Inquest into the death of Louis NAUMOVSKI

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Louis Naumovski Hearing dates: 7 March 2017 Date of findings: 7 March 2017 Place of findings: State Coroners Court, Glebe Findings of: Magistrate Teresa O’Sullivan, Deputy State Coroner Catchwords: CORONIAL LAW – Cause and manner of death Unascertained File number: 2014/372505 Representation: Sergeant Durand Welsh, Sergeant Assisting Findings: Identity of deceased: The deceased person was Louis Naumovski Date of death: Mr Naumovski died between 25/11/14 and 18/12/14 Place of death: He died at 5/27 Church Street, Balmain Manner of death: Unascertained Cause of death: Unascertained

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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 disappearance and suspected death of Louis Naumovski.

REASONS FOR DECISION Introduction: This inquest concerns the death of Louis Naumovski. Mr Naumovski was found deceased at his home by police on 18 December 2014. He was 59 at the time of his death. The manner and cause of his death were not able to be ascertained at autopsy, largely due to the level of decomposition. The police brief was tendered at the inquest. The officer in charge, Senior Constable Vanderwee, was the only witness.

The Inquest: Section 27(1)(d) of the Coroner’s Act 2009 legislates that an inquest “is required to be held...if it appears to the coroner concerned that the manner and cause of the person’s death have not been sufficiently disclosed”.

The purpose of the coronial jurisdiction, according to law, is to make formal findings as to the following five aspects of a death:

• the identity of the person

• the date of their death

• the place of their death

• the manner of their death

• the cause of their death.

Guided by these five aspects, an inquest investigates the facts and circumstances of a death, places them on the public record, and in certain cases will examine changes that could be made to prevent similar deaths in the future.

The cause of death has not been sufficiently disclosed and there is some question over the manner of death. As such, in this case, an inquest is mandatory on the issues of manner and cause.

Section 81 (1) of the Coroners Act 2009 (NSW) requires that when an inquest is held, the coroner must record in writing his or her findings. These are my brief findings in relation to the suspected death of Louis Naumovski.

Findings in the Inquest into the death of Louis Naumovski

The Evidence: Background: Mr Naumovski was born on the 24 September 1955. He was 59 years old at the time he was discovered by police on 18 December 2014. Mr Naumovski did not have any children and was not married at the time of his death.

Louis NAUMOVSKI had a difficult upbringing. His childhood, according to his sister Diane GRUZDANOVSKI, was spent in a household where alcoholism and domestic abuse were commonplace. “He was a gentle soul,” she says, “and all of that affected him emotionally.” At the age of eighteen he married. When the marriage ended 12 months later, Diane believes the distress was so great that he never fully recovered. He told Diane that he never stopped loving Louisa, his ex-wife.

In 1980, when Louis’s father passed away, he was residing in England. He then returned to Australia and helped care for his dependant mother.

Later, he moved to Thailand for a period, before returning again to Australia. At some point, he became a heavy user of drugs and alcohol. He also attempted suicide on several occasions. Police electronic holdings reveal three previous selfharm incidents. These occurred on the 29 January 2014, 23 October 2010 and 23 December 2009. Diane states that by the end of the 80’s or 90’s he had attempted suicide on seven or eight occasions and that wrist cutting and overdose were his two preferred methods.

After his mother died, Louis struggled with his moods and with drug and alcohol abuse. These problems eventually alienated him from his sister Diane, but she continued to call him via phone.

The discovery of Mr Naumovski’s body: Around 9:30 a.m. on 18 December 2014, police attended Mr NAUMVOSKI’s residence at 5/27 Church Street, Balmain, after a call from a neighbour that Mr NAUMOVSKI had not been seen for three weeks. Police noticed an odour in the area and the fire brigade subsequently attended to force entry.

Mr NAUMOVSKI was located deceased in the bedroom of the small unit. He was on his back on the bed, with one leg propped up. A pedestal fan was at the foot of the bed, blowing directly onto him.

Findings in the Inquest into the death of Louis Naumovski

Police located an empty Durogasic fentanyl five-pack container in the rubbish bin with three used wrappers. The fentanyl was prescribed by Dr ZELTZER and dated the 25 November 2014. The dosage on the wrapper is one patch per three days.

Police located what appeared to be Mr NAUMOVSKI’s diary on the living room table.

The author of the diary has written that he is allergic to fentanyl. Also on the living room table was a Woolworth’s gift card and associated receipt. These were from Woolworths on Darling Street, Balmain, and the receipt was dated 20:46 on the 25 November 2014.

A handwritten letter to Dr Jonathan BRETT was also on the table. It is signed with Louis NAUMOVSKI’s name, but is undated. The letter thanks Dr BRETT for his assistance and at the end mentions that Mr NAUMOVSKI intends returning to Thailand. The letter is not completely coherent and rambles across topics, so its reliability as to Mr NAUMOVSKI’s future plans is questionable.

Due to the level of decomposition, the identity of Mr Louis NAUMOVSKI was confirmed via fingerprints. An expert statement from Karen HALBERT from Fingerprint Operations is contained within the brief of evidence and confirms his identity.

Mr NAUMOVSKI’s place of death is likewise straightforward. There is no evidence suggesting he died anywhere other than where police located him: 5/27 Church St, Balmain.

Date of death: Regarding the date of Mr NAUMOVSKI’s death, statements were obtained from several neighbours: Beryl KNIGHT, Peggy GREEN and Nerida BRANSBY. None of them were able to accurately recall when they had last seen Mr NAUMOVSKI alive.

However, BRANSBY and GREEN both state he was not around for a period of time leading up to 18 December 2014. BRANSBY states she “didn’t see him for a while.” GREEN states, “I had not seen him for five or six weeks prior to his death.” KNIGHT recalls seeing him “around November 2014” while putting out rubbish.

Relevant to the manner of death, KNIGHT states that on this occasion he said, “I will not be here by Christmas.” Her statement made on 11 May 2016 suggests that she did not take this as a reference to suicide, although her precise opinion on this point is open to interpretation. In that statement she says: “I knew what he meant. He wasn’t eating.

He was going to hospital to get fed.” However, in her conversation with Constable VANDERWEE on the 18 December 2014, she states that she believes Mr NAUMOVSKI’s comment was a reference to one of his previous suicide attempts.

Findings in the Inquest into the death of Louis Naumovski

She also states that when she saw him in November 2014, “He looked so unwell.” She did see him on a later date, being a Sunday, but neither the month nor date is disclosed within her statement.

In her statement, KNIGHT states that on the last Monday of November before she went into hospital, Mr NAUMOVSKI tried to borrow $40 from their butcher. She was in hospital for two weeks in December 2014. The last Monday of November 2014 is the 24 November 2014.

The last disclosed contact with Mr NAUMOVSKI before his death was a phone conversation between him and his sister Diane on the 24 November 2014. As a result of this conversation, Diane deposited $50 into his bank account. Constable VANDERWEE has confirmed via St George bank records that Mr NAUMOVSKI’s account shows a $50 deposit on the 24 November 2014. This $50 amount is withdrawn from his account at 11:28 a.m. on the 24 November 2014.

The 25 November 2014 date on the fentanyl packet located at Mr NAUMOVSKI’s residence is strong evidence he was alive on this date. The Woolworths gift card and receipt dated 20:46 on the 25 November 2014 corroborates the evidence he was alive on the 25 November 2014.

When asked if Mr NAUMOVSKI’s state of decomposition assisted with narrowing the date of death, the pathologist who conducted the autopsy, Dr POKORNY, responded that variables such as temperature made this too difficult.

On the evidence before me, I am not able to ascertain the exact date of Mr Naumovski’s death. I find that he died between 25 November, 2014 and 18 December 2014.

Cause of death: Mr NAUMOVSKI’s decomposition also hindered Dr POKORNY in finding a cause of death. Dr POKORNY states that the cause of death was unascertained after autopsy, “likely due to the obfuscating effects of decomposition.” Toxicology tests revealed alcohol, THC, multiple benzodiazepines, and the opiates fentanyl and paracetamol. The tests were conducted on splenic blood, as decomposition prevented peripheral blood sampling. Although the fentanyl level detected was similar to those reported in peripheral blood in fentanyl overdoses, no data is available for corresponding concentrations in the spleen. Fentanyl is also subject to significant post-mortem redistribution, further rendering impossible an interpretation of the splenic blood samples that would clarify the fentanyl’s contribution to cause of death.

Findings in the Inquest into the death of Louis Naumovski

Regarding the drugs detected in the toxicology, Dr POKORNY states the following: “Although due to the suboptimal nature of the samples that could be obtained, the interpretation of these levels is not possible, it is noted that a number of these drugs have similar sedating effects and even at modest concentrations their effects in combination may be unpredictable and potentially toxic.” The autopsy also revealed coronary artery narrowing, which may have caused a “relative ischaemia”, particularly if the heart was enlarged. Decomposition, and the subsequent shrinking of the heart, prevented accurate knowledge of Mr NAUMOVSKI’s heart size during life. Dr POKORNY states: “In combination, the coronary artery narrowing and possibly cardiomegaly could have caused a sudden cardiac arrhythmia, with or without infarction (heart attack).” The lungs showed microscopic changes consistent with bronchopneumonia. Dr POKORNY states: “Development of terminal bronchopneumonia is in keeping with a period of obtundation [a greatly reduced level of consciousness] prior to death, as may be seen in deaths associated with sedative and opiate toxicity inter alia.” On the evidence before me, I am not able to ascertain the cause of Mr Naumovski’s death.

Manner of death: The fact that the cause of death is unascertained makes finding a manner of death even more difficult. Mr NAUMOVSKI may have died from an intentional overdose related to suicide, or from complications relating to an unintentional overdose, or from medical complications related to his heart or lungs.

No suicide note was located. The only relevant letter located was the one addressed to Dr BRETT, where Mr NAUMOVSKI expresses an intention to live in Thailand.

In her statement dated the 30 April 2016, his sister Diane states that during her call on the 24 November 2014 she detected no signs of suicidal ideation or low mood. To the contrary, she described his mood as “good”.

This is at odds with her conversation with Constable VANDERWEE on 19 December 2014, where Diane purportedly states that Mr NAUMOVSKI was angry at her for refusing to send him money. Similarly, on the 19 December she states to Constable VANDERWEE: “I know my brother. He killed himself. Just like his brother. Now they’ll be buried together.” Mr NAUMOVSKI’s mood is relevant in determining whether his death was suicide or accidental. However, it should be noted that the standard of proof is the Briginshaw v Findings in the Inquest into the death of Louis Naumovski

Briginshaw civil standard.1 The evidence should be “clear, cogent and exact” before a finding of suicide can be made on the balance of probabilities. It is likely the conflict between Diane’s statements makes it unsafe to use her evidence as a reliable basis for accurately assessing Mr NAUMOVSKI’s state of mind before his death.

If Diane’s statements are unreliable, there is no suggestion within the brief that this death is intentional. The formally typed statement taken on 30 April 2016 was taken 16 months after her verbal conversation with the officer in charge, and Diane’s recollection may have unintentionally changed.

Diane does express the opinion within her statement that Mr NAUMOVSKI’s niece, Violetta HRISTOVSKA, had spoken to him on the same day as her, that is 24 November 2014, and that the phone call may have upset him.

Violetta, in her statement, states that she does not recall the date of her last conversation with Mr NAUMOVSKI, but that during her last conversation he expressed how angry he was with Diane. He had told Violetta that he sent Diane a message telling her to “burn in hell.” Violetta states that Mr NAUMOVSKI’s mood on that day was the “same as always”, referring to his anger at Diane.

Medication: Relevant to the issues of manner and cause of death are the statements of two of Mr NAUMOVSKI’s treating doctors, Dr Stephen GIBSON and Dr Jonathan BRETT. Dr GIBSON states Mr NAUMOVSKI was a long-term patient of RPA Hospital, with admissions since 2000. Significantly, Dr GIBSON’s statement includes the following comments:

• In 2000 he was noted to be a “drug dependant patient” suffering chronic alcohol abuse. He was also suffering abdominal pain, which became an ongoing issue over the years.

• In 2001 he was admitted to the RPA inpatient psychiatry unit for depression.

He was again noted to be abusing alcohol. Frequent admissions for alcohol abuse related complications continued.

Dr GIBSON’s first contact with Mr NAUMOVSKI came on 6 June 2002, following Mr NAUMOVSKI’s referral to the RPA pain management centre. Dr GIBSON states that Mr NAUMOVSKI was depressed and was abusing multiple medications, including opioids, benzodiazepines, and alcohol. Dr GIBSON referred him to the Pain Service psychiatrist and advised that only slow release opioids should be used in Mr

1 (1938) 60 CLR 336 Findings in the Inquest into the death of Louis Naumovski

NAUMOVSKI’s care due to the “hazard of immediate release opioids in polypharmacy situations.” Mr NAUMOVKSI declined to attend the Pain Service psychiatrist and also ceased the sustained release opioids that Dr GIBSON recommended.

From approximately 2002 his abdominal pain was successfully managed with methadone and low dose amitriptyline. However, Mr NAUMOVSKI subsequently developed what Dr GIBSON describes as an “abuse pattern with regard to benzodiazepines.” In 2005 he was admitted to RPA for opioid and benzodiazepine detoxification. Later that same year he was again admitted, this time for illicitly using ketamine.

He was discharged from Pain Management Centre services on 21 February 2013 due to failing to attend scheduled appointments.

In February 2013 and June 2014, Mr NAUMOVSKI was admitted to ICU following insulin overdoses.

From October 2006 until his death in 2014, Mr NAUMOVSKI’s opioid prescribing was under the supervision of the RPA Drug Health Service. There, he came under the care of Dr Jonathan BRETT, who first met Mr NAUMOVSKI after what Dr BRETT recalls as an insulin overdose in 2012. At the time, Dr BRETT was an advanced trainee in addiction medicine under the supervision of Dr MURNION, an addiction specialist.

In 2014, Mr NAUMOVSKI came directly under the care of Dr BRETT, who became his prescriber for Suboxone (buprenorphine) in June 2014. Dr BRETT states that Mr NAUMOVSKI regularly failed to attend appointments and remained “ambivalent” about being on an opioid substitution program.

Dr BRETT formed the following impressions of Mr NAUMOVSKI during his time as his treating doctor:

• He was socially isolated.

• His isolation compounded his chronic pain and substance use issues.

• He had chronic dysthymia (depression in layman’s terms), personal vulnerabilities and was impulsive.

• He was ambivalent about treatment for his substance use disorder and had relatively poor engagement with the chronic pain team.

He continued to obtain prescriptions for benzodiazepines and was very guarded about this. Dr BRETT was in the process of trying to address this issue.

Findings in the Inquest into the death of Louis Naumovski

Dr BRETT states that Mr NAUMOVSKI denied “suicidal cognitions”. He initially took his Suboxone regularly, but his adherence steadily declined, and he did not attend his last scheduled appointment, stating over the phone that he no longer felt Suboxone was necessary. He was offered a further clinic appointment but declined.

Dr BRETT makes several relevant observations in his statement:

• Mr NAUMOVSKI suffered from opioid substance use disorder, which involved him obtaining opioids from GPs and also, reportedly, from illicit sources. While on opioid substitution programs with the Drug Health Service clinic, he had periods of poor engagement and would seek opioids, mainly OxyContin, from GPs.

He had a number of episodes of inpatient treatment at Concord Hospital for this disorder, but the last was several years before his death.

• Mr NAUMOVSKI suffered from an alcohol substance use disorder. Dr BRETT states, “He drank alcohol in a dependant pattern in the past but for the 2-3 years preceding his death this had turned into a heavy episodic pattern of drinking.”

• Mr NAUMOVSKI had made multiple self-harm attempts. Since at least the late 1980’s he had a history of taking intentional overdoses of his medicines, including antidepressants and insulin. Before his death, he had had extensive contact with Camperdown Community Mental Health.

Mr NAUMOVSKI’s clinical history is thus characterised by both non-suicidal overdoses and intentional self-harm attempts via overdose.

On the evidence before me I am not able to ascertain Mr Naumovski’s state of mind leading up to his death, nor the manner of his death.

Louis Naumovski: The coronial process can at times seem impersonal and it is worth remembering that Mr Naumovski’s sister remembers him as a brilliant salesman who sold computers and then real estate. For three years running he won a prize for best salesman at the real estate business where he worked. He was a man who was once married and in love, who excelled at his profession, and who cared for his ailing mother. Not long before his death he gave his sister a lovely framed photo of himself looking happy and healthy.

Part of the strength of our coronial process is that the death of a troubled, reclusive man such as Mr NAUMOVSKI is not forgotten. His passing is afforded the same scrutiny as any other person.

I offer his family my sincere condolences.

Findings in the Inquest into the death of Louis Naumovski

Findings required by s81(1) As a result of considering all of the documentary evidence and the oral evidence heard 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 deceased person was Louis Naumovski Date of death Mr Naumovski died between 25/11/14 and 18/12/14 Place of death He died at 5/27 Church Street, Balmain Cause of death Unascertained Manner of death Unascertained I close this inquest.

Magistrate Teresa O’Sullivan Date 7 March 2017 Findings in the Inquest into the death of Louis Naumovski