Inquest into the death of Massimo SUKLAN

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Massimo SUKLAN Hearing dates: 15-16 December 2014 Date of findings: 16 December 2014 Place of findings: NSW State Coroner Court – sitting at Walgett Local Court Findings of: Magistrate Michael Barnes, State Coroner Catchwords: Coronial Law- Drug overdose File number: 2013/212311 Representation: Sgt Paul Bush assisting the NSW State Coroner , Magistrate Barnes

Findings: Identity of deceased: The person who died was Massimo Suklan Date of death: Mr Suklan died on 11 July 2013 Place of death: He died at Nebia Hill Opal Field, Lightning Ridge.

Cause of death: Mr Suklan’s death was caused by opiate toxicity.

Manner of death: The circumstances under which Mr Suklan ingested the drug that led to his death are not able to be ascertained.

Table of Contents

The Coroners Act 2009 (NSW) in s81 (1) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death.

These are the findings of an inquest into the death of Massimo Suklan Introduction Shortly before 10.00pm on the evening of 11 July 2013, Mark Suklan entered the Emergency Department of the Lightning Ridge Hospital and told staff he thought his father, who was in a car outside, was dead. That was quickly confirmed and police were called.

Mark Suklan told the officer who responded he did not know why his father may have died. When the officer found a needle stick injury with an associated smear of dried blood on the anterior surface of the deceased’s left forearm, and another blood smear on his right hand she became suspicious that the death may not have been due to natural causes and detectives were called to the hospital.

The autopsy indicated that Massimo Suklan had died from morphine toxicity.

The Issues In all inquests the coroner must try to establish the identity of the deceased, the date, place, medical cause and the manner of the death. In this case, only the last of these – the manner or circumstances in which the death occurred is in doubt. In particular, who supplied the morphine that seems to have killed Mr Suklan, who injected it and when the death was first actually discovered.

The evidence Social history Mr Suklan was born in Italy and immigrated to Australia with his parents in 1955 when he was 3 or 4. The family lived in Camperdown in Sydney. Young Massimo, or Max as he was called, had a relatively normal childhood and after leaving school he trained as a mechanic and worked in the family business.

He began using marihuana in his late teens and seems to have continued using it throughout his life. This created tension between him and his father but the family business was nonetheless left to Max when his father died in 1989. The business soon failed and Max had to obtain employment elsewhere. It seems he worked in a variety of semi—skilled roles but didn’t settle in any of them.

Findings in the Inquest into the death of Massimo Suklan

He remained living in a house owned by his parents but was forced to leave in about 1997 when his mother become dissatisfied by his failure to maintain it as agreed. His sister said that when she was cleaning the house she found unused hypodermic syringes. His medical records contain reference to his telling a doctor that he used heroin about 25 years ago.

In the decade before his death, he was estranged from his only sibling, a sister 10 years his junior, and his mother.

Mr Suklan was twice married and had a child with each wife but did not maintain contact with the children when he separated from their mothers.

For 1984 onwards, Mr Suklan was charged with a variety of criminal offences involving dishonesty and traffic.

The evidence before the inquest does not establish when he moved to the opal fields near Lightning Ridge but his closest friend from the miners’ camp said he had been there for at least 10 years when he died. His first court appearance in the locality was in 2000. Apart from a few driving matters, he was not charged with any criminal offences after moving to the region.

His closest associate in the years preceding his death, Kevin Moore, told the inquest that Mr Suklan lived at a number of locations on the opal field in what are referred to as miners’ camps. At the time of his death he was living in a caravan situated on another person’s claim. There were no shower or toilet facilities, nor electricity. It was clearly a very rough life style. Mr Moore said Mr Suklan used to come to his camp most days to use the facilities and to relax in the relative comfort of his camp.

Medical History Mr Suklan was seriously injured in a motor vehicle crash in 1978. His injuries included head trauma. Soon after the crash, he was diagnosed with schizophrenia which he attributed to the head injuries.

In 2002, Mr Suklan sought and received assistance from the Lightning Ridge Drug and Mental Health Service. That continued up until his death.

He was treated by staff of the service for schizo affective disorder. At the time of his death that treatment included a monthly injection of Paliperidone given intramuscularly, in his deltoid region.

Mr Moore told the inquest that periodically, Mr Suklan’s mental state would deteriorate with symptoms that resembled paranoid schizophrenia: ―Sometimes he’d think people were after him and he’d go bush. I’d go and round him up and take him into town to see the mental health people.‖ Mr Moore said.

Findings in the Inquest into the death of Massimo Suklan

Mr Suklan’s mental health case manager, Peter Collinson, told the inquest that Mr Suklan’s irascible manner made other welfare service personnel so wary of him that they refused to deliver meals or transport him into town. Mr Collinson assumed many of these roles which he said enabled him to better establish a rapport with Mr Suklan and thus provide treatment to him, in particular his depot injections. Mr Collinson also said that Mr Suklan’s general health was very poor and he refused to seek appropriate treatment for his numerous ailments. He suffered from liver disease, hepatitis and heart disease. He suffered chronic pain as a result of the car crash referred to earlier.

On a number of occasions Mr Suklan was admitted to a mental health facility in Orange for extended in-patient treatment.

Mr Collinson, who has lived and worked in mental health care in the Lightning Ridge area for 20 years, told the inquest that illicit drug use was so widespread in the region that it was the norm. In his experience, there was a ready supply of prescription and other drugs in the area.

Mr Moore said Mr Suklan regularly smoked marihuana but he was not aware of him using other illicit substances.

Events leading to the death Mr Suklan’s older child, Mark, who was born in 1974, had no contact with his father after his parents separated until about 2011 when his father tracked him down in Perth.

In recent years he had been living in Western Australia where he had a partner and young child. In 2012, Mark Suklan came to Sydney looking for work. He told police it was his intention for his family to join him if/when that occurred.

In December 2012, Mark Suklan was convicted of serious driving offices and sentenced to a term of imprisonment which he served at Muswellbrook Correctional Centre. During his sentence he continued contact with his father via letter and telephone calls. On his release on 21 June 2013, his father drove to Muswellbrook, collected Mark and brought him back to the mining camp near Lightning Ridge.

The inquest did not receive evidence about how this came about or what was planned in the longer term because Mark Suklan cannot be located.

All evidence about what happened during Mark’s stay at the mining camp came from Max Suklan’s friend Kevin Moore.

He told the inquest that because Max’s camp was so lacking in amenities, he agreed to Mark staying in his camp as he had a caravan he was not using where Mark could sleep.

For the next couple of weeks the routine of the three men was apparently fairly consistent: Mark Suklan and Kevin Moore slept at the latter’s camp; Max Suklan slept in his own camp but came to Mr Moore’s camp mid-morning and spent the day Findings in the Inquest into the death of Massimo Suklan

socialising with his son. It is not clear how they passed the time, other than Mr Moore’s evidence that they tinkered with motors on the various vehicles strewn around his camp site. They regularly drove into Lightning Ridge to buy food and alcohol.

The day of the death July 11, 2013 started in accordance with this routine. Mr Suklan came over to Mr Moore’s camp at about 10.am. After an hour or so Mr Moore went into Lightning Ridge and Mark Suklan went with him. Mr Moore says they were in town for a couple of hours and then met up back at his car and drove back to the camp. He was unable to say what Mark did during the time he was in town.

Mr Moore said he went into the bus in which he sleeps soon after lunch and lay there reading throughout the afternoon.

He says he could hear the Messrs Suklan conversing and laughing in the shed-like structure that partially enclosed the caravan and bus. He said he noticed nothing out of the ordinary during this period.

He said that on one stage, he saw Mr Suklan sleeping in a lounge chair, but thought nothing of it as he often dozed in the afternoon.

Mr Moore said that between 5.00 and 6.00pm, Mr Suklan left to go back to his camp.

He said that he recalls Mr Suklan calling out to him as he left.

In his police interview undertaken on the day of the death, Mr Moore said: Between an hour or so, (sic) Mark went outside to talk to his girlfriend.

Mark then returned to my house and told me that dad is dead.

He went with Mark Suklan to where Max routinely parked his car about 10-15 metres from the shed. He saw Mr Suklan sitting in the passenger seat of his car. His seat belt was on. He was obviously dead.

In his first police statement, he said after finding Mr Suklan dead, “15-20 minutes later, I decided to bring him to the hospital” At the inquest he was questioned about the reason for the delay. He could not explain it. He denied he and Mark Suklan discussed what might have cause the death. He said he wasn’t curious and had no reason to ask. He denied seeing Mark dispose of any drug paraphernalia.

Mark Suklan and Kevin Moore drove the deceased Max Suklan to the Lightning Ridge Hospital. They arrived there at about 9.40pm. At their request a nurse came out to the car, looked at Max Suklan and confirmed he was dead. In view of the circumstances, police were called.

Findings in the Inquest into the death of Massimo Suklan

The investigation Initial police response When the first response officers arrived, the senior of them, Sergeant Bradbury, inspected the car, Mr Suklan’s body and spoke to Mark Suklan and Mr Moore. She observed that Mr Suklan was wearing a long sleeved jacket and a long sleeved shirt.

When she spoke to the two men, they told her that they thought Mr Suklan had left Mr Moore’s camp when he said goodbye to them and walked towards his car at about 5.30pm.They claimed that when Mark Suklan went outside to get better reception on his mobile phone at about 9.30, he was surprised to see his father’s car where it had been parked all day and alarmed to find Max Suklan in it, dead. He confirmed the identity of the dead man.

Sergeant Bradbury immediately became suspicious about the versions given to her and attempted to have a scene of crime officer and detectives attend. She was unsuccessful.

She caused Mr Suklan’s body to be taken into the hospital mortuary. She systematically removed the clothing and examined the body. She found a smear of blood on the anterior aspect of Mr Suklan’s left forearm and what appeared to be a fresh puncture wound near it. She also found a smear of blood on the palm of Mr Suklan’s right hand. Sergeant Bradbury’s experience in dealing with intravenous drug users caused her to examine other sites on the body for signs of injecting, with negative results.

This new information heightened the officer’s suspicions and so she again contacted the on-call detective and a crime scene officer. Both again refused to attend.

Accordingly, she contacted the on-call duty officer who directed detectives to attend.

In the meantime, Sergeant Bradbury had caused Mr Suklan’s car to be searched.

Nothing of significance was found.

After having her request to have the vehicle towed to the local police holding yard declined, Sergeant Bradbury was directed to drive it there herself.

Scene examination Before Sergeant Bradbury left the hospital detectives Hutchinson and Innes took up with her there and acquainted themselves with what she had discovered to that point. They then took Mr Moore and Mark Suklan back to the opal field’s camp where the death had occurred. There they searched Max Suklan’s camp and Mr Moore’s camp. They did not find anything of relevance to this investigation.

Findings in the Inquest into the death of Massimo Suklan

Ongoing investigations A few days after the death, Sergeant Bradbury contacted the Department of Forensic Medicines at Newcastle where an autopsy had been performed on Mr Suklan’s body.

She was told that no cause of death had been found. Over the next few days she tried to contact Mark Suklan to advise him of the autopsy results but was unable to do so. About a week after the death, he attended the police station and told Officer Bradbury that he wanted to take possession of his father’s car and mobile phone.

This request was denied on the basis that those items had relevance to the on-going coronial investigation.

In August or September 2013, Sergeant Bradbury was advised of toxicology results of blood taken from Mr Suklan at autopsy which indicated he had died from opiate toxicity.

In September 2014(sic) Sergeant Bradbury attended Kevin Moore’s camp where Max Suklan had died, in relation to another matter. He mentioned the death and told the officer Mr Suklan had taken morphine on the day of his death He also said; “Mark gave it to him. He got it for him.” When asked why he hadn’t volunteered this information at the time of the death or in the days immediately after, Mr Moore claimed he was scared that Mark Suklan might do him harm.

At the inquest, Mr Moore confirmed that Mark Suklan had told him he had got morphine for his father, but continued to deny that he saw them using any drugs or that he saw Mark Suklan dispose of any drug paraphernalia. He also continued to assert that Max Suklan had gone to his car at about sunset and they had been surprised to find him some hours later.

Mr Moore also denied colluding with Mark Suklan to repress evidence about the circumstances of his father’s death.

It is believed that Mark Suklan returned to Western Australia sometime after his father’s death. Inquiries made with police in that state failed to locate him. The officer in charge was advised that warrants for his arrest were current in Western Australia.

Accordingly, he could not be located to give evidence at the inquest.

Autopsy results On 17 July 2013, an autopsy was conducted on the body of Mr Suklan by an experienced forensic pathologist at the Newcastle Department of Forensic Medicine.

An examination of the external surfaces of the body located a number of small puncture marks on the anterior left forearm overlaying a small vein. No other injuries or signs of trauma were located.

Findings in the Inquest into the death of Massimo Suklan

An examination of the internal cavities and organs of the body disclosed no abnormalities or diseases sufficient to explain the death.

Toxicology results became available in August 2013. They showed no alcohol, but metabolites of the active ingredients of cannabis and significant quantities of morphine and its metabolites were found.

Conclusions Mr Suklan suffered from a number of serious physical and psychiatric illnesses.

His lifestyle no doubt exacerbated these problems, in that he lived in very primitive conditions that were unhygienic and uncomfortable and he regularly smoked marihuana, possibly to lessen the pain of old trauma injuries.

The autopsy report indicated that he died from opiate toxicity. I accept this evidence.

It is clear that Mr Suklan must have ingested the drug while in the camp of his friend Mr Moore on the afternoon or evening of the day he died. Mr Moore claims not to know what went on in his camp in the hours before the death was discovered because he was inside the bus in which he sleeps and could not see the deceased.

I doubt this is true.

The account given to police at the time of the death is incongruous: Mr Suklan would not have gotten into the passenger seat of his vehicle if he was about to drive himself home as claimed by his son. Nor is it likely that the other two men would not have noticed his car had not moved for some hours after he had apparently told them he was leaving, when it was only parked some 10 to 15 metres from the open shed-like structure in which Mark Suklan was seated.

Mark Suklan allegedly told Mr Moore in the days following the death that he had given his father morphine on the day he died. The use of the drug is consistent with the toxicology results but the allegation that Mark Suklan had given it to his father could not be put to Mark Suklan because he cannot be located. Mr Moore did not make the claim until more than a year after the death when the toxicology results may have already been made known to him.

Further, Mr Moore is not a reliable witness in that he has given a number of inconsistent versions as to what happened on the night in question; he has given accounts of the relevant period that I find difficult to believe and he clearly has some animus for Mark Suklan.

I conclude I am unable to be sufficiently certain of the source of the opiates found in Mr Suklan’s post mortem blood or the circumstances in which he came to ingest it.

Findings in the Inquest into the death of Massimo Suklan

Findings required by s81(1) As a result of considering all of the documentary evidence and the oral evidence given at the inquest, I am able to confirm that the death occurred and make the following findings in relation to it.

The identity of the deceased The person who died was Massimo Suklan Date of death Mr Suklan died on 11 July 2013 Place of death He died at Nebia Hill Opal Field, Lightning Ridge Cause of death Mr Suklan’s death was caused by opiate toxicity Manner of death The circumstances under which Mr Suklan ingested the drug that led to his death are not able to be ascertained.

I close this inquest.

Magistrate Michael Barnes State Coroner Walgett, NSW 16 December 2014 Findings in the Inquest into the death of Massimo Suklan