Inquest into the death of Scott Clements

STATE CORONER’S COURT

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OF NEW SOUTH WALES

Inquest in into o the death of Scott t Clements

23 October 2015

23 October 2015

State Coroners Court, Glebe

Magistrate Harriet Grahame, C Coroner

Coronial Law

“Brika Mulligan, Coronial Law Advocate - Advocate assisting

ithe Coroner

i i

On the balance of probabilities, I find that Scott Clements died between 19 August 2014 and 14 October 2014 at his home at 317/2-12 Glebe Point Road, Glebe

NSW 2037. The cause and manner of his death remains

unknown.

IN THE STATE CORONER’S COURT GLEBE

NSW

SECTION 81 CORONERS ACT 2009

REASONS FOR DECISION

This inquest concerns the death of Scott Clements.

Introduction

Scott was a year old 36 year old man who was living alone in the University Hall Apartments (317/2-12 Glebe Point Road, Glebe) at the time of his death. He had lived there for around 3 years. Scott had previously worked in retail and for a courier

company. At the time of his death he was off work due to a work injury.

He apparently enjoyed swimming and playing a keyboard.

Scott was reported to be attending a University preparation course at TAFE with the

hope of commencing a science degree in 2015.

Scott had a longstanding history of mental illness including severe depression, drug and alcohol issues and a chronic sleep disorder. He had made a number of documented suicide attempts.’ He had consulted psychiatrists and psychologists in relation to these issues and had tried various different prescription medications and therapeutic

approaches over the years.

Scott had a somewhat troubled family and relationship history’. At the time of his death

he was in irregular contact with his mother Beverley Clements. They would speak on

' See history taken at Camperdown Health Centre, Exhibit 1, Tab 41

? See for example Statement of Dr Tuon, Exhibit 1, Tab 40

3 See statement of Beverley Clements, Exhibit 1,Tab 1 also statements of Emily Clements, Kristy Harris, Paul Wendt, Exhibit 1

the phone every two months and see each very occasionally. He appears to have had sporadic or no recent contact with his siblings.’ He had a history of traumatic

relationship breakdowns.

At the time of his death Scott was socially isolated. The caretaker’ of his building stated that she never saw visitors or people with Scott. He appeared shy and withdrawn and

“kept to himself”.

The role of the Coroner

&.

The role of the Coroner is to make findings as to the identity of the nominated person, and in relation to the date and place of death. The Coroner is also to address

the issues concerning the manner and cause of the person’s death.®

Background

On 14 October 2014 Perry Calkin, an employee of Blue’s Point Real Estate, attended Scott's unit block in relation to rental arrears. He noticed that a quantity of mail had accumulated in Scott's letterbox and proceeded to knock on the door in an attempt to speak with Scott. When there was no answer, he used a key to enter the apartment.

Once inside he immediately noticed a foul smell and saw Scott sitting slumped behind a desk. He was fully clothed. As Mr Calkin approached he noticed bodily fluids beneath

the chair.’ It was immediately obvious that Scott was dead and police were called.

Initially police were concerned that Scott may have had a head injury as there appeared to be an amount of congealed blood and other bodily fluids gathered at the top of his head which looked like a wound. A crime scene was declared and but further

investigation allayed these early suspicions.

Police investigations revealed the last known sighting of Scott was on August 19 2014, when he attended Camperdown Health Centre for a menta} health review. Employees

of the unit block where Scott lived last remembered seeing him around the beginning

• See statements of Emily Clements and Kirsty Harris, Exhibit 1, Tab 3and 4 > See statement of Martha Andropoulos, Exhibit 1, Tab 5

® Section 81 Coroner's Act 2009 (NSW)

7 Statement of Perry Calkin, Exhibit 1, Tab ?

of August. It appears that Scott's rent had not been paid since August 11 2014. His real

estate agent stated that Scott always paid his rent on time.

Identification

12,

Scott’s body was taken to Glebe Mortuary. At a later time he was formally identified by

way of a finger print check.

The Autopsy

Scott's body was taken to the Glebe Mortuary where an autopsy was conducted on 16 October 2014.” The body was in an advanced state of decomposition, but the pathologist found no evidence of bodily injury. The “wound like” area identified by

police was confirmed to be part of the advanced decomposition process.

Internal examination revealed extensive post mortem organ decompositional changes on both macroscopic and histological examination. No pre-existing natural pathology

was identified.

Due to the extent of decomposition of the body, samples for toxicological analysis were limited to blood squeezed from the spleen. The Forensic Pathologist reported that the alcohol level found may have been wholly or partially attributable to post mortem fermentation. There were non toxic levels of Diazepam and its metabolites Nordiazepam, Oxazepam and Temazepam. There were also non-toxic levels of Morphine (free) and the anti-psychotic drug Quetiapine. However, the accuracy level of these results is somewhat questionable given the circumstances involved in analysis. It should be noted that methylamphetamine was also detected but levels could not be

ascertained.

Overall, a cause of death could not be determined, due mainly to the effects of bodily decomposition. The Pathologist did not offer an opinion as to the time of his death.

However, due to the discolouration of his skin and the advanced decomposition it can

be estimated that Scott had been dead a number of days, possibly weeks.

§ Statement of Merilyn Richards, Exhibit 1, Tab 31 ” Autopsy Report for the Coroner, Dr Issabella Bouwer. Exhibit 1, Tab 33

Investigations into Drug Use

At the time Police found Scott, it was clear that he had significant contact with drugs.

The unit had a small hydroponic system set up to grow Cannabis and large amounts of prescription medicines were found. On the desk he was sitting at was a used syringe, a water pipe or bong and some aluminium foil with a burn mark on the bottom.” There were also a large number of prescription medicines in blister packs, some empty and some containing pills and Cannabis seeds. Later, evidence was seized which suggests that Scott was purchasing prescription medicines on line and having them sent to his

home.!!

Evidence taken from Scott's medical records confirms a longstanding drug problem and establishes that Scott had recently sought medical advice about a recent relapse into drug use, including ice and prescription medication.'? He informed medical staff that he had previously tried Cannabis, LSD, MDMA, heroin, ice and that he had a habit of

abusing prescription drugs.

Investigations of Scott's Mental Health Issues.

19,

Scott had longstanding mental health issues. The medical records obtained by the Coroner outiine a number of documented suicide attempts over the years. His family

were also aware of these issues since his teenage.

Scott experienced some difficulty developing successful therapeutic relationships and his contact with one psychologist ended after she obtained an apprehended violence

order against him."?

A check of Scott’s recent medical records show that he had attended the Montrose Medical Practice on a regular basis since August 2010. He does not appear to have had any major physical illness aside his mental health concerns. He attended the practice twice in July and three times in August 2014. On 18 August 2014 he was referred to the

Camperdown Crisis Centre by psychologist Annabel Evans after expressing suicidal

" Statement of S/C Scarfo, Exhibit 1.

'! Statement of S/C Scrafo, Exhibit 1. See also the Australian Customs Seizure Notice attached to the statement.

'? Medical Records of Scott Clements, Exhibit 1, Tab 41

3 Statement of Amanda Symboluk, Exhibit 1, Tab 42

thoughts. He had apparently told Ms Evans that while he had a history of suicide attempts and he could guarantee his safety in the short term, he may still choose

suicide in the future.

He later told a member of the Crisis team that if things had not improved by January 15

2015 he would commit suicide and agreed to an appointment the following day.”

On 19 August 2015 Scott attended Camperdown Health Centre as planned. He reported that he had used Ice and Diazepam within the preceding 24 hours. He did not appear to be psychotic or thought disordered. He spoke about a number of stressors he was experiencing including social isolation, recent drug use relapse, insomnia and unresolved childhood issues. It is recorded that he did not appear to be suicidal and strongly denied immediate plans to self-harm or take his own life. He was described as

having some insight and was actively seeking further drug and alcohol treatment.

He expressed his loneliness and lack of social contact. He told staff the computer was “90% of his life, there is nobody else, - I could vanish for 12 months and nobody would

know ol3

The service made contact with his GP and anti-depressants and further therapy were to

be considered.

There is no evidence that Scott saw any medical practitioner after this appointment. In particular, he did not attend a scheduled appointment at Royal Prince Alfred Hospital Drug Health Service on 21 August 2014.

Did Scott commit suicide ?

27,

It is certainly possible that Scott took his own life. There is ample evidence of prior attempts and current despair. However in the circumstances of escalating drug use, it is also possible that his death may have been accidental. Without a note or other specific

indication, suicide is not established on the available evidence. While he had no known

'4 See medical Records at Exhibit 1, Tab 41 '5 Mental Health Assessment documents, 19/8/2015. Exhibit 1, Tab 39

physical ailments, the advanced decomposition of his body means that natural disease

or accidental death cannot be ruled out.

Findings

28. On the balance of probabilities, I find that Scott Clements died between 19 August and 14 October 2014 at his home at 317/2-12 Glebe Point Road, Glebe NSW 2037.

The cause and manner of his death remains unknown.

1 offer my sincere condolences to his family GU Mihir

Magistrate Harriet Grahame Deputy State Coroner