Inquest into the death of Margaret Rose CARR

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Margaret Rose Carr Hearing dates: 15 February 2019 Date of findings: 15 February 2019 Place of findings: State Coroners Court, Lidcombe Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: Coronial Law; cause and manner of death File number: 2017/00065513 Representation: Mr Peter Bain, Coronial Law Advocate (Sergeant) – Advocate assisting the Coroner Findings: On the balance of probabilities, I find that Margaret Carr died between 27 February 2017 and 1 March 2017 at her home address, 725/55 Walker Street, Redfern. The cause and manner of her death remain unknown.

Non-publication order Photographs contained in Exhibit 2 contain sensitive images and are not to be published or released.

These findings have been written without the benefit of a transcript

IN THE STATE CORONER’S COURT GLEBE NSW SECTION 81 CORONERS ACT 2009 REASONS FOR DECISION

1. This inquest concerns the death of Margaret Rose Carr.

Background

2. Margaret was 62 years of age at the time of her death. She was born on 5 July 1954 to George and Amy Carr. She had three brother and two sisters and spent her childhood in Melbourne and Tasmania.

3. Unfortunately, Margaret developed a substance abuse issue in her teenage years. She gave birth to her only daughter, Lisa, when she was a young woman. Later she left the family home and Lisa was raised by her grandparents.

4. Margaret appears to have become estranged from her family in the following years. She lived in the inner city and Kings Cross area of Sydney.

5. Margaret eventually reconnected with her daughter, Lisa. They lived together for a time in the Redfern/Waterloo area. Lisa indicated that Margaret continued to struggle with a drug problem, mainly heroin and cannabis. This led to a somewhat strained relationship and eventually Lisa moved out. Although Lisa tried to maintain a relationship with her mother, there were long periods where the two did not have any contact.

6. The last time that Lisa saw her mother in person was in April 2016. They remained in fortnightly phone contact until around November 2016. Lisa tried to call her mother at Christmas 2016, but was not able to make contact. Lisa reported that the last time she spoke to her mother, Margaret sounded unwell and was wheezing.

7. Lisa attended her mother’s inquest and described Margaret as a bit of joker who loved reggae music. She had struggled with drugs but had a pleasant, friendly side to her personality. She cared deeply for her part dingo dog, Ziggy and had made good friends in her local community.

8. Unfortunately, Lisa was not contacted until well after her mother’s death. While there were some attempts by the NSW Police to locate her, they were unsuccessful. Lisa found out by chance when she came to visit. It must have been a terrible shock. I offer Lisa my sincere personal condolences. I thank her for her attendance at this inquest.

The role of the Coroner

9. 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 make findings in relation to the manner and cause of the person’s death.

Medical History

10. Margaret had a complex medical history and suffered from a variety of chronic conditions.

She had been diagnosed with chronic obstructive pulmonary disease, endocarditis, a tricuspid murmur, hepatitis C, asthma, osteoarthritis and cognitive impairment. She had been a long term drug user and had been on the methadone program sporadically over the years, most recently recommencing treatment in 2015. She was known to suffer certain psychological conditions and had been described as a hoarder. She may have experienced undiagnosed or untreated depression and anxiety over many years.

11. Margaret’s GP1 confirmed that she was prescribed a number of medications. She also stated that Margaret was not always compliant with investigations and treatment that she had been advised to undertake. Lisa confirmed this opinion.

1 See medical records of Dr Tjandra and statement of Senior Constable Matthew Robinson, Exhibit 1 [2127]

12. Margaret had been advised to have a lung function test in August 2016, however she failed to attend. Margaret last attended her general practitioner on 15 February 2017 where she was prescribed antibiotics for a urinary tract infection. Coughing and wheezing was also noted.

Prior Concerns for Margaret’s welfare

13. Margaret had been a social housing tenant since 13 July 19872. Lisa remembered her mother as previously clean and house-proud. She told the court that she felt the change in her mother may have been connected with developing mental illness. By the time of her death, Margaret’s difficulties with hoarding were well known and she had real challenges maintaining her home in an appropriate manner.

14. In 2005 Margaret was offered a transfer due to the poor condition of her property. She was offered a smaller property that was thought would be easier for her to maintain. The Brown Nurses (Sisters) provided her with assistance and a senior tenancy specialist from the Department was involved in her relocation. This tenancy lasted five years, but also ended in termination.

15. Margaret’s next tenancy with Housing NSW was the property where she died in Redfern. It was a ground floor unit. Margaret built a close circle of friends in the area and had the companionship of a small dog, Ziggy to whom she was devoted.

16. A water leak at Margaret’s property brought her to the attention of the tenancy team and Redlink, a Department of Family and Community Services funded multi-service centre that operated locally. The purpose of Redlink is to connect residents with security, health and legal services, as well as conduct activities aimed at addressing social isolation, crime prevention and personal wellbeing. Workers became concerned about the conditions Margaret was living in and strategies to assist and support her were developed.

17. In September 2015, the Redlink team applied for Margaret to take part in the Hoarding and Squalor Intensive Treatment Plan (HSIT) through Mission Australia. This plan was specifically designed to address the physical, cognitive and psychological factors which might contribute to the squalor and compulsive hoarding. The HSIT continued to monitor Margaret and offer her practical assistance over the next nine months. Unfortunately when 2 Statement of Stuart Trembath, Exhibit 1, page 67

the program ended in June 2016, Margaret appeared to regress and once again have severe difficulties managing her household.3 She became difficult to engage with and refused some offers of help.

18. On 24 January 2017, NSW Police had been called to check on Margaret. Her neighbour was concerned that she had not been seen for 24 hours and reported that this was unusual.4

19. Police investigations revealed that Margaret was alive. However, police were sufficiently concerned about her unhygienic living conditions to report the matter to Housing NSW.

Police were informed that Margaret had been moved previously because of the condition of her unit. Constable Grant was particularly concerned about rotting food and rubbish, vermin and insects as well as human waste and urine. He stated that rubbish was piled so high that police were barely able to walk on the floor.

20. As a result of this report Redlink and other services were contacted. Inquiries were again made with a variety of agencies that might be able to assist Margaret.5 Margaret asked for a few weeks to commence clearing rubbish before accepting further help from the Salvation Army. She committed to clearing out two wheelie bins a day. More regular contact with the Redlink service also recommenced at this time.

The events leading up to her death

21. On 27 February 2017 Margaret attended the local Housing NSW office at Waterloo. She was described by a staff member as “very pale” and “not looking well.”6This is the last confirmed sighting of Margaret. On 28 February she failed to present herself back at the office, as expected. On 1 March the workers became concerned and called the police.

22. Later investigations of the internal security surveillance system of the building in which she lived, indicated that she had returned home at 2.53 pm on 27 February 2017 and did not appear to have left the unit again.

3 Statement of Stuart Trembath, Exhibit 1, page 69 Statement of Constable Thomas Grant Exhibit 1, page 57 onwards 5 Statement of Stuart Trembath, Exhibit 1, page 70 6 Statement of Senior Constable Matthew Robinson, Exhibit 1 [7]

Discovery and subsequent investigations

23. At 12.50pm, on 1 March 2017, in response to concerns raised by the Department of Housing, NSW Police once again attended Margaret’s residence. Senior Constable Robinson reported that on approach he could smell a very strong odour and that he saw flies and cockroaches around the front door.7 There was no response to knocking and it was not immediately possible to gain access by a window. Police could hear a dog barking inside.

24. Police Rescue were called and they arrived shortly afterwards. Officers forced the front door open. Even so, entry was somewhat difficult because of the amount of rubbish inside the unit and the fact that it was partly blocked by a wheelie bin. The floor was entirely covered with rubbish. There were clothes mixed in with food and other discarded items.

25. Police found Margaret face down in her bedroom, lying between the bed and a large wardrobe. She was wearing a “nighty” that covered part of her body8. Significant decompositional change indicated that she had been dead for some time. Her small dog was barking and appeared to be guarding her body.

26. During the subsequent investigation, police became aware of the report about her welfare made back in January 2017. Further investigation revealed that this report had been acted upon appropriately.

Cause and time of death of Death

27. An autopsy was conducted by Dr Lorraine Du Toit-Prinsloo on 8 March 2017. The reliability of the findings is affected by the degree of decompositional change evident. Post mortem CT scanning was precluded by her body size.

28. Toxicological testing showed elevated levels of alcohol, however this is likely to be the result of the obvious decompositional change. Diazepam, Nordiazepam and Nortriptyline were present in non-toxic levels. Amitriptyline was present in toxic but not lethal level. The reported level of Methadone can be found in long term users due to a developed tolerance but has also been reported in fatalities.

Statement of Senior Constable Matthew Robinson, Exhibit 1 [8] Statement of Senior Constable Matthew Robinson, Exhibit 1 [8]

29. All toxicological levels should be treated with caution due to the decompositional change present. The forensic pathologist noted that both Amitriptyline and Methadone can result in prolongation of the QT-interval. It is possible that their combination could cause cardiac arrhythmia and sudden death. However, this is regarded as a mere possibility.

30. The forensic pathologist was unable to ascertain a clear cause of death. I note that there were no indications of suicide or foul play at the scene. There were no signs of forced entry, robbery or assault. It appears likely that her death was due to natural causes, but there may also have been a drug related element to her death. For this reason a clear cause of death cannot be reliably established on the available evidence.

31. Margaret was last seen on 27 February 2017. It is likely that her death occurred on or shortly after that day. While there was decomposition to her body, this does not reliably indicate a more accurate time of death.

Identity

32. Police were aware from Housing NSW records that Margaret lived alone at the address where the body was found. Margaret’s identity was later formally confirmed by fingerprint analysis.9 Findings

33. On the balance of probabilities, I find that Margaret Rose Carr died between 27 February 2017 and 1 March 2017 at her home address, 725/55 Walker Street, Redfern. The cause and manner of her death remain unknown.

34. Finally, I offer my sincere condolences to her friends and neighbours, and to her daughter Lisa. A funeral was conducted by members of her local community and church. Margaret is survived by Lisa and by her devoted dog, Ziggy.

Magistrate Harriet Grahame Deputy State Coroner 15 February 2019 9 Statement of Detective Senior Sergeant Wayne Miller, Exhibit 1, Page 22