days until 19 May 1994 at 4.45p.m., when brain death was certified.

A post mortem examination conducted on 20 May 1994 disclosed that the cause of death was "anoxic encephalopathy due to a cardiac arrest due to severe closed head injury" (see the statement of the forensic pathologist, Dr. J.D. Gilbert, Exhibit C.11a).

There was some debate about what may have motivated Mr. Lewin to do what he did. Dr. Asz, for example, speculated that he "wanted to make a statement" (see his statement, Exhibit C.28a, p3), whereas Professor Goldney strongly disagreed with that statement, saying that Mr. Lewin’s behaviour was "hardly my concept of an impulsive act" (Exhibit C.35, p3).

Mr. Lewin’s death was unexpected by the staff at Glenside Hospital, particularly because there had been a general feeling that his condition had improved somewhat in the few weeks or so prior to his death. His fairly cooperative attitude at the Guardianship Board hearing on 29 April 1994, and his generally favourable presentation to Dr. Asz on 12 May, seemed to indicate some improvement in his condition. However, Professor Goldney agreed with the suggestion of Mr. Braithwaite, counsel for Mr. Lewin’s family, that a general improvement in Mr. Lewin’s condition may have been accompanied by the gaining of insight, which might have been a "dawning of a pretty dreadful truth". He said, "They are seeing where they have come from, so to speak, and don’t want to go there again" (T.461).

Peter Lewin had a long history of psychiatric illness. His first admission to Hillcrest Hospital took place in September of 1975 when he was 19 years old, possibly related to abuse of a wide range of drugs, including LSD, marijuana, cocaine and heroin.

In January of 1978 he was admitted to Hillcrest Hospital again, and marked auditory hallucinations and paranoid ideas were noted.

However, his illness was not diagnosed until February of 1979, upon a further admission to Hillcrest Hospital, when a schizo-affective disorder was diagnosed. Clear paranoid ideas and auditory hallucinations were evident at that time.

Mr. Lewin had 35 further admissions to Hillcrest Hospital, with most of them being attributed to substance abuse, particularly of anti-parkinsonian medication, and non-compliance with Modecate. His behaviour was at times impulsive and aggressive, and from time to time was highly self-injurious. On one occasion, he doused himself with turpentine and tried to set himself alight. Many other admissions took place after overdosing on drugs of various types.

In May of 1993, Mr. Lewin was transferred to Glenside Hospital when Hillcrest Hospital was closed. He was initially managed in the North Birches Open Unit, since he was cooperative to the extent that he was prepared to take oral medications, particularly Modecate, and other medication for side-effects.

In June of 1993, Dr. Harry Hustig commenced duties as Director of Extended Care at Glenside Hospital, and assumed responsibility for the medical decisions made in relation to Mr. Lewin’s care (T.327).

In December of 1993 Mr. Lewin was discharged to a hostel on the basis that he would continue to attend Glenside to receive intra-muscular injections of anti-psychotic medication. However, he gradually became more agitated after this time, and on 24 December 1993 he was detained by the police pursuant to the Mental Health Act and brought back to Glenside Hospital because he had been found lying on the railway track near Colonnades Shopping Centre at Port Noarlunga. Mr. Lewin explained his behaviour on the basis that he did not have enough money to buy his mother a Christmas present (see the evidence of Ms. Edwards, the social worker at T.91). The medical staff at Glenside detained Mr. Lewin that day, and Dr. Hustig confirmed the detention order. However, he did not extend the detention order beyond 26 December 1993 (T.336). Mr. Lewin was given additional medication in the form of Chlomazepam and oral Fluphenazine.

Mr. Lewin returned to reside at the hostel, known as Mitchell Park Lodge, where he was visited by Ms. Edwards. During one visit, she said that he appeared to be having an "oculo-gyritic crisis" (where the eyes roll back into the head and are locked in that position, an extremely painful condition), but there was some doubt about the genuineness of this situation and she interpreted his behaviour as a ploy to get Benztropine. Prior to her arrival, Mr. Lewin had called the ambulance, and when the ambulance officers were unable to dispense any medication to him, he became distressed and ran out into the traffic (T.91).

On 4 January 1994 another crisis took place, whereby Mr. Lewin took an overdose of Benztropine tablets and was taken to the Royal Adelaide Hospital, where he was detained pursuant to the Mental Health Act. He was transferred to Glenside soon afterwards, and then he was discharged on 7 January 1994 back to the hostel. Dr. Hustig said that Mr. Lewin’s object in this behaviour was not suicide, but to "enjoy being psychotic" (T.339).

It is noteworthy that during this admission, Mr. Lewin was treated with additional oral anti-psychotic medication, and this appeared to assist him because his behaviour settled to the extent that he could be discharged.

This is significant because on 20 January 1994, Mr. Lewin’s dose of Modecate was reduced from 50mg every two weeks to 25mg every two weeks.

At this stage, the Glenside staff had been under the impression, as was Mr. Lewin, that the Guardianship Board treatment order was still in existence. In fact, the last treatment order had been revoked in March of 1992. When this was discovered, Mr. Lewin initially wanted to discontinue Modecate treatment altogether. After some negotiation, he agreed to a halving of the dose to 25mg fortnightly (T.333). Mr. Lewin’s medication remained at that level until his death.

On 15 February 1994 Mr. Lewin presented at the casualty department at Glenside, where he was seen by Dr. M. Drennan. There is nothing documented about his mental state at the time, and it is recorded that he was given Temazepam.

On 16 February 1994 Mr. Lewin was seen again in the casualty department at Glenside by Dr. Drennan, at just after midnight. It was noted that he was suffering from auditory hallucinations and suicidal ideas, and she gave him Temazepam. Dr. Drennan noted that he was dissatisfied with his present accommodation, but she did not admit him to hospital, leaving it for discussion with Ms. Edwards, the social worker, the following day.

On 18 February 1994 Mr. Lewin attended at the All-Care Day Surgery at Semaphore on his own initiative, seeking Modecate. This is a clear indication that even with his limited insight, Mr. Lewin was aware of his need for anti-psychotic medication.

On 23 February 1994 he attended again at the casualty department at Glenside, where he was displaying paranoid ideas in relation to his accommodation. This was treated as an accommodation issue only, and he was not admitted to hospital.

On 28 February 1994 he attended again at Glenside casualty department, when he complained of insomnia, auditory hallucinations and other signs of psychosis. He was provided with chlorpromazine and not admitted to hospital.

On 3 March 1994 Mr. Lewin failed to attend the Modecate Clinic for his intra-muscular medication.

On 14 March 1994 he attended at Glenside casualty department in an agitated and restless manner, requesting anti-parkinsonian medication (Benztropine). It was noted that he was rolling on the floor, tearful and distraught. He was provided with Benztropine on that occasion, but not admitted.

As I will discuss later in these findings, Professor Goldney noted that none of these attendances at the emergency service resulted in an entry in Mr. Lewin’s casenotes detailing a proper mental status examination. The evidence available indicates that he was showing clear signs of psychosis and yet his level of anti-psychotic medication was not increased (Exhibit C.35, p2).

On 18 March 1994, Ms. Edwards attended at Mr. Lewin’s mother’s home and, due to the clear psychotic symptoms he was displaying, conveyed him by car to Glenside Hospital. He was seen there by Dr. Bem, a trainee psychiatrist, who conducted a comprehensive examination, noting that Mr. Lewin was hearing voices, was suffering auditory hallucinations telling him to kill himself, that he was displaying paranoid and suicidal ideation. Dr. Bem admitted him to the hospital.

Professor Goldney said that Dr. Bem conducted the "most comprehensive mental state examination in the notes", and that the symptoms noted by Dr. Bem constituted a "excellent description of a person with a psychotic condition" (Exhibit C.35, p2). Professor Goldney said that it was unexpected that his intra-muscular anti-psychotic medication was not increased, and that oral anti-psychotic medication was used instead (Exhibit C.35, p2).

On 28 March 1994 Matthew Proctor died at the Bowden Railway Station. I record this event because it is noteworthy that Ms. Edwards was conscious of the possibility that such a tragic event might have an unsettling effect upon Mr. Lewin, although the two men did not appear to know each other well. She said that she consulted with the staff at the hostel where he was staying, asking them to let her know if he showed signs of becoming unsettled (T.104). However, the death did not appear to have such an effect upon him. Indeed, she did not think that Mr. Lewin even knew about Matthew Proctor’s death until about a week later (T.112).

On 7 April 1994, Mr. Lewin was seen by Dr. John Veale, who renewed his prescription for Biperidon (an anti-parkinsonian medication), and he described Mr. Lewin as "lively and spontaneous" on that day (T.294).

On 27 April 1994 Mr. Lewin overdosed by taking large quantities of Benztropine. He was taken to the Queen Elizabeth Hospital, detained, and transferred to Glenside Hospital the same day. Dr. Hustig saw him on 28 April 1994, and said that although he did not require continuing detention, he "would benefit from further inpatient supervision" (Exhibit C.35,p2). Notwithstanding this, Mr. Lewin was either discharged or released on trial leave two days later.

On 29 April 1994, Mr. Lewin appeared before the Guardianship Board, and administration and treatment orders were made, with his consent (see Dr. Hustig’s evidence at T.342). Professor Goldney commented that it is "not clear what additional steps were taken by his treating doctors following that order" (C.35, p5).

Mr. Lewin received his final dose of 25mg of Modecate on 5 May 1994, and at that time the casenotes were endorsed that he "appears stable" (T.345).

On 12 May 1994 Mr. Lewin was reviewed at Glenside Hospital by Dr. Asz, who noted that he "appeared to be coping well at the hostel. No perceptual dysfunction or thought disorder" was noted (see Dr. Asz’s statement, Exhibit C.28a, p1). Dr. Hustig said that this was the last occasion on which Mr. Lewin was seen at Glenside (T.344).

When preparing his report, Professor Goldney examined a number of statements which were tendered at the hearing, together with the two volumes of casenotes prepared at the Glenside Hospital in relation to Mr. Lewin’s treatment (there were another six volumes of casenotes relating to his treatment at Hillcrest Hospital), a copy of Dr. Hustig’s letter to the Public Advocate of 16 March 1994, which summarised Mr. Lewin’s treatment, and also a copy of the six-page summary relating to Mr. Lewin’s treatment at Hillcrest Hospital, which was prepared at the time of his transfer to Glenside (the letter and summary are together marked Exhibit C.32).

Dr. Hustig described Professor Goldney’s report as "a very fair report".

Professor Goldney’s criticisms of Mr. Lewin’s treatment can be summarised under the following headings:-

1. Diagnosis of schizophrenia

Although this issue was not specifically discussed in relation to Mr. Lewin, since his treatment commenced in 1975, it is worthy of note that it was not until his third admission to Glenside in 1979 that a schizo-affective disorder was diagnosed. Mr. Lewin’s first admission to Hillcrest Hospital in 1975 was when he was 19 years of age.

It would seem that Professor Goldney’s comments in relation to the benefits of early diagnosis and aggressive treatment of schizophrenia, which I discuss in my findings in the matters of Proctor and TenHoopen, are equally apposite to this case.

2. Basic treatment approach

The closest that the evidence comes to describing an overall treatment plan for Mr. Lewin is the contents of the letter Dr. Hustig wrote to the Public Advocate dated 16 March 1994 (Exhibit C.32). The relevant parts of that letter for the present purposes are as follows:-

"Since that time (January 1994) he has continued to receive Modecate on an intermittent basis and would appear to have resumed his previous habits of abusing anti-parkinsonian medication and it would appear from the intermittent contact with emergency services that he is again slowly deteriorating. He has been non-compliant with his outpatient appointments. It is of note that on 18 February 1994 he actually attended the All-Care Day Surgery at Semaphore to receive an injection of Modecate on his own initiative . . . Certainly Mr. Lewin’s case speaks quite clearly of the need for a treatment order and I have no doubt as his condition gradually deteriorates with abuse of anti-parkinsonians and other medication, that he will probably require a further period of hospitalisation and at this time re-application of the treatment order may be required.

Over the period of the last two years, reviewing the casenotes, I believe that Mr. Lewin’s treatment has been quite appropriate and there is no evidence of any adverse effects or harm arising from the administration of intra-muscular medication, but rather it would appear to have been of benefit clinically".

 

 

This summary should be seen in the context of the evidence Dr. Hustig gave about the difficulties of treating a person with chronic schizophrenia, in the sense that it was extremely difficult to bring his situation under control. He described a situation whereby as soon as a reasonable level of functioning was achieved by treatment, Mr. Lewin would be discharged from hospital to a situation where he was poorly supervised, the treatment regime would deteriorate, and they would then have no option but to wait for his condition to become worse to the extent that his re-admission to hospital would be necessary.

Dr. Hustig said:-

"We are kind of caught between getting them to a reasonable stage of recovery within hospital with lots of supports, lots of 24 hour supervision etc., and then we’ve got to take the quantum leap to really very poorly supervised spots, certainly the boarding houses and hostels have improved over the last decade, but by and large there is still three to four occupants per room, and generally the level of intrusiveness that these patients have is actually pretty high. The standard of cleanliness of the places is marginal, and the things to do with one’s leisure time etc. is actually quite restricted, so really we are sort of caught in a problem that the environments we send them out to are actually quite deleterious in terms of their mental illness . . . We’ve got to let go knowing full well that we are not on top of the problem and basically we keep pushing, trying to . . . with several bites of the cherry, trying to establish these patients at a better level".

(T.357)

 

 

This sense of frustration and helplessness seems partly due to the fact that during 1993 and 1994 Mr. Lewin was not the subject of a treatment order made by the Guardianship Board. His medication level had been maintained at a higher rate while staff at Glenside were under the mistaken impression that the treatment order was in existence, but when it was discovered that it had lapsed in 1992, his medication level was halved. Professor Goldney commented:-

"It could be argued that with such a long history, the treatment order should not have been revoked. However, this is speaking very much with the benefit of hindsight".

(Exhibit C.35, p4)

 

 

Professor Goldney was not critical of the failure by Glenside Hospital staff to gain control over Mr. Lewin’s psychiatric condition, except in the area of medication levels, with which I will deal shortly. He said:-

"However, with the complicating factor of abuse of anti-parkinsonian medication, such criticism may appear to be somewhat harsh".

(Exhibit C.35, p5)

 

 

3. Medication

Although he acknowledged the difficulties of treating Mr. Lewin because of his abuse of anti-parkinsonian medication, Professor Goldney was critical of the fact that Mr. Lewin was only receiving a low dose of anti-psychotic medication. I have already referred to the fact that in February of 1994 his dose of Modecate (Fluphenazine Deconoate) was reduced from 50mg every two weeks to 25mg every two weeks.

To some extent, Dr. Hustig’s explanations for this change were contradictory. He said:-

"every time we push up his Modecate . . . we have to push up the side-effect medication as well and that gives him increasing stocks to abuse, so we end up in a sort of cyclical position. At that stage, we didn’t have any Depots that didn’t cause problems of extra-pyramidal side-effects".

(T.348)

 

 

This seems somewhat at odds with his statement in the letter to the Public Advocate in March 1994, in which he said:-

". . . There is no evidence of any adverse effects or harm arising from the administration of intra-muscular medication, but rather it would appear to have been of benefit clinically".

(Exhibit C.32)

 

 

Professor Goldney said that after the dosage of Modecate was reduced, and his signs of psychosis began re-emerging, it should either have been increased again or another medication should have been tried. He said:-

"For someone with a severe illness, it (25mg fortnightly) is like a drop in the ocean really".

(T.446)

 

In particular, Professor Goldney said that, after Mr. Lewin was re-admitted to Glenside on 18 March 1994, the medication should have been reviewed. He said:-

"I think if you’ve got someone who’s got an active psychotic condition and two months before, his medication has been reduced, it defies logic not to re-introduce the high dose of medication, or change to another medication. I mean to continue on the same dose, I mean why? It’s pointless".

(T.450)

 

 

When it was suggested that even at 50mg fortnightly, Mr. Lewin’s symptoms were not being controlled, Professor Goldney replied:-

"OK, increase it beyond 50, or change it to one of the others".

(T.451).

 

 

4. Qualifications of staff

Dr. Hustig said that, around the time of Mr. Lewin’s death, Glenside Hospital was suffering an acute shortage of qualified consultant psychiatrists, although it could not be said in Mr. Lewin’s case (as it could in the case of Matthew Proctor) that he had suffered from a lack of contact with specialised advice. In fact, he had seen a number of consultants in the previous six months or so.

Dr. Hustig said:-

"The larger problem we had there at the time was really the total lack of medical staff and part of that actually relates to difficulties in (a) recruitment of public sector psychiatrists and (b) an attitude that the College had towards this branch of psychiatry where they only actually gave us authorisation for one trainee . . . I was actually running the service purely with career medical officers and at this stage there was only one psychiatrist".

(T.362)

 

 

Dr. Hustig acknowledged that, from February 1996, the situation improved somewhat (T.362).

5. Quality of record keeping

Professor Goldney reserved his sternest criticism arising from this case for the quality of record keeping in the casenotes arising from Mr. Lewin’s various attendances at Glenside Hospital. In particular, during February and March 1994, when Mr. Lewin’s psychosis was re-appearing after his dose of Modecate was halved, the attendances were not well documented in terms of a description of his mental state by Glenside staff. The exception to this was, as I have already outlined, the consultation on 18 March 1994, when he was seen by the trainee psychiatrist, Dr. Bem.

Professor Goldney was also critical of the lack of documentation of Mr. Lewin’s mental state in the last week or so of his life when he was seen by Dr. Asz (Exhibit C.35, p3). He pointed out:-

"It is the only way in which one can monitor whether or not a person is going to get away with a lower dose, or whether they may need a re-introduction of a higher dose".

(T.452)

 

He rejected any suggestion that to require a proper mental state examination was a counsel of perfection, describing it as "standard medical practice" (T.453).

Professor Goldney suggested that the lack of such observations probably explains the overall failure of Glenside staff to come to grips with Mr. Lewin’s condition. He said:-

"Finally, at the risk of overstating the following, I must emphasise that a comprehensive mental state examination is the only way in which one can gain an assessment of a patient’s psychiatric state. It is analogous to observing pulse, blood pressure and respirations and the sites of pain in patients with physical illness. The absence of such mental state examination recordings in the notes is my main criticism".

(Exhibit C.35, p5)

 

 

These criticisms were accepted by Dr. Hustig at T.348 and T.50. Dr. Hustig said:-

"I think Professor Goldney’s comments on our casenotes are apt, and it is one that I’ve certainly taken to heart, and I’ve set about trying to ensure that both there is more objective rating and more documentation within the notes".

(T.360).

 

 

I find that Peter James Lewin, late of 1a Arnold Street, Underdale, aged 38 years, died at the Queen Elizabeth Hospital, Woodville on 19 May 1994 as a result of anoxic encephalopathy due to cardiac arrest due to severe closed head injury.

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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