Inquest Into The Circumstances Surrounding The Death Of Brian Joseph Duff

INQUEST INTO THE CIRCUMSTANCES SURROUNDING THE DEATH OF BRIAN JOSEPH DUFF REASONS FOR FINDINGS Brian Joseph Duff died at his flat at [redacted], Melrose Drive, Lyons in the Australian Capital Territory, sometime between 9.20 p.m. on 14th February 1997 and 9.50 a.m. on 15th February 1997, most probably about midnight on 14th.

The cause of death was a toxic overdose of the drug Clozapine, an anti-psychotic drug, self-administered at that location between those times, with the terminal event being pulmonary oedema related to a cardiac arrest. There is insufficient probative evidence that Mr Duff wilfully overdosed with the intention of taking his own life. The evidence is equally consistent with an unplanned result. I will return to the reasons for reaching this conclusion later.

Because he was, at the time of his death, subject to a Community Treatment Order made by the Mental Health Tribunal, under the Mental Health (Treatment and Care) Act 1994, his death was regarded, under Section 3(2) of the Coroners Act 1997, as being a death in custody.

wfR DUFF'S MEDICAL BACKGROUND Mr Duff had a long history of mental illness. He suffered from chronic schizophrenia, which was classed as "very severe", and in the top 20% of the most chronic cases. He had been involved for many years with the Mental Health Service, and had had several hospital admissions for treatment. He had demonstrated violent behaviour towards others, including members of his family, so much so that Protection Orders had been taken out against him. He had also previously displayed some suicidal traits, as well as self-harm, and had attempted to goad Police into shooting him after threatening them with a knife on 28th March 1996.

This last-mentioned incident followed the fatal shooting by Police of Mr Duff s friend, Mr Warren I'Anson, also a schizophrenic, and appears to have been a "copy-cat" episode.

Mr Duff was the subject of an involuntary detention by order of the Mental Health Tribunal on 20th June 1995, extending to 30th June 1995. This followed a report by Dr Way that he suffered a relapse of schizophrenia, following the suicide of a friend, and had slashed his wrist. He was also psychotic, with persecutory delusions, and refused to accept adequate treatment.

The next involuntary detention occurred on 28th March 1996, after the incident with the Police, during which he was hospitalised. During the ensuing several months, the Mental Health Tribunal considered and granted several applications for treatment orders, resulting in an order of 19th December, 1996 which was in force at the time of his death.

The order of 19th December 1996 directed:

1. Continuation of psychiatric treatment by Dr M. Evans or her delegate.

2. Continuation of attendance at the Phillip Health Centre for treatment and supervision as arranged and directed.

3. Continuation of acceptance of supervision by the Intensive Rehabilitation Team.

4. That he reside as directed.

The Mental Health Tribunal made this order on the grounds that Mr Duff was incapable of being able to weigh for himself the considerations involved in making a decision whether to accept adequate treatment for his mental dysfunction, and concluded that the order was necessary for his own protection.

The order, as finally made, followed a letter from Mr R. Bromhead, then Mr Duff s case manager, to the Mental Health Tribunal. Mr Bromhead noted a visible loss of weight by Mr Duff over the preceding six months. He also said he had been unable to gain access to Mr Duff s flat for a period of three months, and on eventually doing so, found it to be in a state of disorganisation.

Mr Bromhead formed the view that Mr Duff was unable to cope with living in the community, and believed that it should be made possible, under an order, to place him in a hostel, involuntarily if necessary; hence, the application for variation of the order.

Mr Don Wilson, who had known Mr Duff since 1994, took over as his case manager on 16th December, 1996. There was a meeting that day between Mr Wilson, rvt- Duff, Dr M. Evans (the psychiatrist involved in Mr Duff s treatment) and Mr Bromhead. At that time, Mr Wilson said that Dr Evans told him that Mr Duff was in a higher risk suicidal category and it was suspected that he was not complying with his medication.

Dr Evans said that, at that meeting, she noted a deterioration in Mr Duff s observable mental state. She noted "features indicative of more internal preoccupation, behaviour suggestive of hallucinations, persecutory delusions regarding his neighbours and his chronically present formal thought disorder".

Dr Evans said she discussed the possibility of a further deterioration in Mr Duff s condition, in which event, she said, he should be admitted to the Psychiatric Unit at Canberra Hospital. In the meantime, he was to continue taking 350mg of Clozapine (3 x 100 and 2 x 25mg tablets) daily.

Dr Evans said she recalled no other changes to the basic management plan, "such as a dosette box (where each dose of medication is in a separate container) no longer being used to monitor medications" . She added that she had "no recollection of being informed of when the Intensive Rehabilitation Team (of which Mr Wilson was member) took that decision".

This evidence was in contrast to that of Mr Wilson, who said that he was not aware at any stage that Mr Duff s medication was to be issued in dosette boxes. He had given Mr Duff the Clozapine tablets in foil packs sufficient for four weeks, as had Mr Bromhead.

Following the meeting on 16th December 1996, Dr Evans ordered a blood drug level test to be carried out "to give some indication of drug compliance". She also wrote a letter to the Mental Health Tribunal supporting Mr Bromhead's application for variation of the existing order (which occurred, as earlier stated, on 19th December 1996). A further meeting was held between Mr Duff, Dr Evans and Mr Wilson on 16th January 1997.

Dr Evans said she had no communication from anyone regarding Mr Duff during the interval. By the time of that meeting, she had received the results of Mr Duff s Clozapine level as taken on 16th December 1996. She explained that the tests are carried out at a central testing instrumentality in Melbourne, and take about three weeks to process.

The level as shown in the result was "low", and indicated that Mr Duff was not taking the dosage of Clozapine prescribed. When asked about this, Mr Duff assured her that he was "taking it now".

Dr Evans noted that Mr Duff s "physical appearance had improved, he was not preoccupied, was able to be engaged in conversation, and warm in his affect towards me". However, she felt that the "typical and long term features of his illness, such as a degree of formal thought disorder and evasiveness of issues such as his accommodation, remained".

Mr Wilson also believed at that time that Mr Duff s condition had improved. He had been trying to get Mr Duff to accept some kind of supported accommodation, such as

Hennessy House, and at that time, Mr Duff was much more favourably inclined to the idea.

It was agreed that, because of his improvement, Mr Duff would not be subject to an application for an emergency involuntary treatment order.

Despite Mr Duff s assurance that he was taking his medication as prescribed, Dr Evans believed that a re-test of the Clozapine level should be carried out, and made an appropriate request.

It is not clear when the results of that test, which showed a zero Clozapine level, were received by Dr Evans. In her evidence (transcript p.19, 26.11.97) she said the results were received "after Brian had died". In her undated statement forwarded by her solicitor, Mr Took, on 9th January 1998, she said (paragraph 42) that Mr Duff s level on 14th February 1997 "was close to zero, or words to that effect".

Dr Evans said that she made this remark to Mr H. Krueger, a member of the Mental Health Crisis Team, on that date.

On the other hand, Mr Krueger said Dr Evans told. him, at 6.30 p.m. on that date, that Mr Duff s level was not "close to zero" as asserted by her, but "zero", a statement that he recorded in the team's official log.

There was no evidence in the files produced recording the date of receipt of the results, although, as Dr Evans earlier stated they are received after an interval of three weeks, they should have been in her possession about 7th February. As noted, there was some dispute between Dr Evans and Mr Krueger as to the precise words used during their meeting on 14th February. If Mr Krueger's recollection, supported by his notation in the log, is correct, the result should have been known on 14th February.

A reference to this appears in a record of an interview on 26th March 1997 with Dr Evans, conducted by Tim Leggett and Eugene Meegan, during an internal investigation into Mr Duff s death.

Their record was that "(Dr Evans) also mentioned (to Mr Krueger) that it was known that Brian was not reliable with taking (Clozapine) as his last (Clozapine) level was zero".

No advice to this effect (i.e., "zero" or "close to zero" level) was passed to the Case Manager, Mr Wilson, who said it would have caused him to adopt a more urgent approach to his management plan.

On 20th January 1997, Mr Duff allowed Mr Wilson to enter his flat. This had not occurred before, and, in Mr Wilson's view, represented a real break-through in their relationship, because it indicated that Mr Duff had more trust in him.

Mr Wilson said that, for that reason, he did not go "rummaging and searching through" the flat. He did ask Mr Duff whether he was taking his medication, and was shown a card with 10 x 100mg tablets. As Mr Wilson had given Mr Duff his medication only six days before, he expected there would be some there, and accepted Mr Duff s assurance that he was taking the medication as prescribed.

Mr Wilson did concede, however, that the flat was in a grossly disorganised state, and unclean. He noted, when helping to clean it, that the cupbo,;1rds in the flat and the refrigerator contained very little food. He did not believe the state of the flat to be unusual for a patient with schizophrenia. wnen shown Police photog1aphs of the fl.at on the 15th February, while he was in the witness box, Mr Wilson believe it was in such a disorganised condition when he visited it on 20th January. Mr Wilson said he helped Mr Duff with the electricity, about which he had been complaining. He felt that, after that visit, Mr Duff was more inclined to agree to allowing someone in to help clean up the flat. It did not appear to Mr Wilson that there were sufficient factors then existing to warrant Mr Duff s hospitalisation, and he believed that progress was being made in relation to the proposed accommodation plan.

Mr Wilson did not convey his observations of the condition of Mr Duff s flat to Dr Evans. This was an unfortunate omission, and Mr Wilson said he accepted, m retrospect, that he should have perhaps called Dr Evans at that stage. It is clear, from Dr Evans' evidence, that if he had done so, she would have taken steps earlier to have

Mr Duff hospitalised, because the condition of the flat, particularly in relation to the lack of adequate food, indicated that he was not capable of properly caring for himself.

In late January one of Mr Duff s friends, "Doug", suicided. Mr Wilson took Mr Duff to the funeral, but he became too distressed to stay, and Mr Wilson took him home.

Mr Wilson said that Mr Duff expressed no suicidal thoughts then, or at any other time.

Mr Wilson continued in his efforts to find suitable alternative accommodation for Mr Duff. On 30th January he telephoned Richmond Fellowship and Willowview, at Queanbeyan, but was unable to secure a place. He was, however, able to arrange for an assessment at Hennessy House, with which Mr Duff agreed.

On 10th February, Mr Wilson noted that Mr Duff had mild thought disorder and some agitation. The latter, however, was not unexpected in view of the forthcoming assessment at Hennessy House, and in relation to home help which Mr Wilson was proposing to organise pending admission to that establishment.

On 13th February, Mr Wilson took Mr Duff to Hennessy House and spent some two hours there in discussions with staff. Mr Duff had been there previously, and said he was quite agreeable to going there if accepted.

Mr Wilson said that he did not believe, on the evidence available to him, that Mr Duff was hoarding Clozapine. He said Mr Duff was able to tell him the correct number of tablets he was supposed to be taking per dose, and this tallied with the medication produced by him. In addition, Mr Duff did not appear to be disoriented , which would have alerted Mr Wilson to the possibility that he was incapable of taking the correct dose.

On the other hand, Mr Wilson said that if he had known at that time that Mr Duff s Clozapine level was zero, or close to it, he would have been more concerned, and would suspect a rapid decline in his condition. Lacking that knowledge, he did not consider more urgent action should be taken, in view of Mr Duff s imminent admission to Hennessy House. He had also learned, on 14th February, that an earlier appointment had

been made with Dr Evans on the following Monday, 17th February, although that was the only information about Mr Duff passed on to him from the Phillip Health Centre.

As to his general impressions, Mr Wilson said in his evidence that Mr Duff appeared gaunt when he first took over his case management, and looked underweight.

During his interview on 25th March 1997 with Eugene Meegan and Tim Leggett (the internal investigators), Mr Wilson said that over the last eight weeks of his life, Mr Duff had improved overall in his appearance and mental state. His hygiene had improved, he showered and shaved. Food and fluid intake had improved and he had "a hearty appetite". He was more organised and was able to keep appointments. He was more compliant with medications.

On 13th February, Mr Duff made a brief visit to his parents' home at Curtin, and had a cup of coffee. He was talking to himself and wringing his hands.

THE EVENTS OF 14th AND 15th FEBRUARY 1997 At about 3.00 p.m. on Friday 14th February 1997, Mr Duff walked into the Woden Mental Health Unit. On duty at that location was psychologist Kym Starr.

During a twenty-minute consultation, Ms Starr, who did not know him, noted that Mr Duff s speech was difficult to understand, and would trail off to a mumble. He did not express any suicidal tendencies.

Ms Starr said Mr Duff complained that he had been vomiting over the past week, and that the Clozapine he was taking was making him sick. She said he had a dishevelled appearance, and appeared quite anxious and depressed. He did not appear to be under the influence of medication or a drug. He repeated several times, in a distressed tone, "I haven't been able to work in weeks".

Ms Starr said she suggested an earlier appointment with Dr Evans on the following Monday, 17th February. She said Mr Duff appeared quite pleased with that arrangement.

When he left, Ms Starr telephoned Dr Evans and described the interview with Mr Duff, adding that she wanted to arrange the earlier appointment for him. Dr Evans said that Mr Duff "often presents quite unwell", and that, as Ms Starr had not seen him before, she might be over-reacting to his presentation. She suggested that Ms Starr call Mr Wilson to discuss whether Mr Duff s condition might be deteriorating, before she would agree to an earlier appointment.

Ms Starr telephoned Mr Wilson but, because of poor reception, could not properly communicate with him. He then telephoned Mr Lewis Bond, head of the Intensive Rehabilitation Team, of which Mr Wilson was a member, and asked him to speak to Ms Starr. Mr Bond then telephoned Ms Starr, who told him of Mr Duff s presentation.

Mr Bond, who knew Mr Duff, told her that there "could well be a deterioration". He suggested that the earlier appointment with Dr Evans be kept. Ms Starr then left a message with Dr Evans to that effect.

At about 4.15 p.m. Mr Bond informed Mr Wilson about the earlier appointment with Dr Evans. There was no indication given by him that anything else was wrong, or that there was any sense of urgency or crisis.

At about 5.00 p.m. Mr Duff again visited his parents. They believed his condition had deteriorated since the previous day. He was extremely agitated, and was speaking so fast at times that they could not understand him. He said something about the Police being after him.

Mr Duff s father, Mr Roy Duff, telephoned the Police to ascertain whether they were looking for him, and was informed that they were not.

Because of their alarm at their son's mental condition and physical appearance, Mr and Mrs Duff felt that he was in immediate need of professional care and treatment.

Mr Roy Duff accordingly telephoned the Mental Health Crisis Team ("the Team") at 5.50 p.m. and spoke to Ms Kerri Neve. He told her that his son looked terrible, and was confused, "mixing the present with the past".

Ms Neve then spoke to Brian Duff. She said he sounded "severely thought disordered, with periods of clarity, i.e., 'somebody knocks on ... I go for a walk ... hot weather ...

things were very confusing at the moment ... felt alien today' ". He said there had been a fight next door. Ms Neve said she asked Mr Duff if he was taking his medication, to which he replied that he was taking two tablets of Clozapine each night (i.e., not the 3 x 100mg and 2 x 25mg tablets he was supposed to be taking). He told her he was seeing Dr Evans.

Ms Neve said she asked Mr Duff whether he would come to the hospital and see a doctor.

He agreed, but said he wanted to have a shower first. She suggested he have something to eat, and said she would speak to his father about this. She then spoke to Mr Roy Duff, who said he believed Brian should be in 24-hour care. She told him that her concern was his current presentation.

Mr Duff agreed to call the Team after Brian had showered and had something to eat.

At 6.08 p.m. Mr Duff telephoned the Team and said Brian had "shot through". Brian had gone outside, and his father went looking for him without success. Mr Duff said that Brian had said he thought "someone was chasing him". A decision was made by Mr Duff not to go searching around the neighbourhood because he had done so in the past without success.

Ms Neve told Mr Duff that the Team "would do a domiciliary visit to Brian's flat later in the shift".

At 6.30 p.m., Ms Neve's colleague on the Team, Mr Herbert Krueger, had a chance meeting with Dr Evans, who had just received the message that Mr Wilson thought it would be a good idea if she saw Mr Duff on the Monday.

There was a discussion about the conversations earlier with Ms Neve regarding Brian's condition. Dr Evans said that she thought "something was going wrong", and told Mr Krueger that she did not think it would be possible to manage Mr Duff as an outpatient because he would not allow his case manager into his flat on a regular basis, and "the blood test result that I had indicated that he probably wasn't compliant with the Clozapine". She said she concluded by saying "Herb, I think he has to come into hospital", to which she said Mr Krueger responded "...words to the effect of ... that's our next job, we're on our way" and left the office.

Dr Evans' version of that conversation was disputed by Mr Krueger. In addition to the disagreement between them, referred to earlier, as to what was said about the Clozapine blood level, ("zero" or "close to zero") Mr Krueger denied that Dr Evans said that Mr Duff had to go to hospital. He said Dr Evans said only that "he would probably benefit from a stay in hospital, and that he was currently on a Community Treatment Order awaiting the availability of a bed at one of the Hostels".

Mr Krueger also denied saying that the Team would regard a visit to Mr Duff as a first priority. As to that, he said he told Dr Evans only that they "would attempt a visit to his flat during the evening depending on workload".

At about 8.00 p.m. Mr Roy Duff rang the Team to ascertain whether Brian had been found. He was told he had not been. This call was not logged.

Mr Krueger later said that the "fact he was missing and that other priorities had presented themselves ... we were unable to do the assessment". He added they "... did not make a conscious decision not to conduct a home visit (but) simply ran out of time".

About 9.10 p.m. Mr Brian Duff visited the Woden Police Station, where he spoke to Detective Constable Brown, who knew him. Constable Brown said Mr Duff was at first visibly upset. At one stage he became angry about his father, but later calmed down. He had seen him in a similar condition before. Constable Brown had a discussion with him, during which it was suggested that his parents, the Team, or Dr Evans should be

contacted, but Mr Duff disagreed with this. He left the station at 9.20 p.m., saying he was going home to sleep.

Constable Brown said he did not believe any action was called for by him.

It appears that, shortly after this time, Ms Neve and Mr Krueger discussed asking the Police to do a "welfare check", i.e., visit Mr Duff s flat, but decided against this because of the previous incident involving the Police when he produced a knife. They also believed that, because Mr Duff thought he was being chased, "the involvement of the Police would inflame the situation", and there was no indication of danger concerning him.

Another factor was that it was not the practice to conduct domiciliary visits too late at night unless there was cause for concern, which they did not believe existed in Mr Duff s case.

The Team conducted a number of visits to other patients during the course of their shift, and took a number of telephone calls, which were duly logged. There were intervals of some length during which no activity occurred or was recorded.

Ms Neve and Mr Krueger agreed that it was about an eight minute drive from their office to Mr Duff s flat. They also agreed that they did not attempt to locate Mr Duff, and that the workload for the shift had not been significantly busier than usual. They returned to the office about 10.00 p.m.

At about 11.15 p.m. Ms Neve handed over to the night-duty Mental Health nurse, Ms Rees. Mr Krueger had already left the office. Ms Rees was informed that Mr Duff s father had contacted them regarding his concern for his son, that he was unwell and that they had not been able to conduct a domiciliary visit. Ms Rees said no sense of urgency regarding Mr Duff was conveyed to her.

Ms Neve requested that a visit be carried out by the morning shift, when Mr Krueger, who knew all about the case, was again rostered.

Ms Rees said that when she later read the log book, she had "reservations" about the failure of the team to make a visit to Mr Duff s flat earlier in the night, and she would have preferred that that had been done. It was not prudent, she added, for her to make a visit that late at night, because the patient might be asleep. It was frightening, she said, for someone who is psychotic to be disturbed late at night. There was a "degree of risk" with patients in those circumstances, and Police assistance would be required.

Ms Rees agreed, in cross-examination by Mr Ian Duff, who represented the family at the Inquest, that where a Mental Health Crisis Team was busy during their shift, "... they often employed the Police to go around and do a check ...".

At 7.15 a.m. on 15th February Ms Rees handed over to the morning shift team, Mr Krueger, and Mr Athol Webb. She gave them details of the night shift and evening shift contacts.

Mr Duff s case was mentioned, and a visit to his flat was noted as "one of the team's first priorities" .

The Tearn were in the process of transporting a patient for detoxification at 9.10 a.m.

when Mr Krueger received a caii from Mr Roy Duff, inquiring whether Brian had been located. Mr Krueger told Mr Duff that he had not been located, and said that the Team would go to his flat as soon as possible.

At 9.50 a.m., the Team approached Mr Duff s flat from the rear, as on previous contacts he had either refused to answer the door or had responded in an aggressive manner. They found the back door was open, and, on entering, saw Mr Duff slumped in a chair. They tried to rouse him, without success. They could not find a pulse, and observed that his mouth was full of vomit. They noted "lots of foil strips from Clozaril (i.e., Clozapine) tablets lying around". The Police were then called.

Constable A. Kingston arrived at the flat at about 10.00 a.m. He saw, on the floor near Mr Duff s feet:

2 packets of Clozaril 100mg tablets containing 34 tablets, 84 having been dispensed.

1 box of Clozaril 25mg tablets containing 42 tablets, 56 having been dispensed.

A box of 100mg tablets, which was empty, but 50 tablets, still in blister packets, were located near Mr Duff s feet.

Dr McGrath attended, and pronounced life extinct, Mr Webb having identified Mr Duff to him.

A post-mortem examination was carried out by Dr S. Jain, the cause of death principally being established as "blood poisoning by Clozapine". There later was some controversy regarding this finding, and I will return to this aspect of the case in due course.

Following the death of Mr Duff, his brother, Mr Ian Duff, wrote to the Coroner on behalf of the family, expressing concern at the alleged failure of the Mental Health workers associated with his case to exercise appropriate care. He said the family requested an Inquest be held.

THE INQUEST An Inquest having been decided on, arrangements were made for the hearing to commence on 16th September. The hearing continued on 28th October, 25th and 26th November, and 10th 17th and 19th December, 1997.

Mr K. Archer, of the DPP's Office, sought and was granted leave to assist me.

Mr Ian Duff, the deceased's brother, sought and was granted leave to appear on behalf of the family.

The Community Advocate, Ms H. McGregor sought and was granted leave to appear, pursuant to Section 13 of the Community Advocate Act 1991.

Mr R. Livingston sought and was granted leave to appear for "the ACT Government", instructed by the ACT Government Solicitor.

There was an unfortunate misapprehension on my part, and on Mr Archer's part, during the ensuing days of the hearing, regarding Mr Livingston's role. It was assumed, because of many past Inquests involving Governmental bodies, such as A.C.T. Health, that the legal representative of the Government would also protect the interests of those employees of the Government required as witnesses, and who were not separately represented. I am informed by Mr Archer that this belief about Mr Livingston's role was also shared by Ms McGregor and Mr Ian Duff.

Ms Todd subsequently sought and was granted leave to represent Ms Neve.

It was not until the conclusion of evidence that it was announced that Mr Livingston represented none of the other Mental Health employees who had given evidence.

I will return to this later.

Evidence was given by Mr Richard Clarke, Executive Director, A.C.T. Mental Health Services, that, following the shooting of Warren I'Anson by Police in November 1995, an inquiry was commissioned in May 1996 into procedures followed by the Mental Health Crisis Team. This was because the shooting occurred during an attempted contact with the Mental Health Crisis Team and the deceased, who was a schizophrenic.

Mr P. Gianfrancesco, who conducted the inquiry, made a number of recommendations, (Exhibit 30) which were in the process of being implemented by Mr Clarke (who had been appointed in early 1997) at the time of Mr Duff s death. They included:

1. Establishment of a single point of access to the service using a 24-hour toll free number attended by Mental Health staff (Triage).

2. Standardisation of triage response categories.

3. Standardised assessment format.

4. Substantial restructuring of the former Crisis Team.

5. Creation of Regional Co-ordinator positions with catchment area and portfolio responsibilities.

6. Production of an A.C.T. Mental Health Development Plan.

7. Progression of a system of case management.

8. Integration of the Child and Adolescent Mental Health Service with adult mental health programmes.

Mr Clarke said in evidence that Mr Gianfrancesco was commissioned in September 1997 to review progress made with his earlier recommendations, and reported thereon in October 1997 (Exhibit 37).

Mr Gianfrancesco observed that most of his recommendations had been implemented, and, in most cases, exceeded.

He said the Mental Health Crisis and Assessment Service had evolved since the first review "from the small, isolated and poorly performed Crisis Team", described at that time. He added that, at the time of the first review, the Team "was unidisciplinary, poorly resourced, admission oriented, difficult to access, separate from other programs and very expensive".

In his view, "the Service is now more responsive, multidisciplinary, orientated to community based acute care, well resourced and more closely integrated with other mental health programs".

Mr Gianfrancesco went on to say that the Service was then (October 1997) "operating within a clear statement of (its) service priorities, goals and objectives". Its documented goal, he said was: "To provide a highly accessible and responsive acute mental health assessment and treatment service in a setting which is familiar to the client, and maximises the use of supports available to the client in a community environment".

The Service's objectives in achieving that goal were:

1. To provide a timely and responsive 24-hour service to people in the community who require intensive specialist mental health assessment, treatment and support.

2. To provide least restrictive treatment alternatives which will:

(a) avoid inappropriate or unnecessary admissions and

(b) reduce the length of stay for those (for) whom admission is seen to be necessary, by active contribution to the treatment decision making process within the inpatient unit, other community support agencies, family and carers.

3. To provide a new option for treatment in a ieast restrictive environment which matches the spirit of the Mental Health Act.

Mr Clarke said in his evidence that, as part of the reform process, he had arranged seminars for Mental Health staff to inform them of the way in which the Service was being restructured. One, on "Crisis Intervention and Treatment", which Ms Neve attended, had in fact been held only two days before Mr Duff's death.

Mr Clarke's evidence indicated that the new structures and reform strategies in place should avoid, or at the least, significantly minimise the likelihood of a repetition of the tragic result in Mr Duff s case.

A further inquiry was ordered by Mr Clarke immediately following Mr Duff s death. As mentioned earlier, this was conducted by Mr Tim Leggett and Mr Eugene Meegan, whose report (Exhibit 30) was completed on 3rd May 1997.

The Terms of Reference for the investigators were:

1. To collect and examine relevant information about the management of Mr Duff, including the events leading up to 15th February 1997.

2. To interview all health professionals associated with the management of Mr Duff.

3. To identify any service gaps associated with the management of Mr Duff (including) an examination of existing standards, policies and procedures, their adequacy and adherence to them in this matter.

4. (To) provide a written report to the Executive Director Mental Health Services no later than two weeks after the investigation.

The investigation was, in my opinion, painstaking and thorough. The investigators interviewed each of the witnesses from the Mentai Heaith Service who were called at the Inquest. They also interviewed Mr C. Surrao, Manager of the Crisis Term, and Mr A. Webb, a member of the Team.

As at the time of the investigation, it was noted that not all the recommendations in the Gianfrancesco report had been implemented, and the investigators directed their attention to the remaining deficits.

Among their general comments were the following: "The A.C.T. Mental Health Service seems to be afflicted in some areas by lack of accountability by individual workers and programs for their actions in dealing with clients. We have observed many instances of staff passing

responsibility to others or focusing only on their own immediate area of interest", and, later: "Crisis team clinicians and case managers must be accountable for client outcomes".

The investigators made 22 specific comments and recommendations, a list of which is at Annex "A".

In my view, each one of the comments and recommendations is soundly based, on the material gathered during the course of the investigation. The evidence before the Inquest is supportive of those comments and recommendations, and I would adopt them as part of my "Reasons for Findings".

Following the conclusion of evidence, I advised counsel, and Mr Ian Duff, that I required submissions to be in writing, and supplied by 19th December, 1997. Ms McGregor, Mr Ian Duff and Mr Archer made written submissions by that date.

SECTION 55 OF THE CORONERS ACT 1997 The above section reqmres that a Coroner proposing to make adverse comments regarding any person identifiable from a finding or report of an Inquest must provide that person with a notice, setting out the details of the proposed adverse comments. The person concerned must be given the right of making a submission, or giving the Coroner a written statement in relation to the proposed comment.

On 19th December 1997 I handed down notices under Section 55 to Mr Kettle, of the A.C.T. Government Solicitor's Office, who appeared in Mr Livingston's absence. The notices were directed to Dr Evans, Mr Wilson and Mr Krueger, "C/- the A.C.T.

Government Solicitor", and stated they were being handed to "counsel" for those persons, a description to which Mr Kettle, in accepting them, did not object.

I also handed down a notice to Ms Todd, representing Ms Neve.

I requested responses to the notices by 6th January, 1998.

On Ms Todd seeking further time, in view of the Christmas break, I fixed 13th January, 1998 as the date by which outstanding submissions and responses to the Section 55 notices were to be filed with the Coroner's Secretary.

Being then advised that Mr Livingston did not act for the Mental Health Service witnesses who had given evidence, a further adjournment was granted to enable them to seek independent legal advice.

On 13th January Ms Todd advised that she then acted for Mr Wilson, in addition to Ms Neve; Mr Took, a solicitor from United Medical Protection, said he now appeared for Dr Evans, and Mr Bundock said he now appeared for Mr Krueger. Because of this development, additional time was granted for submissions and for responses to the Section 55 notices. The parties were requested to exchange submissions before the due date, and to comment, where considered appropriate, on other persons' submissions. The final date for delivery of submissions was 10th February, 1998.

I will return to an examination of the material submitted shortly. Before I do so, however, I believe I should refer again to the misapprehension regarding precisely whom Mr Livingston represented, because this led to the regrettable situation regarding the late entry of the other solicitors.

There is no question that Mr Livingston stated only that he appeared for the A.C.T.

Government. It is unfortunate, however, in view of what later occurred, that he did not make it clear that he acted only for the body politic, and not for the employees through whom that body politic operated.

As stated earlier, my belief (and Mr Archer's) throughout the taking of evidence was that Mr Livingston did act for those employees, and I understand that Ms McGregor and Mr Ian Duff were also of that belief. The following considerations fostered my view:

l . On many similar occasions, in my experience, when A.C.T. Government instrumentalities have been involved in Inquests, e.g., A.C.T. Health (principally involving The Canberra Hospital), the A.C.T. Government Solicitor has represented, and made submissions on behalf of, the employees involved, in addition to the instrumentalities. Mr Bayliss, of the A.C.T. Government Solicitor's Office, who usually acts in these matters, invariably adopts this role, to the extent of having statements prepared, and sometimes even causing records of interview to be conducted by private investigators, on behalf of his client's employees. Witnesses who are not employees, e.g. Visiting Medical Officers, are always separately represented.

2. In the present case, where Police conducted records of interview with witnesses, I noted, before the Inquest commenced, that Ms Manzoney of the A.C.T. Government Solicitor's Office, was present, and was invited to ask questions, normal procedure where the individuals are represented by that office.

3. The usual course of allowing counsel believed to be representing witnesses to examine them last, i.e., after the other parties had examined or cross-examined them, was followed in this case without comment from Mr Livingston.

4. As mentioned earlier, on being handed the three Section 55 notices for Dr Evans, Mr Wilson and Mr Krueger, in which they were advised that the notices were being handed to those witnesses' "counsel", Mr Kettle, of the A.C.T. Government Solicitor's Office (which was also shown as their address), accepted them without demur.

I accordingly trust that on future similar occasions, counsel instructed by the A.C.T.

Government Solicitor to represent the A.C.T. Government or its instrumentalities clearly advise whether they also represent their employees.

I return now to an examination of the substantial amount of material which was supplied on behalf of the persons to whom the Section 55 notices were delivered.

It should be noted that Section 55(3) provides that, where a person so requests, a Coroner shall include in the Inquest report any statement made under Section 55(l)(b), or a fair summary of it. All four persons involved made submissions, through their counsel, but only Dr Evans and Mr Wilson made written statements. Although their counsel made no request under Section 55(3) I have annexed copies of their statements at "F" and "G". In Dr Evans' statement, which is unsigned, there are several references to "1997" which should read "1996". Also at paragraph 10, reference is made to Mr Duff s discharge from hospital on "30th March 1996". I believe this should read "20th March 1996".

DR EVANS Under date of 9th January 1998, Mr Took responded on behalf of Dr Evans to the Section 55 Notice, a copy of which is at Annex "B".

As to the proposed criticism that Dr Evans had failed to ensure that Mr Brian Duff was aware of the potential dangers involved with not following instructions in the taking of Clozapine, Mr Took said his client had explained carefully to him the necessity of following instructions in taking the drug, and its side-effects.

In addition, Dr Evans' psychiatric registrar, Dr Emma Adams, in a Statutory Deciaration accompanying Mr Took's submission, said she had also gone through in detail and on several occasions with Mr Duff the effects and side-effects of Clozapine, including what might happen to him if he did not take it in accordance with instructions. She said that, during these discussions, they developed "a genuine rapport and a therapeutic alliance, and this was helpful in our discussions".

Nurse Donna Hodgson, of the Inpatient Psychiatry Unit, at The Canberra Hospital, said that after Mr Duff started on Clozapine, he was provided with literature and video education, and was given ongoing contact with the Clozapine programme, i.e., weekly education groups. She believed he had a good understanding of the medication, and of the need for monitoring its use. She said he often frequented her office "to ask Clozapinerelated questions and just to talk".

Nurse Hodgson said Mr Duff was "very compliant and co-operative towards his haematological monitoring", and was never overdue for a blood test.

Although Dr Evans, in her evidence (page 12, transcript of 26.11.97), agreed that the signing of the Clozapine consent form was not "what would be called a truly informed consent because he was so ill that he was the subject of a treatment order", she went on to say that the process was carried out so that "there was a record that the formal discussions had been attempted with Brian".

Dr Evans added that the discussions went into the potentially lethal effect of Clozapine.

The concession made by Dr Evans regarding absence of an "informed consent" was the principal reason for this proposed ground for criticism.

I tum now to the second proposed criticism, i.e., that Dr Evans failed adequately to supervise the taking by Mr Duff of the Clozapine, and continued to provide such medication without appropriate monitoring of his condition.

In Dr Evans' statement, (Annex "F") attached to Mr Took's submission, she stated that she was not a clinical director, or the supervisor of the work of clinicians from other disciplines. It was also not her duty, she said, to make home visits for assessment or treatment purposes, nor to physically supervise the taking of medications. Her role was to provide medical consultations for patients being case-managed by other members of the A.C.T. Mental Health Service.

Mr Took submitted a statement from a consultant psychiatrist, Dr J. Saboisky. In it, the doctor said Dr Evans had worked for him briefly as his registrar at Calvary Hospital, and he had supervised her psychotherapy training. He said he had a lengthy background in psychiatry education and with the "Maintenance of Professional Standards Group".

Dr Saboisky said it was not the role of consultant psychiatrists to oversee patients whilst they are on medications. He said that, in the case of a chronically mentally ill patient,

health professionals are frequently involved, and "it is the Case Manager who assumes responsibility in this regard". As to that quoted comment, I should state that I do not attach any weight to comments by Dr Saboisky not directly related to Dr Evans' role.

As to Dr Evans' involvement with Mr Duff, Dr Saboisky said that she "provided evidence of a level of monitoring typical of a consultant psychiatrist and appropriate for this particular patient. Specifically she saw Mr Duff regularly and recorded his history, her mental state examination findings and spoke to his Case Manager, i.e., she monitored his progress, including the beneficial effects of treatment".

Dr Saboisky said that blood drug level tests had been ordered when Dr Evans suspected non-compliance by Mr Duff in taking his medication. However, he added, "without supplementary evidence from the patient, their family and friends or the Case Manager, a practising psychiatrist would not see a low blood serum level as a psychiatric emergency". Dr Saboisky concluded that Dr Evans' "management would not attract any criticism from her peers, because it does not deviate from best practice guidelines for the management of chronic schizophrenia".

Mr Livingston made three submissions on behalf of "the A.C.T. Government" on 5th and 13th January, and 11th February 1998.

It is noteworthy that the submissions take the form of responses to the Section 55 notices, in defence of the conduct of Dr Evans and Mr Wilson, notwithstanding Mr Livingston's disclaimer that he acted for them during the Inquest.

Only the person named in a Section 55 notice is entitled to respond thereto, and each one of those persons, has, through his or her legal representatives, responded to the notices.

However, I accept that Mr Livingston intended his submissions to be helpful, and they will be assessed generally, in that light. I do not, however, regard as helpful his comments, in his submission of 11th February, as to a Coroner's role. I believe, after 25 years as a Coroner, that I have a reasonably sound appreciation of a Coroner's duties and responsibilities.

That said, Mr Livingston did provide a statement dated 4th February 1998 from Professor G. Parker, Head of the School of Psychiatry at the University of New South Wales, and a psychiatrist of undoubted eminence in his profession, which I have found, in the main, to be of considerable assistance.

In a most comprehensive appraisal of the evidence in Mr Duff s case, Professor Parker expressed ( 1) his concerns regarding the reported cause of death, and (2) his opinion of the standards of treatment afforded Mr Duff by Dr Evans.

I should state that, in my view, the Professor's concerns regarding the cause of death were misplaced. Dr Jain, who performed the post-mortem examination on Mr Duff, responded to the Professor's statement under date of 9th February, advising that the Professor had misinterpreted the terminology used in his (Dr Jain's) report. In addition, while Professor Parker noted that there was no statement that drugs other than Clozapine, had been tested for, such as benzodiazepines, the A.C.T. Government Analyst has advised that tests were made for those substances, as well as a wide variety of others, none of which was detected.

It should be noted that Professor Parker did not claim any expertise in the field of pathology, and, in my view, Dr Jain's undoubted expertise in this area must result in his observations being given substantially more weight than those of Professor Parker, and Dr Jain's finding as to the cause of death is accepted.

Regarding Dr Evans' involvement with Mr Duff s treatment, Professor Parker said that, on the extensive evidence provided to him, including most of the material before the Inquest, Mr Duff had been adequately and appropriately advised regarding Clozapine.

He noted that when Mr Duff signed the consent form, there was no indication that he was then "floridly psychotic or thought disordered". In addition, there had been significant involvement in the education process by Dr Adams and Nurse Hodgson, and his compliance with blood testing was "exemplary".

For those reasons, Professor Parker stated, Dr Evans should not be the subject of adverse comment as to her instructing Mr Duff in the taking of Clozapine.

As to the other proposed criticism, i.e., that she failed adequately to supervise Mr Duff's medication or monitor his condition, Professor Parker said he could "find no evidence to indicate any abrogation of duty or any erroneous clinical decision making, or even that she veered too far to the 'least restrictive environment' injunction".

The Professor said that, on the other hand, he found "clear evidence of detailed, comprehensive, thoughtful, intelligent and pluralistic assessments of Mr Duff by Dr Evans. Many consultant psychiatrists do not document material in the file, leaving such documentation to their registrar. The hospital notes indicate that Dr Evans made frequent and detailed assessments. She developed a comprehensive treatment plan, involving antipsychotic medication, rehabilitation, accommodation and case management components".

In Professor Parker's view, Dr Evans' management of Mr Duff was effected "at an extremely high level. It does not, in my view, merely meet an acceptable level of management competence, but is near to exemplary". He added that, while he felt that there "were substantive concerns about aspects of management neglected by other staff ' he could see "no grounds for imputing or determining any professional misjudgment by Dr Evans". I should here make it clear, as I did in relation to Dr Saboisky's report, that I do not attach any weight to comments by Professor Parker not related directly to Dr Evans' role.

Mr Ian Duff, on behalf of the family, has submitted that the proposed adverse comments were justified, despite the additional material supplied. However, having regard to the Statutory Declarations of Dr Adams and Nurse Hodgson, and to the reports of Dr Saboisky and Professor Parker, both psychiatrists of extensive experience, and in the case of the latter, unquestioned eminence, I believe that I would not be justified in making either of the adverse comments earlier proposed about Dr Evans' involvement in Mr Duff s case.

MR WILSON Mr Wilson was notified of proposed adverse comments regarding his role as Case Manager for Mr Duff. A copy of the Section 55 notice is at Annex "C".

On behalf of Mr Wilson, his solicitor Ms Todd responded under date of 9th February

1998. She enclosed with her submission statements by Mr Wilson and Mr L. Bond, who was head of the Intensive Rehabilitation Team at the relevant time, and hence Mr Wilson's supervisor. A copy of Mr Wilson's statement is at Annex "G".

Ms Todd pointed out that Mr Wilson had been Mr Duff s Case Manager for a relatively short period, i.e., seven to eight weeks. She said that, at that time, the staff orientation manual was expressed in such general terms as to provide little guidance, and that the standard of care for each Case Manager was indeterminate, being left to the discretion of each individual in light of the circumstances of the patient's illness.

In Ms Todd's submission, as to the first proposed adverse comment, Mr Wilson provided comprehensive, detailed and regular supervision of Mr Duff as documented in his evidence and in the Intensive Rehabilitation Team file, including:

1. Sixteen visits between 23rd December 1996 and 13th February 1997, an average of two meetings weekly.

2. Checking with him on several occasions as to the taking of his medication, including checking that Mr Duff knew the correct dose.

3. Contacting possible forms of supported accommodation on four occasions (two contacts on 9th January 1997 and two on 30th January 1997), and organising and attending Mr Duff on a comprehensive, lengthy visit to Hennessy House.

4. Attempting to organise some form of home help to assist with his living skills and maintaining his flat, and to accustom him to this idea.

5. Helping him clean his flat on the entry on 20th January 1997.

6. Assisting him with reconnecting his electricity.

7. Ensuring that he attended pathology for his regular blood (white cell) tests.

8. Ensuring that he attend appointments with Dr Evans.

9. Driving around Woden if Mr Duff was not at home at the time of a pre arranged visit, until he found him.

10. Informing him of the death of his friend, Doug, in a supportive and responsible manner (an approach described as "desirable" by Mr Bond).

Ms Todd noted Mr Bond's "total support for Mr Wilson's case management of Mr Duff ', pointing out that he said it can take up to twelve months to build a trustworthy relationship between Case Managers and clients with Mr Duff s degree of severity of schizophrenia. Mr Wilson had had only two months to endeavour to do so.

Mr Duff had had previous Case Managers, and Mr Wilson was inexperienced compared with them. In addition, Mr Wilson "received little or no support or direction from the Mental Health management and structure".

Mr Wilson's evidence was that, whilst he had considered the Emergency Action criteria in the Mental Health Act (Treatment and Care) 1994, he did not believe Mr Duff met them.

In the absence of firm criteria for involuntary admission, and of suitable supervised accommodation at the relevant time, coupled with a lack of clear guidance about non compliance with a Community Treatment Order, Ms Todd submitted that Mr Wilson's

supervision of Mr Duff was appropriate, given these structural and organisational constraints.

Mr Wilson also had to be careful, in establishing a rapport with Mr Duff, not to deviate to any substantial degree from the practices and routines he was used to with the previous Case Managers.

For example, Mr Wilson followed the plan of his predecessor, Mr Bromhead, of leaving Clozapine in four-week batches with Mr Duff at his flat. Mr Bond said this was, in any event, a standard practice, except where a client had a known and recent risk of suicide.

Although there had been the incident with the Police in March 1996, there was no recent manifestation by Mr Duff that he was suicidal.

As to Mr Wilson's monitoring of Mr Duff s taking of his medication, Mr Bond said that asking a client with Mr Duff s level of schizophrenia, every time he was visited, whether he was taking his medication, would provoke a negative reaction. It could also cause tension and reduce the level of trust between the client and his Case Manager.

Regarding the state of Mr Duff s flat when Mr Wilson entered it on the one occasion that Mr Duff permitted him to do so, Mr Bond said that it was quite common for clients of the Intensive Rehabilitation Team to live in such conditions. He added that this would not cause Mr Wilson to do any more than he did, i.e., arranging home help and organising the placement at Hennessy House.

Mr Bond said that for Mr Wilson to "fossick around the flat to see if he's taking his medication", where a client with Mr Duff s condition was concerned, "would be a disaster and alienate the person totally".

Again, for Mr Wilson to just drop in on Mr Duff, would, in Mr Bond's experience, be regarded by the latter as an invasion of his privacy. Mr Duff was regarded as an "extremely independent" client, whose visits by Mr Wilson had to be by arrangement.

As to the delivery of the Clozapine, Mr Bond said that issuing the medication in the normal dosette box of seven days supply (as Dr Evans believed was being done), would not necessarily prevent Mr Duff from stockpiling it, or taking an overdose.

Where a client was refusing some aspect of supervision under a Community Treatment Order, Mr Bond said, there was no unlimited right of forcible entry into their residence, or to force them to take medication, or to force them into hospital.

Finally, Mr Bond expressed his "utmost confidence" in Mr Wilson, whom he regarded as "an excellent case manager ... particularly so under the circumstances in which he was working on the Intensive Rehabilitation Team". He added that he could not find "any fault at all" with Mr Wilson's case management of Mr Duff in the circumstances.

As to the third paragraph of the Section 55 notice, Ms Todd submitted that Mr Wilson did not consider the state of Mr Duff s flat to be such that "more drastic action" should be taken, because an admission to Hennessy House was anticipated, and home help could be arranged.

It was conceded, however, by Ms Todd, that, in retrospect, it was "an unfortunate mistake" on the part of Mr Wilson not to inform Dr Evans of the state of Mr Duff s flat, although it was reasonable for him, in the light of other evidence avaiiabie, not to do more than he in fact did.

Mr Ian Duff submitted that the disorganisation and lack of food in his brother's flat, with his weight being 52 kilograms at the time of his death (down from the normal weight for his height of 75 kilograms), meant his brother was "slowly starving".

Mr Bromhead had noted a weight loss before handing over to Mr Wilson. However, while Mr Wilson thought Mr Duff looked gaunt and underweight when he took over, he believed he had improved in appearance over the eight weeks of his management.

I am inclined to accept Mr Ian Duff s submission. Mr Wilson should have been more concerned with what must have been evidence of Brian's inadequate intake of food, reflecting an inability properly to care for himself.

The evidence before the Inquest was that, had she known of the condition of the flat, Dr Evans would have treated Mr Duff s future treatment with more urgency.

Having regard to the submissions made on behalf of Mr Wilson, to his further statement, and, in particular, to the statement of his experienced supervisor, Mr Bond, I believe I would not be justified in making the proposed adverse comments regarding Mr Wilson's alleged failure adequately to supervise Mr Duff s treatment or the taking of his medication. I do, however, at the appropriate point, intend to make an adverse comment regarding his failure to advise Dr Evans of the condition of Mr Duff s flat.

It is a matter of some irony, on the other hand, that Mr Wilson has indicated that he would have treated Mr Duff's case with more urgency had he been told by Dr Evans that his Clozapine level was "close to zero" or "zero", or had he been aware of the way he presented to Ms Starr on 14th February.

This break-down in communication between members of the Mental Health Service was noted, at the time of their report, by Messrs Meegan and Leggett, in their comment that they had observed many instances of staff, inter alia, "focusing only on their own immediate area of interest".

I will return to this aspect of the Inquest later.

MR KRUEGER Mr Krueger was notified of proposed adverse comments regarding his role as a member of the Mental Health Crisis Team on the evening of 14th February 1997. A copy of the Section 55 Notice is at Annex "D".

Mr Krueger did not make a statement under Section 55( l )(b), but his solicitor, Mr Bundock, made a submission on his behalf.

Mr Bundock referred to Mr Archer's submission, in which he suggested that the Tearn had a number of options in responding to the requests of Mr Duff s father and Dr Evans, to take action regarding Mr Duff s hospitalisation. They were:

1. Visit Mr Duff at his flat;

2. Call the Police for their assistance;

3. Communicate with his family as to his possible whereabouts; or

4. Go and look for him.

As to (1), Mr Bundock submitted that, if Mr Duff was at the flat, he would probably not have answered the door, as he was known to be reluctant to respond to callers. Further, the Team knew there had been trouble near the flat, and that Mr Duff had absconded from his parents' home.

The information available to the Team and their knowledge of Mr Duff indicated a situation demanding attention, "but not a situation where Mr Duff s safety was immediately in peril".

It was conceded that the Team did have time, during the evening, to visit the flat, but decided against it, for the reasons stated.

As to (2), Mr Bundock said the Team discussed calling the Police, but decided not to because of the incident in March 1996 where he had tried to goad the Police into shooting him by brandishing a knife at them.

As to (3), Mr Bundock said there was no evidence that the family could have assisted in any way.

As to (4), it was submitted that this was impracticable, because there was no logical starting point, if he was not at his flat.

Mr Bundock referred to the dichotomy between his client and Dr Evans regarding what was said at their chance meeting on the evening of 14th February. Contrary to what Dr Evans had said, i.e., that Mr Duff had to be taken to hospital, and that Mr Krueger had agreed to make it "his next job", the true position was that as recorded in the Team's log by Mr Krueger, which was: "... Brian Duff, who she reports is not taking any medication, last Clozapine level was 'zero', they are waiting for a place in one of the hostels. She felt he could possibly do with a stay in hospital".

As noted earlier, Mr Krueger claimed that he had told Dr Evans that the Team would visit Mr Duff, "depending on the workload", and that the matter would not be regarded as a first priority, as suggested by her.

Mr Bundock submitted that the log showed that the Team had been occupied on tasks with other clients through their shift, including potential suicide risks. Their responses to those clients had been appropriate.

Mr Bundock conceded that the team could have called at Mr Duff s flat at some time after 8.40 p.m., adding that "if they had done so, they would have escaped criticism for not calling but would almost certainly not have found him there".

Mr Bundock made a number of further observations regarding his client's participation in the events of the evening of 14th February 1997.

Firstly, he said, his client was a general and psychiatric nurse, and had had the latter qualification for fourteen years. He was accustomed to making assessments as to the urgency of situations involving psychiatric patients. It was possible, in hindsight, to find

that an assessment was mistaken, but, in Mr Duff's case, there was no indication of urgency which would have caused a different assessment to be made.

Mr Krueger was, Mr Bundock said, a caring professional. He was deeply distressed at finding Mr Duff on the morning of 15th February, to the extent that he was obliged to take five days sick leave.

After Mr Duff's death, Mr Krueger was removed from the Team to a ward, for a period of supervision. His work there was assessed to be of a high standard (copies of the relevant "Professional Performance Appraisal, Level 3 - Mental Health Nurse" reports were attached to Mr Bundock's submission). He was returned to the same level he had been with the Team, but was later "effectively downgraded following the Coroner's comments".

In Mr Bundock' s submission, the decisions made by his client and his colleague, Ms Neve, were reasonable having regard to the information available to them at the time.

Finally, Mr Bundock submitted that "there is nothing to be gained by the Coroner criticising a system of care which has been significantly changed since Mr Duff s death (and was in the course of being reorganised at that time)".

Having considered the submission made by Mr Bundock, and the submissions made by other counsel, as well as that made by Mr Ian Duff, I have reached the view that the adverse comment proposed to be made by me regarding Mr Krueger in the Section 55 notice should stand.

It should here be noted that, at the time of Mr Duff's death, the Team did not have a hierarchial structure, i.e., Mr Krueger and Ms Neve were equals. The system then was that the person who took the original call for assistance, in this case, Ms Neve, acted as the co-ordinator of future action.

MS NEVE Ms Neve, who was represented throughout the hearing by Ms Todd, was notified of proposed adverse comments regarding her role as a member of the Mental Health Crisis Team on the evening of 14th February 1997. A copy of the Section 55 Notice is at Annex "E".

Ms Todd submitted that none of the material produced during the course of other counsel's submissions should be used to found any adverse comment regarding her clients, Ms Neve or Mr Wilson. I should here state that I agree with her. My conclusions will be based on the evidence placed before the Inquest, although, as she has conceded, some of the material, i.e., Professor Parker's report, should be and has been of general assistance to me, with the reservation noted on page 26.

Ms Todd said that Ms Neve had an unblemished record as a mental health nurse over 25 years.

Ms Todd submitted that, when asked during the hearing, whether, with hindsight, her client thought she could have done more on the night, she had answered the question honestly. Ms Todd went on to say: "That is, she answered that, with hindsight, she would not have done anything differently. She meant, it is submitted, that had she been in exactly the same situation again, she would have responded the same way, in the light of having the same information available to her at the time".

On the evening of 14th February, the Team had responded to a number of calls for assistance, including those from persons who could have suicided. It was agreed that they had "approximately one free hour, between 1830 and 1940 when the Crisis Team took no calls and was not attending to any home visits". The only other free time they had was during the hour after they returned to the office, after about 2200 hours, and had to document the evening's work.

It was conceded, Ms Todd said, that the Team did have time to visit Mr Duff s flat, but made the decision to defer the visit until the following morning.

This was not surprising, in her submission, because they had only limited information about Mr Duff s recent history. There was only the Crisis Team file of previous contacts with Mr Duff, the log book, and their own knowledge of Mr Duff s history from previous contact with him. The most recent contact with the Team had been on 10th February 1996, when he was admitted to the less acute side of the Psychiatric Ward at The Canberra Hospital.

Although there were numerous instances in the Team file of Mr Duff having thought disorder, there were no grounds then for an emergency admission.

Ms Neve conceded not having read the file that evening, but, in Ms Todd's submission, it would have given little assistance as to Mr Duff s current state.

As to his medication, Ms Neve knew only that Mr Duff, in his conversation with her, was taking two Clozapine tablets nightly, but that, following the conversation between Dr Evans and Mr Krueger, his Clozapine level was "zero". She had no information about the correct dosage, or how it was being monitored.

In Ms Todd's submission, the only conclusion available to her client was that Mr Duff was not taking his medication, which was insufficient for her to suspect that he was stockpiling Clozapine, or to suspect that if such stockpiling was taking place, it was for the purpose of overdosing.

Ms Neve said that, when she spoke to Mr Duff on the evening of 14th February, she believed that "even though he was severely thought disordered, he did have the presence of mind to tell me what his current treatment regime entailed, and that he was aware that things 'were a bit confusing at the moment', which indicated to me that he was aware of his behaviour and his responsibility to accept treatment".

As to the thought disorder noted by Ms Neve, Ms Todd submitted that this was not, of itself, indicative of any immediate danger so far as a schizophrenic patient was concerned. Professor Parker, in his report, said that thought disorder was insignificant in schizophrenic persons as an indicator of the ability of the patient to function, and to give informed consent.

In the absence of any directives from Mental Health Services, Ms Todd said, "individual Crisis Team members were left to determine on the basis of their own clinical experience and judgement, the priority to be given to a particular call and response to be made thereto".

The Team was unaware that Mr Duff was subject to a Community Treatment Order.

They were also unaware that Mr Duff had called on Ms Starr, or that contact had been made between Ms Starr, Mr Wilson and Mr Bond which led to the appointment with Dr Evans on the following Monday morning.

Ms Todd submitted that Mr Krueger should be believed as to his recollection that Dr Evans had said merely that Mr Duff "could possibly do with a stay in hospital" and that this was meant as an intention to stabilise Mr Duff s condition before his admission to Hennessy House.

Ms Todd referred to the evidence that Ms Neve had attended the training seminar which Mr Clarke had told the Inquest had been held two days before Mr Duff s death. She said that Ms Neve's failure in the witness box to recall the content of the instruction was of no relevance, and could be the result of poor teaching technique or lack of significant content. In any event, she submitted, it was "totally unprobative of (Ms Neve's) competence or handling of Mr Duff s situation on 14th February and should · be rejected".

Evidence was given by Ms Rees that, some days after Mr Duff s death, she had a conversation with Ms Neve. Ms Rees had been present at the Police shooting of Warren I'Anson as a member of the Mental Health Crisis Team. She said that Ms Neve said, something along the lines of "I thought about it very carefully and I decided I would

rather be in my position now than your situation with Warren I'Anson". Ms Rees said she was "very shocked" by that comment, and noted it in her diary. Ms Rees said in evidence that she interpreted that statement as meaning that Ms Neve had made a decision on the night not to visit Mr Duff for a reason associated with what occurred with Warren I'Anson.

Ms Todd said that Ms Neve had "clearly and emphatically" denied the allegation that she had chosen not to visit Mr Duff s flat out of fear for her own safety. She said the comment she made to Ms Rees was a reference to her feeling of "powerlessness to change the situation". She added "I was referring to the similarities in the situation where she was powerless, and I felt a certain empathy with her at the time".

I should say that I accept Ms Todd's submission that Ms Rees' reaction to the comment was subjective, and that Ms Neve's explanation should be accepted.

As to the second point in the Section 55 notice, that Ms Neve failed to request the Police to visit Mr Duff s flat, i.e., to do a welfare check, Ms Todd made a number of submissions.

Firstly, her client knew that there had been the incident when Mr Duff had brandished a knife at Police and called on them to shoot him. Further, on the evening of 14th February, he told his father that someone was chasing him, and that the Police were after him.

Ms Neve said that she discussed with Mr Krueger the desirability of calling the Police, but decided against it because the presence of Police may have provoked an undesirable reaction from Mr Duff.

Secondly, Ms Todd said that the "Memorandum of Understanding" between the Police and Mental Health Services (Exhibit 32) was produced in response to the I'Anson incident. She noted that this document was tendered after her client had given evidence, and she was not asked whether it was available to her on the evening of 14th February, or whether it would have been of any assistance if it had been available.

Ms Todd pointed out that, in any event, the bulk of the Memorandum is devoted to the reverse situation to that facing her client, i.e., where Police refer persons to the Mental Health Service. As to calling the Police by the Team, the document had only two relevant sections, one of which dealt with "urgent referrals", where it was believed the person's behaviour could lead to harm or injury. The Police, in this instance, were permitted to assess the urgency of the request themselves.

In Ms Todd's submission, in light of the contact between Mr Duff and Constable Brown that evening, the Police may very well have taken the view, if asked for assistance, that the situation was not urgent, as Constable Brown did not consider any action was required of him. If, on the other hand, Constable Brown had contacted the Team, the situation as outlined by him would not have qualified for the definition of "urgent".

The only other relevant portion of the Memorandum, Ms Todd submitted, was in relation to requests for routine Police assistance. Whilst there was no definition of the situations which may there be involved, there was reference to the inclusion of "pre-planned visits where Police back-up is needed to manage potential conflict situations".

In Ms Todd's submission, the principal criterion for "urgent" Police assistance was whether the clienf s behaviour couid iead to harm or injury, and her client was not of the view that evening that Mr Duff fitted into that category.

In addition, Ms Neve gave evidence that if Mr Duff refused voluntary admission to hospital, he did not, in her opinion, meet the criteria for emergency admission under the Mental Health (Treatment and Care) Act 1994. Those criteria (Section 37) required (1) that a person had refused treatment and care; (2) where the Mental Health officer or doctor believed on reasonable grounds that detention is necessary for the person's own health or safety or for the protection of the public; and (3) where the person cannot be managed in a less restrictive environment.

As to whether Crisis Teams were reluctant to involve the Police, Ms Todd said she endorsed "Mr Bundock's submission on behalf of Mr Krueger that a reluctance on the

part of workers at the 'coal face' to involve the Police after the I'Anson incident is perfectly reasonable". Ms Todd said that Ms Neve had commented, inter alia, that "with someone like Mr Duff it was a difficult call to make ... I was not in a position where I could justify calling the Police if something did go wrong and Mr Duff was accidentally injured or killed ... I did not consider at the time that Mr Duff was in need of immediate treatment and care in the sense that it was absolutely essential that night".

As to the third point in the Section 55 notice, i.e., that Ms Neve had failed fully to brief Ms Rees as to the urgency of the situation she agreed that, with hindsight, there was a necessity for urgent action. However, the proposed adverse comment involved a finding that Ms Neve believed at the time that there was such a necessity, and, in view of the earlier submissions, this should not be accepted.

As to whether Ms Neve "fully briefed" Ms Rees, Ms Todd said the evidence was that Ms Rees had been told of the conversations regarding Mr Duff earlier in the evening, that Mr Duff was unwell, and that the morning shift was going to a domiciliary visit.

Ms Rees knew that Mr Duff had left his parents' house, and that Dr Evans "had indicated Mr Duff needed a stay in hospital".

Ms Rees was satisfied with this verbal handover, but on checking the log book, "had reservations" about the failure of the Team to do a domiciiiary visit, and became concerned then.

Ms Todd pointed out that, despite this concern, Ms Rees had not instigated any action herself. She admitted she could have gone to the flat with Police assistance, or sought the assistance of another worker. She said she did not do so because of the problems associated with disturbing psychotic clients late at night. She deferred to Ms Neve's plan because she was not privy to all the information available to her (Ms Neve).

Ms Todd said that Ms Rees had been involved in the contact between the Team and Mr Duff on 10th February 1996, recorded in the Team's log book, and knew of his condition. Even so, in her submission, Ms Rees did not act on her "concerns".

For those reasons, Ms Todd submitted, Ms Rees' evidence was of little probative value.

In conclusion, Ms Todd said that there were many structural deficiencies in the Mental Health system at the time of Mr Duff s death. She said it would be a "great injustice if specified workers in Mental Health were to be held accountable for structural deficiencies which should be addressed at the management level, because if blame is unduly placed on individuals without adequately addressing those structural problems, it is likely that there will be further tragedies such as occurred in Mr Duff's case".

Having considered Ms Todd's submissions, and those of Mr Ian Duff and the other counsel involved, I believe the proposed adverse comments should stand, with the exception of the comment involving Ms Rees.

FINDINGS ON SECTION 55 NOTICES This Inquest has been a traumatic and difficult experience for all those involved with it.

Firstly, for the Duff family, who have lost a loved one and are grieving that loss, I know that there is nothing I can say to them or which I can do which might lessen that grieving.

However, I can say that I am satisfied that there has been a most thorough and exhaustive search for the truth about the events leading up to Brian's death, and the family's request for the holding of an Inquest has been justified.

Secondly, the relevant members of the Mental Health Service have been required to spend lengthy and obviously stressful periods in the witness box, being questioned and cross-examined by several counsel, as well as by Mr Ian Duff, representing the family.

The Inquest was also preceded by an internal inquiry when the same members were required to make statements and answer questions.

It is obvious that, as well as the family, those personnel were also very distressed about Mr Duff's death.

Mr Krueger, for example, was so upset following his finding of Mr Duff, on 15th February 1997, that he had to take sick leave.

Staff involved in the treatment of patients by the Mental Health Service are constantly facing stressful situations and are required to make difficult decisions, sometimes quickly and not always with adequate information.

Their task can also be frustrating, thankless, and, sometimes, potentially dangerous.

It is easy for a Coroner, or other judicial officer, with the benefit of hindsight, and in the orderly atmosphere of a Courtroom, to be critical of decisions such as those made by such staff many months earlier, and which have transpired, objectively, to be inappropriate.

Having said that, I am afraid that I feel obliged to make the following comments in relation to the Section 55 notices served on Mr Wilson, Ms Neve and Mr Krueger. I have already advised that I do not now propose to make comments adverse to Dr Evans as proposed in her Section 55 Notice.

Mr Wilson As stated earlier, I accept that Mr Wilson should not be the subject of adverse comment regarding his role generally as Mr Duff s Case Manager.

However, I do find that Mr Wilson's failure to report to Dr Evans, and/or the Mental Health Tribunal, as to the lack of food in Mr Duff s flat on 20th January 1997, and the "grossly disorganised and unclean" state of the premises was a mistake on his part.

If he had taken reporting action, it seems, on the evidence of Dr Evans, that more urgency would certainly have attended Mr Duff s future treatment. To that extent, Mr Wilson's failure to do so is deserving of Coronial criticism.

Mr Krueger and Ms Neve Having considered the evidence and the submissions made by counsel, including counsel for Mr Krueger and Ms Neve, I find that, as members of the Mental Health Crisis Team, they failed adequately to respond to requests by Brian Duff s father and Dr Evans to effect contact with Brian Duff on the evening of 14th February 1997, either by conducting a home visit, or contacting Police to do a "welfare check".

Having regard to the evidence of Constable Brown it is a matter of conjecture as to whether that failure was a factor in the events proximate to Mr Duff s death.

If they had observed him in the "calm" state he manifested as he left the Police Station, they may have taken no immediate action.

However, they did know that his Clozapine level was "zero" or "close to zero", which indicated non-compliance with his medication. This may have explained his earlier irrationality at his parents' home, and could have been cause for taking action as requested by his father and Dr Evans.

In either event, the Team's failure to make any attempt to contact him, or the Police, means that the status of }y1r Duff s condition \Vas never investigated by them, ai. d in this regard, their conduct is deserving of Coronial criticism.

As to the other ground in Ms Neve's Section 55 Notice, i.e., failure fully to brief Ms Rees as to the necessity for urgent action in relation to Mr Duff, I am persuaded, principally by the submissions made by Ms Todd, that an adverse comment in this regard would not be justified.

RECOMMENDATIONS Any recommendations which I, as Coroner, would have had in mind following this Inquest have already been made in the Gianfrancesco and Meegan/Leggett reports and have been accepted and actioned by Mr Clarke, who was appointed Executive Director of the Mental Health Service shortly before Mr Duff's death.

It is a matter of sad irony that, following the Gianfrancesco report, action had already commenced to remedy the many systemic deficiencies in the Service's procedures and cultures, but not all had finally been put into place at the time of Mr Duff's death.

The Meegan/Leggett report revealed further areas of potential improvement, which had also received attention. As Mr Clarke said, in his evidence, the steps taken to effect the changes recommended had enabled the Service to move to best practice in community mental health.

It is clear to me that, had the Service been operating at the time of Mr Duff's death in the manner in which the evidence shows that it now does, the likelihood of a similar tragedy occurring would have been, if not eliminated, certainly significantly minimised.

There are insufficient grounds for referring the actions of any person involved in this Inquest to the Director of Public Prosecutions under Section 58 of the Coroners Act.

I should add that, following the Meegan/Leggett report, administrative action was taken against the personnel criticised in that report, and I do not believe any further action is appropriate.

I would therefore not make any additional recommendations to the Attorney-General under Section 57 of the Coroners Act.

OBSERVATIONS ON FINDINGS As to the manner and cause of death, I note that while there was evidence of suicidal tendencies earlier, there had been none exhibited by Mr Duff for almost 12 months prior to his death. I say this, bearing in mind the death of his friend Doug. Even that event did not produce any reaction from Mr Duff suggestive of a suicidal intention.

To record a finding of suicide, a Coroner must be satisfied, on the balance of probabilities, that death has been caused by the wilful act of a person intent on taking his or her life.

As stated in Re Davis (deceased) [1967] 1 AllER 688: "Suicide is not to be presumed. It must be affirmatively proved to justify the finding".

I could not be satisfied, on the evidence before this Inquest, that suicide had been "affirmatively proved".

As stated at the outset, the evidence is equally consistent with M...r Duff taklt1g an overdose of Clozapine without having any intention of ending his life.

CONCLUSION I am satisfied that the requirements of Section 13(1) and Section 52(1) of the Coroners Act 1997 have been met, i.e., the "manner and cause" of Mr Brian Duff s death have been established by this Inquest.

There were several issues addressed by counsel in their submissions to which I have not referred in these "Reasons for Findings". Without intending any disrespect to those involved, I believe I have dealt with all the issues relevant to my task as a Coroner under the Sections of the Coroners Act 1997 mentioned above.

I would like to express my gratitude to the counsel appearing in the Inquest for the assistance they gave me. I would also like to thank Mr Ian Duff for his thoughtful, and forthright, presentation of the family's position.

Finally, I wish to express my sincere condolences to the Duff family on the loss of their loved one.

CORONER 6th March, 1998

I

ANNEX "A" Investigation Team Comment Mr Brian Duff presented to the Phillip Health Centre on 14/2/1997 but was unable to say l1ihy. The triage "tWrker, Ms Kym Starr, made an assessment to the best of her abz'Uty and tried to involve more expen·enced clinicz'ans in the decision making process. On the basis of these discussions she believed that an appointment with his doctor in three days time was sufficient intervention. Later that evening Mr Roy Duff referred his son to the mental health.service by directly contacting the Crisis Team. He mis unamire that Brian had presented to the Phillip Health Centre earlier that afternoon.

In an integrated community mental health service the triagefunction provides an initial point of contact with the mental health services. Triage aims to screen and assess all contacts before making appropriate referrals.

Recommendation.

That a single point of referral and entry into the ACT Mental Health Service be developed as a matter of urgency.

That a screening process be implemented to prioritize referrals based upon set documented guidelines and that the screening practitioner (Triage) be separatefrom the assessing practitioner (Crisis Team).

That the triage worker be a clinician with experience in assessing people with serious mental illness and have the ability to respond appropriately to all contacts which are made.

That a standardized assessment tool and process be developed and adoptedfor all persons referred to the ACT Mental Health Service Mr Duff was known to be unreliable with oral medications and had previously been treated wt.'th depot injectionsfor that reason. Compliance with Clozaril was monitored by Mr Wilson, solely by asking the client if he was taking medication as prescribed. He did not use any assertive measures to monitor compliance and he relied on the doctor to inform him of the results of blood tests. Dr. Evans was amire of the results of the blood tests but Mr Wilson remained unam:zre that these tests indicated that Mr Duff had not been taking Clozaril as prescribed.

Medication compliance can be monitored in a variety of rmys including, direct staff supervision, blood sampling, observationfor side effects, using dosette boxes, requiring the return of emptyfoil packaging before the next scn'pt is issued, monitoring mental state or some combination of these. If these approaches are not a viable option then consideration needs to be given to the appropriateness of using oral medication for non compliant clients.

I Recommendation.

That clients who are known to be unreliable with oral medications should have strict supervision of their medication intake if they areprescribed Clozaril or any other potent drug.

That treating doctors and case managers collaborate and actively share information or concerns relevant to client management Mr Duff posed a chronic risk of injury to himself and others. This was indicated not only by his history of violent and impulsive behavior, but also by thefact that he was an J Jew unmarried and unemployed male in his thirties who lived alone with supports, abused drugs and alcohol and suffered from a chronic illness, yet several clinicians did not believe that he was at risk Recommendation.

That clinicians with client management responsibilities be apprised of risk identification and risk management strategies appropriate to safe management of seriously mentally illpeople in the community.

He was also a known abuser of non-prescription drugs. There was no indication that Mr Duff's illicit drug use was being monitored.

Recommendation.

That clients suspected of using nonprescription drugs be monitored by urine drug scree11ing and that they be educated as to the likely effects of non prescribed drugs on their mental health.

Mr Wilson was the case managerfor Brian Duff but he relied on the assessment of an inexperienced triage worker. He displayed a remarkable lack of curiosity when informed that Mr Duff needed an earlier appointment, given that he had been relatively well the day before. This did notprompt him to take any action not even to ring the triage worker directly and inquire about the nature of Mr Duff's changed mental state.

Thefunction of the case manager seems to havefocused mainly on the social and welfare needs of the client. There was no evidence of comprehensive assessment, careplanning, or assertive treatment. A lack of accountabilityfor the care and treatment of Mr Duff was evident. This may have been due inpart to Mr Wilson's relative lack of experience and or lack of supervision in managing Mr Duff's care.

Recommendation.

Discipline specific clinical supervision should be made available to all clinicians within the ACT Mental Health Service.

That ACT Mental Health Service develop a training program in bestpractice models of case management for all staff with case management responsibilities

!

/ That communication links between all components of the Mental Health service be reviewed as a matter of urgency.

That an individual service plan be developed for every case managed client of the mental health service. Thisplan should contain clearly identified client related goals to be attained and a stated review date.

The Crisis Team deferred the home visit and assessment of Brian Duff because he was as seen a low priority. This view was based on "priorknowledge" of the client. An assessment was clearly called for given that "there was possibl f a variety of reasonsfor his confused mental state". However, all other work was deemed more important although "circumstances suggested that an assessment should be done". The Crisis Team was based only minutes awayfrom Brian Duff 'sresidence. The workload for the evening had not been significantly busier than usual. They spent a large part of the evening worki.ngfrom their car in and around the suburbs of Canberra yet they did not attempt to make contact with him nor to inform any community agent who may have assisted. It is recognized that anyform of intervention by the Crisis Team staff would not necessarily have prevented the death of Mr Brian Duff. However the investigation team believe that Ms Kerri Neve and Mr Herb Krueger failed to explore all the options available to them.

These options were a) the team to conduct a home visit either alone or with police support, especially when considering the geographic closeness of Mr Duff's residence to the Canberra Hospital.

b) to contact thepolice to do a welfare check c) to contact Mr Roy Duff and establish if Brian had re contacted him and to inform him that they had not done a home visit as they said they would.

d) to discuss the situation with the doctor_on call andformulate aplan of action.

Recommendations That each client taken on by the Crisis Team have a documented assessment, action plan and review of outcome.

That the Crisis Team staff work in collaboration with case managersfor thepurpose of continuity of case management plans.

That all Crisis Team contacts with registered clients of the mental health service be documented in the· clients clinical file and that the service move towards developing a single mental health clinicalfile which will be accessible to and utilized by all components of the mental health service.

That the existing Policies and Procedures Manual be revised to address the significant lack of guidelines andprotocols for practitioners working within the Crisis Team e.g.

policy on team response to clients who abscond before an assessment has been made.

I I That one staff member be clearly identified as in charge on each Crisis Team shift and that that person be the most experienced and appropriately trained person on the shift.

That all staff of the Crisis Team should partic ipate in an up to date best practice training program relevant to crisis intervention, assessment and treatment techniques and case management principles. Members of the Crisis team would benefit significantly from a site visit and placement in a recognized metropolitan crisis assessment team in either NSW or Victoria That the Crisis Team should have direct access to an identified senior registrar or a Psychiatrist for theprovision of direct clinical services andfor staff development purposes.

That the two Crisis Team Practitioners Ms Kerri Neve and Mr Herb Kruger be reprimanded and professionally counselled for theirfai lure tofulfill their duty of care to Mr Brian Duff.

That all assessments by the Crisis Team be community based in the client's own environment or at the Center rather than transporting clients to the Canberra Hospital for each assessment.

That the Crisis Team expand its role toproviding assertivefollow up and treatment in the community as an alternative to hospital admission.

ANNE X 11 8 11 •

. A U ST R A LI A N CA P ITA L T E R R ITOR Y O F F I C E O F T H E C A N B E R R A C O R O N E R Law Courts of the Australian Capital Territory Canberra City, A.C.T. 2601 G.P.O. Box 370 Telephone (02) 6217 4444 Telegraphic Address: COURTS Canberra In replyplease quote: CD 24197 19th December, 1997 Dr M. Evans, Cl- A.C.T. Government Solicitor,

CANBERRA. A.C.T. 2601 Re: Inquest into the death of Brian Joseph

DUFF Section 55 of the Coroners Act 1997 requires that a Coroner proposing to make a comment adverse to a person involved in an Inquest shall not do so until that person has been given a copy of the proposed comment, and allowed the opportunity of responding to it. A period of not less than 14 days, and not more than 28 days, is to be provided for such response.

Accordingly, I advise you that I propose making a comment adverse to you in the following terms:

1. That you failed adequately to ensure, in view of Brian Joseph Duff's level ofliteracy and disordered thought, that he was aware of the potential dangers involved in not following instructions in the taking of the medication Clozapine.

2. That, in view of Mr Duff's history, you failed adequately to supervise the taking by him of the medication Clozapine and continued to provide such medication without appropriate monitoring of his condition.

\ This advice is being handed to your Counsel, on 19th December 1997. I request that your lJ, response be delivered to the Coroner's Secretary, Mrs M. Heidtmann, by 10.00 a.m. on / January, 1997. 1 I will hand down my findings at 10.00 a.m. on -8th-January, 1997.

ANNEX "C" A U S T R A LI A N C A P I T A L T E R R I T O R Y ffl,

O F F I C E O F T H E C A N B E R R A C O R O N E R Law Courts of the Austral ian Capital Territory Canberra City, A.C.T. 260 l G.P.O. Box 370 Telephone (02) 6217 4444 Telegraphic Address: COURTS Canberra In repv please quote: CD 24197 19th December, l 997 Mr D. Wilson, Cl- A.C.T. Government Solicitor,

CANBERRA. A.C.T. 2601 Re: Inquest into the death of Brian Joseph DUFF Section 55 of the Coroners Act 1997 requires that a Coroner proposing to make a comment adverse to a person involved in an Inquest shall not do so until that person has been given a copy of the proposed comment, and allowed the opportunity of responding to it. A period of not less than 14 days, and not more than 28 days, is to be provided for such response.

Accordingly, I advise you that I propose making a comment adverse to you in the following terms: 1.- That, as Brian Joseph Duff's Case Manager, you failed adequately to supervise his treatment under a Community Treatment Order made by the Mental Health Tribunal on 6th June 1996 and 9th September 1996 and varied on 19th December 1996.

2. That you failed adeguately to ensure Brian Joseph Duff's compliance with his medication regime.

3. That, following your entry to Mr Duff's flat on 20th January 1997, during which you observed the "grossly disorganised and unclean" state thereof, and lack of food, together with his marked underweight appearance, you failed to bring such observations to the attention of Dr M. Evans or the Mental Health Tribunal.

This advice is being handed to your Counsel, on 19th December 1997. I request that your response be delivered to the Coroner's Secretary, Mrs M. Heidtmann, by 10.00 a.m. on Ii"· January, 1997.

ill hand down my findings at 10.00 a.m. on ,tjth January, 1997.

ANNEX "D" A U STR A LI AN CA P ITA L T E R R ITOR Y O F F I C E O F T H E C A N B E R R A C O R O N E R Law Courts of the Australian Capital Territory Canberra City, A.C.T. 2601 G.P.O. Box 370 Telephone (02) 6217 4444 Telegraphic Address: COURTS Canberra In rep(v please quote: CD 24197 19th December, 1997 Mr H. Kruger, Cl- A.C.T. Government Solicitor,

CANBERRA. A.C.T. 2601 Re: Inquest into the death of Brian Joseph DUFF Section 55 of the Coroners Act 1997 requires that a Coroner proposing to make a comment adverse to a person involved in an Inquest shall not do so until that person has been given a copy of the proposed comment, and allowed the opportunity of responding to it. A period of not less than 14 days, and not more than 28 days, is to be provided for such response.

Accordingly, I advise you that I propose making a comment adverse to you in the following terms:

1. That, as a member of the Mental Health Crisis Team, you failed adequately to respond to requests to attend on Brian Joseph Duff on the evening of 14th February 1997, either by conducting a home visit, or contacting the Police to do a welfare check.

This advice is being handed to your Counsel, on 19th December 1997. I request that your response be delivered to the Coroner's Secretary, Mrs M. Heidtmann, by 10.00 a.m. on -e.th. /.:J;,::::._ January, 1997.

I will hand down my findings at 10.00 a.m. on +3th-January, 1997.

A U ST R A LI A N C A P I T A L T E R R I TO R Y ANNE X "E" O F F IC E O F T H E C A N B E R R A C O R O N E R Law Cou rts of the Australian Capital Territory Canberra City, A.C.T. 2601 G.P.O. Box 370 Telephone (02) 6217 4444 Telegraphic Address: COURTS Canberra In rep(v please quote: CD 24197 19th December, 1997 Kerri Neave, Cl- Pamela Coward & Associates,

CANBERRA. A.C.T. 2601 Attention: Ms Todd Re: Inquest into the death of Brian Joseph DUFF Section 55 of the Coroners Act 1997 requires that a Coroner proposing to make a comment adverse to a person involved in an Inquest shall not do so until that person has been given a copy of the proposed comment, and allowed the opportunity of responding to it. A period of not less than 14 days, and not more than 28 days, is to be provided for such response.

Accordingly, I advise you that I propose making a comment adverse to you in the following terms: L That, as a member of the Mental Health Crisis Team, you failed adequately to respond to requests to attend on Brian Joseph Duff on the evening of 14th February 1997, either by conducting a home visit, or contacting the Police to do a welfare check.

2. That, having knowl dge of the circumstances of the case, you failed fully to brief "1s Rees, the night duty member, as to the necessity for urgent action in relation to Brian Joseph Duff.

This advice is being handed to your Counsel, Ms Todd, on 19th December 1997. I request that your response be delivered to the Coroner's Secretary, Mrs M. Heidtmann, by 10.00 a.m.

on -eth January, 1997.

//-._, '").o I will hand down my findings at 10.00 a.m. on 13th January, 1997.

(

AN NEX "F" STATEMENT OF OR MANDY KAYE EVANS RE: THE DEATH OF BRIAN DUFF

1. This statement made by me accurately sets out the evidence which I would be prepared, if necessary, to give in court as a witness. The statement is true to the best of my knowledge and belief and I make it knowing that. if it is tendered in evidence. l shall be liable to prosecution if I have wilfully stated in it anything which I know to be false or do not believe to be true.

2. My name is Mandy Kaye Evans.

3. My qualifications are as follows: Bachelor of Medical Science degree (1981) Bachelor of Medicine and Bachelor of Surgery (1984) - University of Tasmania Fellow of the Royal Australian and New Zealand CoHege of Psychiatrists (1994)

4. I am employed as a Staff Specialist in Psychiatry, a conjoint appointee of ACT Health and the University of Sydney. I have been in the employ of ACT Health for ten years, completing my training in psychiatry in Canberra. I have worked exclusively in psychiatry since August 1988. I have been the co-ordinator of the ACT Branch Training Programme in Psychiatry since July 1995 and the ACT representative on the Federal Committee for Training since 1996. I have been a Visiting Fellow at the NH & MRC Psychiatric Epidemiology Research Centre, Australian National University since

5. I am currently the ACT Chief Investigator for the "Low Prevalence (Psychotic) Disorders Study" conducted as part of "The National Study of Mental Health and Wellbeing", an initiative of the Commonwealth Government. I am the ACT Mental Health Services representative to the ACT Health Research Committee and The Canberra Hospital Junior Medical Officers Training Committee.

6. I provide specialist diagnostic, treatment and consultative services for in-patients and out-patients of ACT Mentai Heaith Services from within the V'../oden region. 1 attend Phillip Health Centre two half days per week in the capacity of a Consultant Psychiatrist in a multi disciplinary team. In this time, I have a case load of approximately 60 patients. I provide the medical consultations for a large number of patients being case managed by other members of the team and assist in the development of management plans for these patients. I also assess patients for referring general practitioners.

7. I had intermittent contact with Mr Duff whilst working as a resident and registrar in the Psychiatric Unit from 1987. Iwas involved in admitting him, day-to-day care and family meetings. I became the speclalist involved in his care in February 1996. His Canberra Hospital file and my own knowledge of him indicate that Mr Duff had his first admission and the diagnosis of schizophrenia made in 1984 (age 20). In total, he had 24 admissions to the Canberra Hospital Psychiatric Unit, as well as admissions to Calvary and Kenmore Hospitals. Over the years, he spent considerable periods of time in facilities providing high intensity support, such as Watson Hostel and Hennessy House and in group houses run by Richmond Fellowship and ACT Mental Health Services, but he left them, preferring to be on his own. He had great difficulty tolerating others Signature: Date: Or Mandy Kaye Evans Witness'. Date:

and nobody outside his immediate family with whom he had any regular contact or intimacy. His exacerbations of illness were often attributed to interpersonal stress. He was disabled to the point of being unable to work and could only be engaged intermittently in rehabilitation activities. He was habitually thin, unkempt and spent much of his time alone and in apparently aimless walking. Mr Duff showed a common behaviour of violence directed towards himself and his immediate family on several occasions. particularly in the first five years of his illness. His family had taken restraining orders against him. He consistently maintained anger towards his family and asked that Mental Health Services not involve his family in his treatment. His discharge summaries from Canberra Hospital indicate almost continuous prescription of injectable anti-psychotic medication (Modecate and Haldol) and oral anti-psychotic medication (Melleril and Stela2ine} throughout his illness. Despite these interventions with medications and social manipulations. Mr Duff was in the 35% of persons with schizophrenia with on-going deterioration.

7. On 8 February 1996, Dr Valmai Kingham, a Career Medical Officer working at the City Health Centre, wrote asking me to take over Mr Duff's care. She outlined that she had cared for him for approximately four years and that "Episodes of acute illness occur when there are severe stressors". She reported three admissions (October 1992, March 1993 and June 1995) in the four years related to psychological and social stresses.

8. Dr Kingham reported that he had been treated with the fnjectable medication Haldol 100 mg fortnightly and subsequently Flupenthixol 30 mg fortnightly since 1991. She also reported oral medications being "added for short periods". She anticipated "some distress" because his Case Manager at the time, Carmel Ronning, was about to leave on one year of maternity leave within weeks.

9. Dr Kingham's anticipation of exacerbation due to his Case Manager's departure was accurate. and Mr Duff was admitted to hospital two days following the writing of the referral. He settled over a period of five weeks in hospital, during which time he continued to take injectable medication. Flupenthixol 60 mg fortnightly and additional Melleril 100 mg twice daily. This represents a very sizeable dose of medication.

10. An assessment of his capacity to perform the activities of daily living was performed by the Occupational Therapist on 20 February 1996, with the conclusion that he had the skills to live independently with some outside supervision. He wanted to return to his flat. and given that he appeared settled, on 30 March 1996 he was discharged home.

11. He was organised to have daily visits with his new Case Manager, contact with the agency "Connections" and work with the ACT Psychiatric Rehabilitation Service Group Northside Contractors organised. Only eight days later. he was readmitted involuntarily, having assaulted a previously treating psychiatrist he enco1.1ntered by chance in a shopping centre, and then allegedly threatening police sent to his flat to apprehend him with a knife, yelling at them to shoot him. This occurred despite the regular receipt of injected anti..psychotic medication.

Signature: Date: Dr Mandy Kaye Evans Witness: Date:

12. The admission that followed was prolonged (28 March 1996 - 2 July 1996). Initially it was difficult to communicate with Mr Duff. He could be hostile and unwilling to talk at times. and at other times it was the severity of disorder of form of his thoughts (ie, the lack of logical connection between the Ideas being expressed) which made it difficult to understand the meaning of the incident with the police. On interviewing him, Iwrote in his hospital file that he was talking about police behaviour in a way which suggested delusional beliefs about them. He seemed to believe they had had a sinister motivation in their fatal shooting of a mental health patient the year before. He seemed to believe this act of his would somehow demonstrate this. He also mentioned joining another patient (who had suicided in mid 1995) but the hospital file demonstrates that It was never clear that suicide was his own motive in the incident.

13. In the first three weeks of this admission, an order to continue custodial treatment a further 28 days was sought and granted by the Mental Health Tribunal on 4 April 1998.

14. Mr Duff was not improving despite treatment with oral medications (Haloperidol and Valium, then Thioridazlne and Lithium) in addition to the depot medication and the highly structured environment provided in the small secure area of the ward. I then took the decision to trial Clozapine treatment and it began on 17 April 1996.

15. My decision to trial Clozapine was based on evidence that Clozapine has been consistently demonstrated to produce better clinical outcomes than conventional treatments for people with chronic schizophrenia. Mr Duff had clearly established chronic schizophrenia which had failed to respond adequately to conventional treatments. Additionally, he had displayed symptoms of being somewhat elevated in mood {intrusiveness, over talkativeness and abbreviated sleep habits) which the literature indicates may respond more positively to Clozapine than other medications, Clozapine was begun two weeks after the granting of the first Custodial Order.

\ · 16. Advice from the ACT Government Solicitor's Office dated 2 June 1996 stated that Clozaplne could be given.

17. Iexplained the new drug to Mr Duff. I told him it offered an approximately 30% chance of improvement over the usual drugs. I explained the side-effects, including the most serious one of possible lowering of white blood cells and the necessity to have weekly blood tests to guard against this. I explained that the dose would start low and work up and that the final dose depended upon his response. I explained the common minor side-effects (altered weight, sleepiness, excessive salivation, dizziness on standing) and the possibility of fits at higher doses. Iwarned Mr Duff to take them only as prescribed.

18. Clozapine is only available as an oral medication. This can make compliance more difficult to ensure, but it offers substantial improvement to approximately one third to one half of those treated with it. These people often become willing to take this treatment. In addition to the hope that Mr Duff would make a substantial recovery and be willing to take the medication, he had a twelve year history of use of oral medications without overdose indicated by his Canberra Hospital discharge summaries.

Signature; Date: Dr Mandy Kaye Evans Witness: Date:

19. Mr Duff started treatment on 17 April 1997 and made a steady recovery in the time frame anticipated. ie, approximately a month. on a moderate dose of 300 mg per day.

His only difficulty was with morning oversedation.

20. In addition to the immediate medication issues. the other aspects of Mr Duffs management were his on-going needs for other forms of treatment, care and control, A further 28 day Treatment Order was sought and granted on 1 May 1996, two weeks into Mr Duffs treatment with Clozapine. When granting this second order, the Mental Health Tribunal and The Office of the Community Advocate were aware that this was the medication being used.

21. By the end of this period of compulsory treatment. Mr Duff was improving and accepting treatment happily. I sought no further order to treat him, but on 6 June 1996, the ACT Magistrates Court was successful in its application to the ACT Mental Health Tribunal for a Community Treatment Order to be in place when Mr Duff was discharged from hospital. This was done without reference to me. The Mental Health Tribunal reviewed this order and re-instated it on 9 September 1996 for a further six months, The Mental Health Tribunal and The Office of the Community Advocate would have been aware of the use of Clozapine at the granting of three of four orders.

22. Mr Duff's discharge was delayed by the legal process surrounding the charges made in relation to the police officers he had threatened on 28 March 1997 and Mr Duff's reaction to it. There were several adjournments in hearings and he became anxious in the face of this stress. I did not discharge him from hospital until this matter was resolved.

23. Drug therapy is only one aspect of the management of a person with chronic schizophrenia: Early in the hospitalisation, Mr Duff's long-term management plan in terms of biological, psychological and social interventions began to be formulated. In the reatm cf biological treatment, his improvement on Clozapine compared with regular depot medications, indicated he should continue the medication. There is evidence that some persons with chronic illnesses continue to improve over a six month period on the drug. A presentation of his case at a weekiy meeting of aii the ward psychiatrists endorsed the use of Clozapine.

24. From a psychological point of view. it was clear that Mr Duff needed stability of professionals working with him. I had had Mr Duff assessed for Hennessy House during the admission. with the aim of providing a stable psychological and physical environment, but it was indicated that there would be no place available within the time- frame for discharge.

25. A referral to the Intensive Rehabilitation Team was then pursued. given the occupational therapy assessment which was done on 20 February 1996 indicated that Mr Duff could manage activities of daily living largely independently, his on-going stated preference to live in his flat and the lack of availability of a hostel place.

26. At the time. the Intensive Rehabilitation Team comprised three or four experienced clinicians with maximum caseloads of ten patients each, who would have up to daily Signature: Date: Dr Mandy Kaye Evans Witness: Date: f "

contact with patients requiring the most support to remain living in the community.

Richard Bromhead, an experienced general and psychiatric nurse on that team, was assigned to Mr Duff and began to meet with him from 2 April 1996 to begin the processes of engagement and formation of a case management plan. He and I had frequent discussions regarding Mr Duff's long-term management. At that time, it was not the practice of these Case Managers to write in the hospital file. My understanding of the case plan at the time of discharge was:-

1. Blologlcal Measures Continue Clozaplne 300 mg per day Ensure compliance with required blood monitoring by taking Mr Duff to these tests and liaising with the Clozapine Co-ordinator To help to ensure compliance with medication by use of a dosette box_ (filled and then checked at the end of the week)

2. Psy_chologfcal Me1suce1 Supportive and problem-solving approaches to psychotherapy

3. Soclal Measures Encourage participation in a greater range of activities. including the Psychiatric Rehabilftation Seivice and Community Agencies

4. Monitoring of Mental State and FunctJoning

5. l,.ialson To help ensure Mr Duff kept appointments with me (made monthly) To discuss progress and amend the case plan according to developments in consultation with me

6. Following discharge, I saw Mr Duff at least monthly, initially at the hospital and then a Phillip Health Centre. This is a typical arrangement with chronically HI patients not in crisis. Until the appointment of 4 November 1996, I was aware of no particular problems, either from Mr Duffs self-report, mental state examination findings or his Case Manager, Richard Bromhead. His mental state and functioning remained improved. He was attending a TAFE course and two rehabilitation activities. It is my recollection that Mr Bromhead told me that he was managing his dosette box and money well. He was completely reliable with respect to attending for regular blood tests, asked questions about the Clozaplne, and according to Donna Hodgson, the Clozapine Co-ordinator, appeared to have a good understanding of the medication.

Signature: Date: Dr Mandy Kaye Evans Witness: Date:

28. On 4 November 1996. my Phillip Health Centre fife records that Mr Duff complained of some increase in feelings of being "stressed" but little other detail could be obtained. It was typical of Mr Duff to be reluctant to give further detail regarding symptoms.

Richard Bromhead reported an increased !ability of mood and difficulty coping with people which Mr Bromhead believed had led him to drift away from rehabilitation activities. He had initiated discussions with Mr Duff about moving to supported accommodation, and my notes record that they were going to look at an ACT Mental Health Services house that day. Idecided to increase Mr Duff's Clozapine dose to 350 mg (3 x 100 and 2 x 25 mg tablets} because there was no evidence from him or from hls Case Manager that Mr Duff was not taking his medication. Mr Duff expressed no reservations about taking the drug or accepting an increased dose.

29. Mr Duff did not attend his next scheduled review with me on 2 December 1996.

notified his Case Manager and we subsequentry reviewed the case management plan.

Mr Bromhead proceeded with an application for hostel placement and wrote to the Mental Health Tribunal on 5 December 1996 requesting consideration of varying the Community Treatment Order to require Mr Duff to accept hostel care when a place became availble, as we felt it unlikely he would accept this voluntarily. At the time.

we believed his symptoms were the consequence of M r Bromhead's impending departure in January, simllar to his reaction to loss of his Case Manager in February.

Mr Bromhead was very conscious of this and at pains to facilitate a smooth transition to Don Wilson, his replacement. as soon as possible. At this point, it was the aim of the treatment strategies to stabilise Mr Duff with an increased dose of Clozapine, while increasing familiarity with his new Case Manager in the period before hostel placement became available. An increase in medication, coupled with increased social support is a standard method of management of such situations.

!o .

30. Inext saw Mr Duff on.16 December 199 . He attend ed with his new and retiring Case Managers. My interview notes recor ed on 16 December 1996 indicate Mr Duff believed neighbours to be talking about him and "building something on the roof'. He was evasive in response to direct questions about psychotic symptoms (eg. hearing voices and being directly persecuted) and issues such as his medication and our plans for him to move to a hostel. ! noted a deterioration in his observable mentai state, with features indicative of more internal preoccupation, behaviour Sllggestive of hallucinations, persecutory delusions regarding his neighbours and his chronically present formal thought disorder. Iassessed his condition as deteriorated.

31. My notes indicate that I ordered a blood drug level to be done to give some indication of drug compliance. This strategy can help to determine if the patient is taking any medication at all, but beyond that, a blood !ever may not tell whether the patient is taking the appropriate amount of medication or taking it on a regular basis. I also wrote a letter to the Mental Health Tribunal supporting Richard Bromhead's application for a variation of the order.

32. I discussed with Mr Bromhead and Mr Wilson that any further deterioration should result in an admission to PSU (Psychiatric Unit, the Canberra Hospital). I recall no other changes to th& basic management plan, such as a dosette box no longer being used to monitor medications.

Signature: Date: Dr Mandy Kaye Evans Witness: Date: ' i

33. Between 16 December 1996 and my next appointment with Mr Duff and Mr Wilson on 16 January 1997, there was no communication to me. By 16 January 1997, I had just received the result of Mr Duff's Clozapine level taken on 16 December 1996. This test is done interstate and it takes approximately three weeks for this type of test to come back to the Canberra Hospital. The levels of Clozapine and Norclozapine (30 and 22 respectively) were low and indicated that Mr Duff was not taking the dosage of Clozapine prescribed. When confronted with this, he was dismissive, saying words to the effect of veah, but I'm taking it now". His account of reduced symptoms and my mental state examination findings of that day indicated improvement. My notes of 16 January 1997 record that his report indicated relinquishment of fears concerning his neighbours. I recorded that aspects of his physical appearance were improved, he was not preoccupied and able to be engaged in conversation. and warm in his affect towards me. Typical and long-term features of his illness. such as a degree of formal thought disorder and evasiveness of issues such as his accommodation, remained.

The history given by Don Wilson was that there was obvious improvement and that Mr Duff was better organised.

34. Despite Mr Duffs assertion that he was now taking Clozapine, my notes indicate that I ordered a repeat Clozapine btood level.

35. Given my assessment of an improvement in Mr Duff's mental state and corroboration of this improvement by his Case Manager, a move to place Mr Duff on an emergency involuntary treatment order was not taken. Breach of Community Treatment Order conditions, such as lack of strict compliance with medication, does not result in an automatic conversion to a CU$todial order. It does not invotve a statutory requirement to notify the Mental Health Tribunal of the "breach", and does not meet the legislative requirement for involuntary detention which demands that persons be treated in the least restrictive possible environment unless ill enough to require "immediate treatment or care''. Given that compliance with medical, including psychiatric, treatments is only 30% - 50%, detention based upon incomplete drug compliance would result in a very large number of involuntary detentions.

36. No further information was passed on to me regarding Mr Duff's condition from Mr Duffs family (eg. their observations of weight loss and deteriorated mental state), his Case Manager or ACT Pathology until after his death.

37. I was not made aware of the poor level of functioning indicated by the state of Mr Duffs flat inspected by Mr Wilson on 20 January 1997 or his reaction to the funeral of another long-term patient at the end of January.

38. On Friday 14 February 1997, I responded to a message left for me by Kym Starr, a Psychologist at the Phillip Health Centre, who was working as the Duty Officer that afternoon. I was at the Psychiatric Unit seeing inpatients and received her message around 3.30 pm. Ms Starr asked me if I would see Mr Duff for an urgent appointment when I was next at the Health Centre on 17 February ·1997, because she had seen him earlier that afternoon and he seemed unwell and distressed. I was unable to ascertain that he had reported any particular worries, except a complaint that his medication W8$ making him feel Sick.

Signature: Oate: Dr Mandy Kaye Evans Witness: Date:

39. I told Ms Starr that Iwas happy to see him and an appointment was made for 1.30 pm on Monday 17 February 1997, the next working day. I told her she should inform his Case Manager, Don Wilson, and check our arrangement for an early appointment with him. My reasoning in this was threefold firstly, a Case Manager should be notified of significant events such as this self-presentation; secondly, my understanding was that Mr Wilson would have been in contact with Mr Duff within the last few days and could help with the judgement as to whether Mr Duffs presentation to Ms Starr represented a deterioration from his state that week. Mr Duff was chronically unwell, thought disordered and unknown to Ms Starr, making it difficult for her to judge how different from his usual self he might have been; and thirdly, Mr Wilson would need to bring Mr Duff to the appointment so that it had to be known to him.

40. At no time did Ms Starr give the professional opinion that Mr Duff should be

• hospitalised voluntarily or on Emergency Action.

41. At approximately 6.30 pm, I returned to the office again. Ifound a message taken by a secretary saying "Don Wilson thinks its a good idea you see Brian. Mara (the receptionist) has made the appointment for Monday 17 February 1997". Nobody else made contact with me.

42. At the same time as I picked up this note, Mr Herb Krueger, on duty for the Crisis Team that shift, was in the office. An informal conversation ensued. He told me that Mr Duff's father had called thm concerned about Brian and that they were going out to see him. I told Mr Krueger words to the effect that I thought Mr Duff should be brought to hospital, as adequate outpatient care could not be given over the weekend.

Ibelieve Itold him Ihad heard about Mr Duff from the Duty Officer at the Phillip Health Centre that afternoon. Itold him that Mr Duff had not been managing well recently and that we were currently awaiting a hostel bed. I told him that we suspected Mr Duff's compliance because his Clozapfne level was close to zero. or words to that effect. I told him that as Mr Duff was not letting his Case Manager into his flat at present, it was unlikely he would let the Crisis Team in to supervise him taking medication over the weekend. Mr Krueger indicated to me that going to pick up Mr Duff was their next job.

Ileft expecting Mr Duff to be admitted that night.

43. On Monday 17 February 1997, I learned that the Crisis Team had found Mr Duff dead on Saturday 15 February 1997, presumably by overdose of Clozapine, resulting in the aspiration of vomit into his lungs. Mr Athol Webb told me the Crisis Team had not attended Mr Duff's flat the night before because of "pressure of work" or words to that effect. I understand that around 300 Clozapine tablets were found scattered through Mr Duff's flat. It indicates that a dosette box was no longer being used for drug dispensing. I have no rec;:ollection of being informed of when the Intensive Rehabilitation Team took that decision.

Signature: Date: Dr Mandy Kaye Evan$ Witness: Date:

ANNEX "G" STATEMENT By Don Wilson I, DON WILSON, of [redacted] Street, Farrer in the Australian Capital Territory, make the following statement.

l-00:.,s , 1. My full name is Donald bewtS Wilson and I have been a registered mental health nurse since late January 1996. Prior to that, I was a registered nurse in NSW since November 1989 and although I didn't have my Mental Health Certificate at that time, I did work mainly in mental health areas during that time.

2. During my training I did a 6 week placement with the Intensive Rehabilitation Team (IRT) however it was not until the time I became Brian Duff's case manager in December 1996 that I commenced full time on the IRT.

3. The IRT is a specialist team consisting of 3 mental health nurses and a social worker which was formed to allow supervision in the community of people with mental illnesses whose condition was not severe enough to be permanently hospitalised but who nevertheless needed close supervision, either because of a Community Treatment Order or otherwise.

4. The team had around forty patients at any one time. Officially, each member of the team was responsible for no more than 10 patients however during the time that I was there and when Brian Duff was one of my patients, I had up to 8 patients to supervise at any one time. From December 1996 to early February 1997 I had eight patients plus a few extra patients due to the other staff members being on holidays. From 10 February 19 I was allocated to care for 11 patients due to a staff shortage. I was also directed to start being the clinical support for the "Young Ones" on Fridays and I was medicating another client for the social worker.

To my memory, we rarely had a full team there during that time so the work pressure was pretty high. A number of these patients, not just Brian, had chronic schizophrenia. I visited Brian on average twice per week (see below), which was more frequent than some other patients were visited. Without formal protocols or directions as to the case management of

particular patients or conditions, it was a matter for individual members of the team to assess how much contact to have with a particular patient. To a certain extent, this was determined by the relative level of need - obviously, the patients who appeared to be coping least were visited most often, and vice versa.

5. The Mental Health Service did not provide as far as I am aware any written protocols or guidelines as to the specifics of how the team was to exercise its supervisory role. The actual case management of particular pat ients was therefore left up to the discretion of the individual worker and was determi ned by various factors, such as the nature and severity of the client's illness, the type of medication they were on and just work load constraints.

6. There were no regular case work meetings where members of the IRT could discuss particular cases with each other and obtain second opinions or advice on the way we managed a particular client. Our supervisor was Lewis Bond and he was approachable but the fact was that we were always just too busy to have casework meetings.

7. As I said at the Inquest, I first became Brian Duff's case manager in December 1996. I took over from Richard Bromhead who had been his case manager for about the previous 6 months since his discharge from hospital. My handover from Richard Bromhead consisted of going around with Richard on meetings with patients and sitting in on consultations with their psychiatrist if it occurred. Richard emphasised Brian's fierce independence and told me about the length of time that it had taken him to get Brian to trust him.

8. My first contact with Brian was at the meeting on 16 December 1996 with Dr Evans and Richard Bromhead. I remember Dr Evans saying that statistically Brian was in a higher risk group for suicide and that it was suspected that he wasn't fully compliant with his medication. She didn't discuss any specifics with us about how we were to monitor his Clozapine intake. I was confused at the Inquest because I did not have the opportunity to check the IRT file first, but I am certain that at the first meeting, we did not have the results of the first clozapine test, because that was the occasion when Dr Evans decided to order tests. (I should point out that i n my evidence to the Inquest, it was not made clear that there were two types of blood tests - the white cell count and the Clozapine levels. The white cell count was the one done at 4 week intervals, and with which Brian always complied. The

results were available immediately. The Clozapine one was of course the one which was only done twice in my association with Brian, and the one in which only one result (for 16 December 1996) was made known to me. The white cell counts of course would only reveal whether someone on clozapine was suffering the deficient white blood cell levels. The white blood cell levels of course, if normal, would not indicate whether or not someone was taking the required dose of Clozapine, because most patients on Clozapine do not in fact suffer from depressed levels of white blood cells. The test that I refer to in my evidence as "two or three" times was i n fact t he Clozapine test, which was done twice but only delivered results once.) I did not have the benefit ofreading my notes first.

9. My recollection of what Dr Evans said to Richard Bromhead at the meeting on 16 December 1996 was that Brian's blood Clozapine should be monitored, and if Brian deteriorated further, he should be admitted to hospital. It was not discussed how this would occur if Brian did not fit the criteria for emergency action or for a custodial treatment order.

10. Generally, I accept that as his case manager on the IRT, I did have a responsibility to ensure that Brian was taking his Clozapine. However, there were a number of factors which made my role fairly difficult.

11. At the time I took over his case management from Richard Bromhead, I knew that Richard had been dropping off Brian's medication in 4-weekly batches. This is quite a common thing on the IRT for people on Clozapine - it was not particularly unusual for us to do that. Dr Evans certainly didn't give us any instructions in relation to the monitoring other than to say that if Brian ever wanted an earlier appointment with her, we could make one for him.

12. I do not understand the reference in Dr Evans' statement to the stoppage of the use of the dosette box (paragraphs 32 and 43 of her statement). I was not aware during my time as Brian's manager that anything other than the usual medication packs (ie. foil packs of tablets) was used. Furthermore, I did not see how a dosette box would necessarily ensure that a patient did not overdose. Dosette boxes can be administered so that each discrete dosage is contained in a separate container. They can contain different doses covering different periods of time - the most com mon is for a 7 day supply. Dosette boxes are therefore used commonly for patients who forget to take their medication or who are not sure how much to

take in any one time. That was not the case with Brian - I discussed his medication with him and he was well aware of the amou nt he needed to take in any one dose. I knew his correct dosage at the time and I did discuss with hi m the amount of tablets he needed to take to satisfy this dose. But giving medication in a dosette box would not stop stock piling or overdosing by a patient who wanted to do so. Also, by looking at the dosette box and how much had been taken it won't tell you whether someone is in fact taking their medication or not - they can still take one out and throw it away, just like they can with the pack which Brian was on.

13. The Clozaril protocol put out by the drug company states that it can only be dispensed in dosages for one week at a time from the first treatment up until the first 18 weeks of treatment expire. Then, no greater than one month's supply is allowed to be dispensed at once. This is all to do with making sure the Clozapine does not affect a patient's white blood cell counts. Therefore, our practise of dispensing 4 weeks Clozapine at one time was not particularly unusual nor against the practice recommended by the manufacturer. Brian was at the stage I became his case manager past the 18 week trial period.

14. Furthermore, during my time of knowing Brian, he never discussed self-harm or suicide with me. He did not have a history of trying to overdose or attempt suicide in any other way.

There had been incidents of self harm that I was aware of and incidents when he had tried to harm other people. He had a history of being on Clozapine when in hospital and although obviously hospital allows closer monitoring of taking his medication, his six months supply to December 1996 as far as I was aware did not indicate that there was any problem with him taking the Clozapine. I discussed with Brian on several occasions the benefits of taking his medication, the importance of taking the prescribed dose only , the need to take the medication even if he missed a dose, and so on. Generally I wanted to give him a lot of positive reinforcement about the benefits of his medication.

15. The IRT file on Brian Duff from the time i n which I was his case manager shows that I did a total of 16 home visits to Brian i n the two months in which I was his case manager. This is an average of two per week, however generally I would visit Brian as needed and at the time I made a home visit I would make an appointment for the next visit. This was determined by how Brian seemed to be feeling on the date of the home visit and his needs. During the

course of my visits to Brian I would ask hi m generally about how he was going and would ask hi m if he was taking his med ication. I was aware from the visit with Dr Evans on 16 December 1996 that there was a question of his compliance with taking his medication.

However, as I said at the i nq uest by the time of our second meeting with Dr Evans on 16 January 1997 Brian's state seemed to have improved. I would also offer him assistance with household things although at that time he would still not let me into his flat.

16. I was aware of the existence of the community treatment order but as is clear from the order itself, the order simply directs the patient to accept the IRT's supervision and to accept treatment of the psychiatrist. It provides absolutely no direction as to the content of the supervision duties.

17. I agree with Dr Evans' statement that by the meeting on 16 January 1997, his general mental state seemed to be improving. I had been trying to get him use to the idea of accepting some kind of supported accommodation and by that meeting he was indicating tentative approval of the idea.

18. From fairly on in my time with Brian I had tried to get him used to the idea of going to some kind of supported accommodation. I raised the issue of Hennessy House with him and he was aware that the community treatment order required him to reside as directed. I also raised with Brian several times early on in my meetings with him, the possibility of voluntary admission to hospital. I referred to hospital during this time when he seemed to have deteriorated at the time of the first meeting with Dr Evans in December 1996. I raised this partly as a way of trying to avoid the possibility of having to admit him involuntarily, but also later on, after his improvement, as a way of highlighting Hennessy House as a more attractive option for him than hospital.

19. I made considerable efforts to try to find suitable accommodation so that the "reside as directed" part of the CTO could be facil itated. On 9 January 1997, I rang Hennessey House and was told there were no vacancies at present. I also phone the Richmond Fellowship who have their own supported accom modat ion and was told there were no vacancies there. There is also a reference to an "IRT house" i n the file entry for 9 January 1997. That is a reference

to a house that was being set up by the Psychiatric Rehabilitation Service and the Richmond Fellowshi p for mutual clients. That was not ready at that time either.

20. By the meeti ng wit h Dr Evans on 16 January 1997 I recall that Brian was much more favourable to the idea of supported accommodation and by that stage I had talked to him a number of times about that idea. It is im portant to point out that Hennessey House and other forms of supported accommodation are not gazetted under the Mental Healt h Act as appropriate places for involuntary admissions. Only Canberra Hospital is gazetted for involuntary admissions. That is, although Brian was directed in the Community Treatment Order to "reside as directed", even if he was "directed" to reside at Hennessey House, if he was not willing to go there on his own accord, then Hennessey House would refuse to admit him, and could not insist that he reside there or take part in any programme. The same applies to other forms of supported accommodation. This was another confusing thing about the CTO. The only place where he could literally reside as directed in the absence of his voluntariness was Canberra Hospital. However, to get Brian to go to Canberra Hospital, by contrast, would require a custodial treatment order and at this time there were no indicators Jf that he would meet the criteria for emergency Q,n and/or a custodial treatment order.

In this respect I agree with Dr Evans's statement at paragraph 35.

21. At the second meeting I recall Dr Evans deciding to make Brian's appointments with her six weekly instead of monthly due to his improved state. The levels of Clozapine tests were available at the meeting on 16 January 1997, but of course they corresponded to the levels taken as at 16 December 1996,on the previous visit, which correlated with his increased symptoms of thought disorder and so on. Generally I recall the meeting being fairly short and Dr Evans seemed well satisfied with Brian's progress.

22. Therefore, on the visit on 16 January 1997, I did not have his Clozapine levels but his mental state was certainly much improved.

23. Brian finally let me into his flat on 20 January 1997 and this was a very big step of progress in my association with Brian. He had not trusted me enough prior to then to let me in. I was therefore keen not to break down the rapport that was being established and I certainly would not have wanted to go rummagi ng or searching through his flat - I had no reason to. I asked

him if he was taking his medicat ion and he went away and come back and showed me he had some. He showed me a card of 10 x l 00mg tablets. At that stage I had last dropped off his medication on 14 January 1997 so it would be expected that Brian 6 days later would still have some Clozapi ne t here. I had no reason to believe that he was not taking it at all. At that stage my mai n concern was to hel p hi m wit h t he electricity which he had been complaini ng was not fixed and I also hel ped hi m clean the fridge. I agree that the flat was i n a terrible mess and that there was not much food in the fridge. However, it was not necessarily unusual for a patient with schizophrenia living in the community to have a flat in a mess and I do not believe the state was a bad as it was in the photos shown at the date of Brian's death.

Perhaps in retrospect I should have called Dr Evans at this stage. However, I truly believe that his merel y letting me into the flat was a great step forward in my relationship with Brian and I was very keen to ensure that the trust I seemed to have established by then was not breached by anything I did which would have been seen by Brian to be too intrusive. The state of the flat did alert me to the fact that he required some kind of home help as an interim measure. Without other factors it would not necessarily indicate a need to initiate hospitalisation. Brian while concerned about the electricity was otherwise fairly easygoing on that occasion and I was keen to ensure I did not do anything which would tead Brian to refusing entry to me on further occasions after this one. Also, by that stage I believed I was making more progress with the support of t he accommodation plan.

24. Certainly, after the 20 January 1997 meeting, Brian seemed accommodating to the idea of letting me organise someone to help him clean his flat.

25. In late January I told Brian about his friend Doug's death and the funeral because they had been friends and I thought Brian would want to know this. He seemed ambivalent about going to the funeral but I gave hi m that option and we left as soon as it seemed to make Brian depressed. He certainly did not tal k about his own suicide in any context and I assumed that he was simpl y grieving for his friend. There was al so no suicidal ideat ion in his conversation.

26. On 30 January 1997 I made furt her phone calls to possible sources of accommodation.

Richmond Fel lowship told me t hey had a six month waiti ng l ist, Willowview at Queanbeyan was only taki ng Queanbeya n resi dents but told me to send an application.

27. Shortly after that I re-contacted Hennessy House and arranged for a meeting with myself, Brian and charge nurse at Hennessey House for an assessment to get him in there. Initially I was told to wait until the CNC was back but I insisted that Brian be assessed.

28. On 5 February I 997, Brian fi nall y agreed to allow home help to come some time the next week to clean up his flat. As by this stage I had arranged the meeti ng at Hennessey House and Brian was agreeable to that idea, I only envisaged that the home help would be an interim thing before we got hi m into Hennessey House. That was another reason why I didn't take further action about the state of the flat.

29. The state of the flat on 20 January 1997 indicated to me that Brian needed help with his living skills - it did not necessarily indicate to me that he was suicidal or was not taking his Clozapine. I had no reason to believe that he was hoarding Clozapine and that therefore I should search the flat or put him on an emergency is iet1 and there were in fact not the f factors met for emergency s ien. I asked Brian to show me his medication and he showed me some tablets. He could tell me the correct number of tablets he was supposed to be taking per dose. Also, at this time Brian didn't appear to be disoriented in time or place, which would have alerted me to a possibi l ity that he was not capable of taking the correct dosage.

30. Had I been informed about the zero blood level of Clozapine I would then have been more concerned and suspect that a rapid decline woul continue rather than view it as a slight deterioration due to his apprehension and anxiety about someone coming to clean his flat, that he was very likely to be in Henessey House within the next 2 weeks, and wanting to talk with Dr Evans about things. I had on the last day of Brian's life ascertained that an earlier appointment with Dr Evans had been made, for the following Monday, and in view of this and of the what I believed to be imminent admission of Brian to Hennessey House, I had no reason to think that more urgent action should be taken, nor was I given any further information from Phillip Health Centre other than that Brian wanted an appointment with Dr Evans. At the time of his interview at Hennessy House, Brian was not showing any signs of suicidal ideation in conversation, no pa ranoid ideation, no pressured speech and no behaviours suggestive of suicid e. Whi le he was thought disordered, it appeared slight - that

is, there was no flight of ideas, and no ideas of reference (that is, things start to have special meaning like the TV is sending messages). There are different extremes of thought disorder and at this time his thought disorder was, I would say, mild. My reference in my police statement to Brian not being able to distinguish between a "therapeutic and a lethal dose" was made because the police officer who interviewed me kept pushing me to provide an answer to this question, and I therefore said he may not have been aware. I did not mean that that was any more than a mere possi bi l ity.

31. On 10 February 1997 I recorded that Brian had thought disorder and some agitation.

However, I expected there to be some agitation because of the planned changes in relation to home help and his pending visit to Hennessey House. It seemed to be more to do with expected apprehension about these factors. As other people caring for Brian have said, he was extremely independent. It was a big task to get him the point of being favourable to any outside help, let alone supported accommodation.

32. On 13 February 1997 we spent a long time at Hennessey House and had a long interview with the CNC, Steve Harper, and showed Brian around. He said he remembered it from his previous time there and we sat around and talked for quite a while and Brian said he was quite agreeable to getting in there if he was accepted. I spent about two hours there with Brian. This seemed a big breakthrough to me and there was still no suicidal ideation or anything else that would cause me concerns in that regard in Brian's demeanour. I could see by the time of this visit to Hennessey House that Brian was really trying to co-operate with his treatment.

33. Since Brian's death and in view of the inquest I have been very distressed about the whole thing and I am currently off on sick leave due to the impact of the Inquest. I have gone over in my head many times my role in looking after Brian Duff and I would like to say the following about it:

34. I did on several occasions not only ask Brian what the dosage was but also made sure that he knew how many tablets to take, to take the correct dose of Clozapine.

35. Dr Evans in her statement cites an excerpt from a Staff Training Manual. I disagree with the paragraph in Andrew Tock's submissions at paragraph 2.3 in relation to the Staff Orientation Manual of ACT Health Services. The extract at annexure G does not say anything so specific as to the role of a case manager. It simply makes a broad statement that the IRT "provides assertive case management and domiciliary and community treatment services to a maximum of 40 people" and "coordinates their rehabilitation program through goal setting and regular reviewing of progress . .. ". This statement provides absolutely no guidance as to how that supervisory role is to be exercised in practice, especially in the case of an independentminded person such as Brian Duff.

36. I am well aware of the criteria i n t he Mental Health Act for emergency action. That criteria amongst other things states that emergency action should only be taken if the person cannot be managed in a "less restrictive environment". It is therefore a fairly strict test for when somebody can be admitted in emergency circumstances.

37. The big difficulty for nurses like myself working in the field and with patients who are on community treatment orders is to do with the lack of guidance in the legislation or from Mental Health about what we do when somebody on a community treatment Order refuses to accept some or all of our supervision. There is nothing to guide us as to how much coercion we use if they refuse, for example, to take their medication or to reside as directed. It seems to be a big grey area, which causes mental health nurses a lot of anxiety as to how far they can go. We are well aware of the need to let people like Brian have as much autonomy and independence as they wish to, but there is a tension between that and not jeopardising their treatment and mental health.

38. In similar cases I have sometimes asked the Mental Health Tribunal for an order that as part of the Community Treatment Order, the Tribunal allow a patient to be admitted to hospital for the purposes of giving them their medication if they miss more than one day's dose.

However the Mental Health Tribunal has refused to make such an order because that would constitute a custodial treatment order, even though only temporary, and for a person to get a custodial treatment order they would need to have met the factors for custodial treatment in the Mental Health Act which I said before is fairly narrow.

39. Therefore, there is a big grey area as to how much coercion is legal or possible with patients who fall between these two areas for legal i ntervention. Where there is partial acceptance of our supervision, not total, we simply do not have the ability to order even partial forced treatment, nor would we necessarily want to. Even the wording of a CTO such as that made for Brian, that a person "accept the supervision of the IRT", shows that it is not clear what is supposed to happen if a person does not accept that supervision willingly or at all.

40. In view of all these above things, I am terribly upset about the death of Brian Duff but I feel in terms of my case management, I am not sure what else I could have done given the above circumstances.

DATED this day of 1998.

. .. '.

DON WTI.,SON