Inquest into the death of Timothy Ricketts

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Timothy John RICKETTS Hearing Dates: 18 September 2023 Date of Findings: 21 December 2023 Place of Findings: Coroner’s Court of New South Wales at Lidcombe Findings of: Magistrate Joan Baptie, Deputy State Coroner Catchwords: CORONIAL LAW – Unascertained death, recent cardiac event with raised troponin levels, significance of Pfizer vaccination, effects of methadone use on cardiac disease, effects of decomposition affecting autopsy.

File Number: 2021/00346986 Representation: Mr D Welsh, Coronial Advocate Assisting the Coroner Findings Timothy John Ricketts (aka Timothy Norford) died between 29 November 2021 and 3 December 2021 at 5/1-9 Terrace Road, Dulwich Hill.

The cause of his death was the combined effects of subacute myocardial injury and methadone toxicity.

The manner of his death was misadventure (drug toxicity impacting underlying natural causes).

1. Introduction 1.1 This inquest concerns the death of Mr Timothy John Ricketts. Mr Ricketts was also known as Mr Timothy Norford.

1.2 Mr Ricketts was born on 13 January 1978. At the time of his death he was 43 years of age.

1.3 Mr Ricketts was located deceased at his home on 3 December 2021. His home was apartment number 5 in a complex at 1-5 Terrace Road, Dulwich Hill. He had resided in this apartment for around twelve months.

1.4 The identity of Mr Ricketts and the location of his death are not in dispute.

This inquest has focused on the manner and cause of his death, together with the date of his death.

1.5 Mr Ricketts’ family have been involved in these proceedings and have provided their assistance and co-operation both prior to the inquest, and during the inquest. His family have referred to their son and brother as Timothy, and I have adopted the same course. This is not meant to be disrespectful, but rather to acknowledge Timothy’s humanity.

1.6 I acknowledge the profound loss, and continuing anguish and heartbreak felt by Timothy’s family. I would like to express my sincere condolences and respect for their loss. I would like to acknowledge and thank his family members for their contribution and participation in this inquest. I hope that Timothy’s memory has been honoured by the careful examination of the circumstances surrounding his death.

2. The legislative requirement for an Inquest 2.1 A coroner is required to investigate all reportable deaths and to make findings as to the person’s identity, as well as when and where the person died. A coroner is also required to identify the manner and cause of the person’s death. In addition, a coroner may make recommendations, based on the evidence deduced during the inquest, which may improve public health and safety.

2.2 During these proceedings, evidence was received in the form of statements and other documentation, tendered in Court, and admitted into evidence. In addition, oral evidence was received from the officer in charge of the investigation, Constable David Chan, as well as expert evidence from the forensic pathologist, Dr Jennifer Pokorny.

2.3 All the material placed before the Court has been thoroughly reviewed and considered.

3. Timothy’s life 3.1 Timothy resided independently with his dog. He had been in at least one significant relationship, which his father described in Court as being like a marriage. Unfortunately, they had been estranged for some time.

3.2 Timothy had a medical history which was significant for anxiety and depression, post-traumatic stress disorder and treated Hepatitis C infection.

3.3 Timothy had a lengthy history of intravenous drug use involving methylamphetamines and heroin. He also was a regular consumer of cannabis. He also had a reported dependency on alprazolam.

3.4 Timothy was a long-term client of the Langton Centre for Drug and Alcohol Rehabilitation in Surry Hills.

4. Involvement with the Langton Centre 4.1 The Langton Centre’s treatment notes and associated correspondence confirmed that Timothy’s complex Post Traumatic Stress Disorder was a debilitating condition for him and impacted on virtually every aspect of his day-to-day life. He experienced difficulties leaving his home and an inability to prioritise and schedule regular daily tasks. He also experienced difficulties with maintaining and keeping friendships, resulting in social isolation.

4.2 The Langton Centre medical records record his intravenous drug use as a persistent feature of his presentations to the service.

4.3 In 2018, the records note that he presented with painful arms due to injecting crushed up benzodiazepine. It was noted at that time that he had a number of injection sites on his forearms and hands.

4.4 The records also confirm that Timothy had previously overdosed due to both oral and intravenous use of methadone, as well as alprazolam.

4.5 At the time of his death, Timothy was receiving “take-away” methadone.

His daily dosage was 150mg. His “take-away” dosage was dispensed from the Savemore Pharmacy at Marrickville. The Langton Centre’s treatment notes confirm that this daily dose had been a long-term and consistent dosage for Timothy. The only periods when his takeaway dosages were suspended reflected periods of time when Timothy had a documented overdose of either prescription or illicit substances.

4.6 Timothy had five hospital presentations between May 2021 and November

2021. These were mostly due to intravenous use of alprazolam.

5. Admission to Royal Prince Alfred Hospital 5.1 On 2 November 2021, Timothy was admitted to Royal Prince Alfred Hospital with dizziness, a generalised headache and a loss of balance. He was also noted to have associated nausea and multiple dry-retching episodes. He was placed under the care of Dr Robertson, Cardiologist.

5.2 Timothy advised medical staff that he had injected methadone intravenously prior to attending hospital. He also indicated that he had bought the methadone “on the street” and that he had used this illicit dose intravenously after vomiting up his prescribed oral dose due to nausea. He told hospital staff that he used methadone intravenously on a monthly basis.

5.3 An electrocardiogram disclosed sinus bradycardia. Rib x-rays showed fractures of the right ribs. He was unable to recall how he had sustained these injuries.

5.4 Blood tests confirmed elevated troponin levels, which may have been associated with three possible scenarios. These three scenarios included:

• an earlier Pfizer COVID-19 vaccine which was administered in June 2021,

• trauma to the chest area resulting in the rib fractures or

• myocardial strain due to intravenous drug use.

5.5 Timothy’s condition improved and he was discharged from hospital on 5 November 2021.

6. Events on 3 December 2021 6.1 On 3 December 2021, Timothy’s case worker at the Langton Centre, Ms Turner, became concerned that he had not collected his prescribed methadone for three days, that is, since 30 November 2021. Ms Turner had attempted to contact Timothy without success.

6.2 Ms Turner contacted police with her concerns. She further indicated to police that Timothy last attended at his dispensing chemist, Savemore Pharmacy at Marrickville, on 29 November 2021.

6.3 Constable David Chan and other police attended Timothy’s apartment complex at 2.41pm on 3 December 2021. Police knocked on the front door, however, they did not receive a response. They noted a strong odour coming from the apartment, which raised their concerns. Police then

gained entry through the unlocked front door and were greeted by Timothy’s dog.

6.4 Police could hear the sound of running water from the bathroom and went to investigate. They found both the shower and the bathroom sink faucets to be fully turned on, with what appeared to be “drug paraphernalia” in the sink.

6.5 The police then located Timothy lying on his back on his bed with his feet touching the ground. He had a towel around his waist. He was clearly deceased.

6.6 Investigating police also located a bucket containing vomit in the bathroom. They also located two bags containing methylamphetamine.

6.7 Police also canvassed the neighbours in an attempt to ascertain Timothy’s last movements, however the neighbours were unable to assist.

6.8 Constable Chan described the bathroom scene in greater detail in his oral evidence before the Court. Constable Chan surmised that Timothy had “inserted the drugs, blood was dripping, he vomited into the bucket, had a shower or not, the shower was on, so he was naked. I have my doubts if he actually entered the shower but he probably was naked at that time, had injection, vomited into the bucket, then went back to the bed and just lay down.” 6.9 Constable Chan was of the view that the syringe which was located in the sink had been used recently. He indicated that he formed that view owing to “the cleanliness overall in the bathroom and the house, you would assume, it is quite well maintained in that sense, so if it’s been used quite a while ago it would have been, you know, the blood stains wouldn’t exist there. Just looking at how things are organised and stuff I am of the opinion Christopher (sic) is a clean person of basic hygiene and if that was old that would have been wiped away from him. Especially, you know, if you’re taking a shower, it’s already wet you’ve got water and all that.

Ample cleaning supplies in the bathroom as well.” 6.10 Constable Chan was questioned about the syringe which was located in the sink. Constable Chan stated that the water was “running on full strength the tap so, I mean, at one stage it probably will be overflowed, submerging that syringe itself, so it looked pretty washed out at one stage so I don’t know if there’s anything left inside to be tested.” 6.11 Constable Chan confirmed that police intelligence indicated that Timothy had a tendency to abuse the conditions of his “take-away” methadone.

6.12 Constable Chan confirmed that he made enquiries about Timothy’s last known sightings. He noted Timothy’s attendance at the Savemore Pharmacy on 29 November 2021. In addition, he was able to confirm that police located a receipt for a mobile phone purchase on 29 November

2021 at 9.34am at a Cash and Carry store at 320 Marrickville Road, Marrickville.

6.13 Constable Chan indicated that he was not of the view that Timothy had intended to commit suicide and he believed that his death was more consistent with a miscalculation associated with the administration of a drug, rather than self-harm.

7. Dr Pokorny – expert opinion on cause of death 7.1 Dr Jennifer Pokorny, Staff Specialist Forensic Pathologist, performed an autopsy on 10 December 2021.

7.2 Dr Pokorny noted changes of decomposition were present. Dr Pokorny commented that “Within this limitation, no significant natural disease and no evidence of significant injury was identified”.

7.3 Dr Pokorny indicated that “microscopic examination revealed areas in the heart suggestive of subacute and remote ischaemic injury, though assessment was limited by decomposition.” In her oral evidence, Dr Pokorny noted the limitations due to decompositional changes, stating “all the detail that you are usually able to see a lot of, that is lost, so although I could see that there were some areas that looked like they probably were scarring, so that's the older areas of injury, the remote areas of injury and some areas that looked, probably, like not quite scarring but healing change headed towards scarring, I just can't see it in enough detail to be certain. That is why I said it is suggestive of that.” 7.4 The toxicological examination disclosed the presence of “alcohol in the blood at 0.086 g/100mL, at least part of which may be due to decomposition artefact. Methadone was detected at 1.4mg/L. This level is within the range considered potentially lethal, however similar levels have also been reported in individuals on the methadone program who died of unrelated causes, as they may develop significant tolerance with chronic use. Methadone levels may also be affected by postmortem artefact in the setting of decomposition. Cannabinoids were also present, in keeping with the use of cannabis in the recent past.” 7.5 Dr Pokorny noted that Timothy had received his first dose of the Pfizer COVID-19 vaccination on 13 July 2021.

7.6 Dr Pokorny concluded that the “cause of death remains unascertained after post mortem examination, though two main possibilities are raised by the findings:

• Although potentially lethal, in the setting of chronic methadone use the significance of the detected methadone level is uncertain. The scene findings suggest recent intravenous drug use. If the methadone had been injected rather than taken orally as prescribed this may have

increased the rapidity of onset of the drug’s effects and increased the risk of toxicity. Information as to whether residue of a specific drug was identified in the syringe found at the scene and/or the opinion of a forensic toxicologist may be helpful.

• Examination of the heart was limited by decomposition changes, though there were features suggestive of subacute ischaemic injury, which would be consistent with his apparent cardiac event leading to hospital admission in November 2021. It is not possible to further classify the cardiac changes due to the degree of decomposition, nor to exclude the possibility of superimposed acute ischaemic injury, but preexisting cardiac disease would increase the risk of sudden death at anytime due to an arrhythmia, a risk exacerbated by concurrent use of methadone, which is known to have pro-arrhythmic effects, even at therapeutic levels”.

7.7 In oral evidence, Dr Pokorny was asked to comment further on Timothy’s hospital presentation in November 2021, specifically his raised troponin levels. Dr Pokorny stated “So troponin, a protein that is in heart muscle cells and when those cells are injured troponin gets released. So elevated troponin is specific for injury to heart muscle but it doesn't tell you necessarily, exactly what that injury is. Usually if you have very high troponin levels that means you've got large amounts of heart muscle that have died so you have a myocardial infarction or a heart attack. You can get lower elevations, smaller amounts of troponin released with other heart injury with the other possibilities that were raised while he was in hospital”.

7.8 Dr Pokorny further commented that something had happened to Timothy’s heart in the “past and probably on more than one occasion [but] I can’t say for sure exactly what that diagnosis was because the decomposition changed” what was visible. She stated that “even when he was in hospital they knew something was going on with his heart but they had a list of possibilities and they hadn't been able to determine exactly which of those possibilities it was. One of those possibilities is that there had been some ischemic injury to the heart due to inadequate oxygen supply to heart muscle with little areas of the heart muscle dying. It is certainly possible that whatever caused that in the past was still there and has caused a new ischaemic event shortly before death so that would be why he died on that particular day”.

7.9 Dr Pokorny further identified the three possible causes for his earlier presentation in November 2021. Dr Pokorny stated that “there was the myopericarditis, inflammation of the heart from the Pfizer vaccine, there was chest trauma, so they saw the rib fractures. The fractures themselves wouldn’t really do anything but if you’ve had enough to impact to fracture your ribs there may be enough trauma to the heart to also injure enough heart muscle cells that you release troponin. Then, yeah, the third possibility was there is some heart strain which is probably a bit of lowlevel ischaemia relating to the drug use.”

7.10 Dr Pokorny compared the treating team’s possible identification of myopericarditis from the Pfizer vaccine in his presentation to hospital in November 2021, with his presentation at autopsy. Dr Pokorny indicated that “certainly the presentation in hospital with the troponin was one of the possibilities for that that was raised by the treating team was that this was a myopericarditis from the vaccination, so there is some inflammation of the heart muscle and the surface of the heart because of the vaccination.

It is unlikely that that would still be ongoing inflammation at the time of autopsy for me to see, but it is certainly possible that the healing changes that I think I can see and can't even be certain about that, could be the healing of a myocarditis, inflammation of the heart muscle, rather than an ischaemic injury to the heart muscle. So something has happened in the past and there is healing, probably at a point where I can see it, but because of the passage of time, as well as decomposition, it is very hard for me to say exactly what that initial cause of that injury to the heart was. I can't totally exclude the possibility that some myocarditis from the vaccine which caused that troponin rise in his previous hospital admission could look like what I saw at autopsy and could be a potential contributing factor.

It doesn't look like there is ongoing myocarditis at the time that he died”.

7.11 Dr Pokorny further commented on “features suggestive of subacute ischaemic injury, which would be consistent with his apparent cardiac event leading to hospital admission in November 2021. It is not possible to further classify the cardiac changes due to the degree of decomposition, nor to exclude the possibility of superimposed acute ischaemic injury, but pre-existing cardiac disease would increase the risk of sudden death at any time due to an arrhythmia, a risk exacerbated by concurrent use of methadone, which is known to have pro-arrhythmic effects, even at therapeutic levels.” Dr Pokorny explained that “because there’s these areas of scarring you have a much higher likelihood that the electric signal is not going to transmit normally and you are going to get some sort of abnormality in the rhythm that is produced, so the heart is not going to beat in a normal, in a rhythmic consistent manner. Depending on what abnormal rhythm or arrhythmia is produced you can get the heart failing to pump properly and inadequate blood supply and sudden death.” Dr Pokorny confirmed that given his pre-existing cardiac injury, Timothy was more likely to suffer from an arrhythmia with fatal consequences.

7.12 Dr Pokorny commented that “you can potentially get some degree of chronic heart strain with chronic drug use, but an acute event that sends you to hospital with acute symptoms, like this case, where he was dizzy and had this acute troponin rise, is probably more likely to be linked with an acute use of the drug shortly before”.

7.13 Another notation in Timothy’s hospital treatment notes from his November 2021 admission related to a diagnosis of endocarditis. Dr Pokorny commented that “Endocarditis is an inflammation or an infection of the lining of the heart, and usually, like the inner lining of the heart, and it usually involves the heart valves. It is commonly associated with injecting drug use where you end up getting an infection and a collection of, sort of,

bacteria and inflammatory material on the valves of the heart. So even if there is decomposition change here, that is something that can be seen with the naked eye, there's usually a large sort of collection there. The heart valves, when I did my examination, looked normal, so there isn't any evidence of ongoing infected endocarditis at that point”.

7.14 In his hospital notes from November 2021, Timothy had confirmed that he had injected his oral methadone dose after vomiting. Dr Pokorny confirmed that methadone is not designed to be injected and if it the dose had been spat out and then injected there is a chance of “introducing bacteria that’s normally quite happy in the mouth but not happy in the blood stream. That is how you can end up with endocarditis but also just a sepsis, an infection of the blood, infection, local infection at the site of injection. Potentially it can sort of spread to any end organ in the body and form a collection or an abscess there as well.” 7.15 Dr Pokorny was asked whether there was sufficient medical evidence to determine if Timothy died from a methadone overdose. Dr Pokorny indicated that “I think it's really difficult in this case because, firstly the drug level we have, we don't even know how closely that relates to what the drug level was around the time of death, because there's this considerable post mortem interval before it was taken. Then, even assuming we have got a level that is reasonably accurate, interpretation is very difficult because as we have already said, therapeutic levels and fatal levels completely overlap. The only way usually you can say in someone who is a regular methadone user that it is likely that this methadone is the cause of death, is to exclude other potential causes of death”. Dr Pokorny continued, “It certainly may be entirely explained by acute and chronic methadone abuse, particularly injecting use rather than the therapeutic use of it, but it also might be separate. In the hospital admission, even with the knowledge of him diverting his methadone and injecting it, they still had other possibilities raised as causes for the troponin rise. So given that, I think I am not in a position to exclude either of those possibilities. So I think if there is methadone injected shortly before death, I think it is very likely that it was a contributing factor, particularly because there are changes in the heart, so older scarring and more recent kind of healing change that makes his heart a lot more vulnerable to arrhythmic effects of methadone. I think it is hard to completely exclude other unrelated causes and be able to say methadone toxicity alone would be the most likely cause of death in this case”.

7.16 Timothy’s father, Mr Christopher Ricketts asked Dr Pokorny if she had experience where a patient had scarring to their heart from the Pfizer vaccine. Dr Pokorny responded by stating “I am not sure that there's much data. Most of the cases that I am aware of both in our experience and in the literature are acute myocarditis, so people who have really overwhelming inflammation in their heart and they die because of that. Not people who then have healed up and then progresses several months and then dies of something else and then this has been there. I think part of the problem is it would be very hard to know for sure because, like I said,

it's nonspecific by that point. So if somebody survives 6 months later and dies of some other unrelated issue it would be very, very difficult to say this area of scarring in their heart is because of a vaccine they had six months earlier. It could be from any number of things really”.

8. Dr Shuang FU – Pharmacologist/Toxicologist 8.1 Dr Shuang Fu, Forensic Pharmacologist/Toxicologist provided an expert report in these proceedings, dated 7 September 2023.

8.2 Dr Fu noted in her report that “It is impossible to extrapolate Mr Ricketts’ firm blood methadone concentration at the time of the death. As Mr Ricketts’ death was between 29/11/21 and 3/12/21, and his autopsy was performed on 10/12/21, Mr Ricketts’ femoral blood sample had been collected approximately around 10 days (240 hours) after death and in summer season (likely high temperature), in addition to his body reportedly had significant decomposition, I am of opinion that at the time Mr Ricketts’ passing, his blood methadone level most likely would have been lower or much lower than 1.4mg/L.” 8.3 Dr Fu noted that “Methadone toxicity cannot be made using numbers alone, and the drug use history and circumstances of death must be taken into consideration. Interpretation of methadone blood concentrations must be done in the context of the clinical history, autopsy findings and circumstances surrounding the death for determining the cause of death.” 8.4 Dr Fu also noted that “Mr Ricketts reportedly was on Methadone Program, although it is unclear to me how many years/months and the doses he had been on, Mr Ricketts likely would have some tolerance to methadone. In contrast, due to Mr Ricketts’ reportedly had a persistent heart issue of bradycardia (slow pulse), which is one of the adverse effects of methadone, therefore, Mr Ricketts probably would be vulnerable to methadone.” 8.5 Dr Fu noted that the “Intravenous administration of methadone results in immediate and complete availability to the body, whereas oral ingestion of the drug results in a relatively slow and often incomplete availability to the body. Specifically, orally administered methadone provides less or much less blood concentration than intravenously administration of the same dose; and the maximum level of methadone from intravenous injection achieved almost immediately after injection, about the maximum level of methadone from oral dose reached about two to four hours after ingestion”.

8.6 Dr Fu concluded that “I am of the opinion that Mr Ricketts’ death probably would have been resulted from his methadone overdose, especially he possibly intravenously injected the drug, which is contradicted with the recommended method of administration. Methadone overdose would have caused Mr Ricketts’ death cannot be excluded”.

9. Considerations as to Time of Death 9.1 The precise time of Timothy’s death is unknown. Constable Chan has been able to determine that Timothy was last seen at either the Savemore Pharmacy on 29 November 2021, and evidence suggests that he attended at the Cash and Carry store at 320 Marrickville Road, Marrickville at 9.34am on 29 November 2021. When police attended at his apartment on 3 December 2021, he was found to be deceased.

10. Considerations as to the Cause of Death 10.1 The postmortem findings were limited due to the presence of decompositional changes. An examination of Timothy’s heart indicated features suggestive of subacute ischaemic injury. The presence of preexisting cardiac disease was likely to increase the risk of sudden death due to an arrhythmia, which could be exacerbated by the concurrent use of methadone. In addition, it is unclear what amount of methadone was taken by Timothy and whether the methadone was orally ingested or administered intravenously.

10.2 Timothy’s heart had sustained damage at the time he was admitted to hospital in November 2021. The presence of the protein troponin indicated that his heart muscle had been damaged, however the cause of that damage was undetermined, although three hypotheses were considered, being myopericarditis relating to his vaccination, trauma to his chest or myocardial strain due to intravenous drug use.

10.3 Dr Fu was of the opinion that a methadone overdose could not be excluded as causing Timothy’s death.

10.4 Dr Pokorny was of the opinion that there did not appear to be ongoing myocarditis at the time of his death and that the Pfizer vaccine was unlikely to have recently contributed to or caused his death.

10.5 In relation to his use of methadone prior to his death, Dr Pokorny was of the opinion that this was a likely contributing factor in his death due to the historical scarring and changes in his heart, making him more susceptible to heart arrhythmias, however it was difficult to exclude other unrelated causes and be able to say methadone toxicity alone would be the most likely cause of death in this case.

10.6 Dr Pokorny was asked to provide her opinion as to the cause of his death applying the legal, rather than the medical standard, that is, on the balance of probabilities on the available evidence. Dr Pokorny indicated that the cause of death could be described as involving a subacute myocardial injury on a background of methadone toxicity or the combined effects of both.

11. Acknowledgements 11.1 I would like to thank Mr Welsh, Coronial Advocate, for his assistance in preparing and presenting this matter.

11.2 I would also like to thank the Officer in Charge, Constable Chan, for his investigation and preparation of the brief of evidence.

11.3 I would again like to thank and acknowledge Timothy’s family for their ongoing involvement.

12. FINDINGS I make the following findings pursuant to section 81 of the Coroners Act 2009

(NSW): The identity of the deceased The deceased person was Timothy John RICKETTS, also known as Timothy Norford Date of Death Between 29 November 2021 and 3 December 2021 Place of Death 5/1-9 Terrace Road, Dulwich Hill Cause of Death The combined effects of subacute myocardial injury and methadone toxicity Manner of Death Misadventure (drug toxicity impacting underlying natural causes) I now close this inquest Magistrate Joan Baptie Deputy State Coroner 15 January 2024 Coroners Court of New South Wales