Inquest into the death of Fazan Khan

CITATION: Inquest into the death of Fazan Khan

[2019] NTLC 011 TITLE OF COURT: Coroners Court JURISDICTION: Darwin, Northern Territory FILE NO(s): Rel No: D0015/2018 DELIVERED ON: 20 June 2019 DELIVERED AT: Darwin, Northern Territory HEARING DATE(s): 11-12 April 2019 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Drug overdose; MDMA; multi-drug toxicity; self administered; dangers of ‘lean’- soft drink mixed with pharmaceuticals.

REPRESENTATION: Counsel Assisting: Dr Peggy Dwyer Counsel for Police: Ms Mary Chalmers, on behalf of the Commissioner of Police Judgment category classification: B Judgement ID number: [2019] NTLC 011 Number of paragraphs: 38 Number of pages: 12

IN THE CORONERS COURT AT DARWIN IN THE NORTHERN TERRITORY OF AUSTRALIA No. D0015/2018 In the matter of an Inquest into the death of

FAZAN KHAN ON 28 January 2018 At 16 Ridgehaven Circuit, Leanyer

FINDINGS Mr Greg Cavanagh SM: Introduction

1. Fazan Khan was born at Royal Darwin Hospital on 7 May 1995 to parents Farah and Yasin Khan. He had a younger sister Amina born in 1996. His parents divorced when he was young and his mother remarried to Kaleem Khan, with whom she had two children, Khadjijah born in 2003 and Hana born in 2008. Fazan was very close to his family and it is clear to me from the evidence and actions of his family members that he was deeply loved by them.

2. Fazan was a healthy baby and child and there were no serious health concerns in his childhood or adolescence. He lived with his mother and step father in Karama. He was a student at Manunda Terrace Primary school and then Dripstone High, before starting at Casuarina Senior College in Year 11. After leaving school he started an apprenticeship as a motor trimmer with NT Shades, and then got a job at Seat City in Winnellie, which specialises in upholstery. Fazan was employed there full time until the date of his death and he was a hard worker who was respected and liked by his colleagues.

3. Fazan had goals for his life, and he enjoyed the love of a devoted family and a group of genuine friends, some of whom he had known since he was a child.

As I said in at the hearing, the inquest vindicates and appreciates the importance of this young man's life. His death is an enormous loss to his

family and it is also a loss of part of our community. It is a terrible tragedy that Fazan died when he was at the beginning of his adult life and so full of potential.

Drug and alcohol use

4. Sadly, Fazan had injuries as a young adult that led to him using quantities of the opiate based pain killer Panadeine Forte. The first was an injury to his shoulder sustained at the gym. At the time, his mother was using Panadeine Forte and noticed some of her tablets missing. Then in September 2017, Fazan reported that he hurt his back from lifting something at his work place and he was prescribed Panadeine Forte to help deal with the pain.

5. At the time of his death, Fazan was taking a number of medications that had been prescribed to him. They were Augmenton Duo Forte once daily (antibiotic); Erythromycin 3 x daily (for bacterial infections); Ibuprofen, 1 tablet 3 x daily and Voltarin rapid (pain relief) and Mirtazapine (antidepressant).

6. I heard evidence from many of Fazan’s friends that he was a regular user of prescription drugs, including Xanax and Oxycodone. One thing he appeared to do regularly was to mix and drink a concoction called “Lean”, which involved crushing Codeine tablets (and sometimes other pharmaceuticals like Phenergan), mixing them with water and letting the mixture sit before pouring it through a coffee filter, and then mixing the resulting liquid with soft drink.

7. “Lean” has been linked to a number of fatalities in the United States, where it is known as “purple drank” and has killed a number of hip hop artists. It is highly addictive, and highly dangerous, especially when mixed with alcohol.

It can cause slurred speech, blurred vision, sedation, dissociation from one’s body, impaired motor skills, lethargy and drowsiness. High dosages can cause vomiting, weakness, headache, itching, dry mouth, hives, chest pain, fainting, hallucinations, seizures and tremors. The codeine in Lean is a breathing

depressant, as is alcohol, and when mixed the results can be fatal. Signs of abuse include slurred speech, sedation, and drowsiness, also vomiting, headache and tremors.

The night before Fazan’s death - 26 January 2018

8. On 26 January 2018, Fazan spent time with a long term friend of his who had lost contact with him after school finished in 2010, but had re-connected with him in 2015 and maintained a friendship from then until the time Fazan died.

That night, and into the early hours of the next morning, they were playing computer games and talking.

9. While his friend drank only alcohol, Fazan made up two bottles of the drink ‘Lean’, using codeine tablets and blue tablets his friend thought were Phenergan. Fazan made up two 1.25 litre bottles for himself and drank one, while he stored the other in the fridge. According to his friend, Fazan also crushed up a tablet of codeine and snorted it. Fazan had obviously had some experience doing so because he was confident describing the effects to his friend and he encouraged him to try some. Fazan and his friend went to bed around 2am in the morning.

10. When Fazan’s friend got up at 8am the next morning, Fazan had already gone.

He texted at midday saying that he had gone to visit his mother in hospital because she had been suffering chest pains.

27 January 2018 - The party at Roy’s house

11. On 27 January 2018, a long term childhood friend of Fazan’s hosted a party at his home on Ridgeway Circuit, Leanyer to coincide with the JJJ hottest 100, which had been moved to the day after Australia Day. That friend invited Fazan and around 14 others to the party and people came and went all day and into the night.

12. Fazan left the Hospital where he had been visiting his mother and arrived at the party around midday. At around 5pm that afternoon, at Fazan’s request, his friend dropped over the extra bottle of ‘Lean’ that Fazan had mixed up and left at his home the night before. That friend did not go inside the party but spoke to Fazan from the car and he later told Police that Fazan was grinding his teeth and told him that he had taken the drug MDMA.

13. Throughout the course of the evening, Fazan drank the Lean and he spoke to the other party goers, in a manner that seemed relaxed and happy. He consumed some alcohol, including “a couple” of rums in the afternoon and several beers. I received a statement from a friend of Fazan’s, who stated that Fazan told him he had been taking a lot of pills during the week and had only had a few hours’ sleep the night before. Fazan mentioned his lack of sleep to a few of the guests and a number of people at the party said that he looked exhausted.

14. At some stage in the early evening, Fazan was sick. At around 6pm, he was seen by the party host to vomit on the lawn and at around 8pm, Fazan spent about 15 minutes in the toilet.

15. It is clear that there were illicit drugs at the party, including cannabis, 3,4methylenedioxymethylamphetamine (otherwise known as MDMA or ecstasy) and some pharmaceutical drugs that were being misused. Not all of the persons who attended used those drugs, but some did, including Fazan. One of the guests saw that Fazan purchased one MDMA pill and took it in the afternoon. He was also seen to take Xanax pills and to consume them with rum.

16. The party attendees came and left at different times of the afternoon and night.

Given that it was a party and there was substantial amounts of drinking, and some drug taking, it is not surprising that the party guests do not have perfect memories of the timing of events. The host told Police that he went to bed at about 11pm. One person who left the house at around 12.30am on 28 January

2018 said that as he was leaving, he saw Fazan still awake in a chair outside the house and he thought everyone else appeared to have gone to bed. One of the persons at the party headed for bed between 12am and 2am and he gave evidence that prior to going to bed he saw Fazan seated on the floor in the kitchen with his back against a kitchen cabinet, apparently asleep. Fazan was snoring and the friend tried to wake him up, but when Fazan told him he would be alright, the friend went to bed, leaving Fazan in the same position.

Fazan’s body found

17. It appears that a number of people slept over at the house in Leanyer on the night of the party. They were the party host and his girlfriend, the younger brother of the host, who was living at the house while his mother was away, and three other friends, including Fazan.

18. The host went into the kitchen at around 10am, with his girlfriend close behind. They saw Fazan slumped in the kitchen against a cupboard. At around the same time, another female walked into the kitchen, because she was due to pick the hosts up and take them to a function. They contacted “000” at 10.15am and commenced CPR under instruction by the call taker, until ambulance officers arrived at 10.20am.

19. Sadly, it was too late to assist Fazan and the stiffness in his body indicated that rigor mortis had commenced and he had been deceased for a period of time. Ambulance officers arrived at 10.20am and Fazan was pronounced deceased at 10.21am.

Cause of Death

20. After Fazan’s death, an autopsy was performed by Dr Marianne Tiemensma on 29 January 2018. I was extremely impressed with the expertise of Dr Tiemensma, as well as the clarity of her written report and oral evidence.

21. The autopsy and investigation confirmed that the cause of Fazan’s death was multi-drug toxicity – predominantly oxycodone and 3,4methylenedioxymethylamphetamine (MDMA, Ecstasy) in keeping with overdose after oral ingestion. Oxycodone is a semi-synthetic narcotic analgesic used for moderate to severe pain. 3,4methylenedioxymethylamphetamine is an amphetamine derivative used illicitly as a recreational drug for its stimulant and hallucinogenic properties.

22. Dr Tiemensma relied on toxicological analysis which showed toxic levels of oxycodone and MDMA in Fazan’s blood. Detected in his blood stream at nontoxic levels was alprazolam (otherwise known as XANAX, a drug commonly used in short term management of anxiety disorders), codeine, paracetamol and Promethazine (an antihistamine with sedative qualities). Is it possible that Fazan had in fact metabolised some of those drugs so that they were at toxic levels when he ingested them but not at the time of the autopsy. Fazan’s stomach contents contained some of those drugs, as well as Naloxone and codeine.

23. Dr Tiemensma conducted a head to toe examination to look for any possible injuries and found none. There were no needle injection marks visible on Fazan’s body. There were no defensive wounds to suggest that Fazan had been in a fight.

24. The stomach contents contained oxycodone, naloxone, MDMA, codeine and promethazine. This supports oral ingestion of a variety of prescription and non-prescription substances.

25. When Dr Tiemensma gave oral evidence, she was able to clarify why several of the autopsy findings that appear curious at first instance, had a rational and innocent explanation.

• First, although a number of those who attended the house on the day Fazan died and saw him deceased noted that there was a discolouration

of the left-hand side of his face, Dr Tiemensma explained that this was not suspicious, but was likely to be caused by the intense congestion of the face as a result of impaired blood flow. To an untrained eye, it can look like bruising.

• Second, Fazan’s hands were held out in front of his body in an unusual position because rigor mortis had set in when he was slumped in a seated position. Because he was then laid flat, gravity meant that the position of the hands and arms later changed.

• Third, Fazan drank alcohol during the day, vomited at around 6pm and might possibly have drunk a little more after that, but there was no alcohol detected in his blood or stomach contents. When Dr Tiemensma performed the autopsy, she had to open the abdominal cavity and stomach and she noted that there was a smell of liquor. The explanation for the toxicology report showing no alcohol is that Fazan died hours after he had last consumed alcohol and he had metabolised it before the post mortem samples were taken. How quickly someone metabolises alcohol depends on how much they drink and their individual rate of metabolism.

• Fourth, Alprazolam was present in the blood and not the stomach. That means that it was past the stage of stomach metabolism and had been absorbed in the blood already.

• Fifth, Naloxone was present in the stomach but not the blood, suggesting it was taken more recently and the body had not had time to absorb it.

Naloxone is often given in a formulation to reverse overdose, and Fazan did not take Naloxone on it’s own, making it appear at first curious that it was present in his stomach. However, Dr Tiemensma explained that Naloxone is present in some formulations (like the drug Targin) with Oxycodone. That is because Naloxone specifically helps to counteract the gastro intestinal effects of opioids but won't interfere with the effects of pain relief and sedation. The evidence suggested that Fazan took a

tablet of Oxycodone that contained Naloxone. The tablet that was undigested found in his oesophagus contained exactly the same substances.

• Sixth, an undigested tablet, shown to be oxycodone and naloxone on toxicological analysis, was present in the oesophagus. That is further evidence that one tablet with both substances was taken by Fazan later in the night and not fully digested. The reason why the tablet would get stuck in the oesophagus was that the drugs that Fazan had consumed were likely to cause drowsiness, sedation, sluggish speech, and difficulty in swallowing. Given the absence of injuries, it was considered very unlikely for somebody other than Fazan to have placed the tablet there.

Police Investigation found no suspicious circumstances

26. A coronial investigation by Police found no suspicious circumstances surrounding this death. I have reviewed that investigation and I agree that there are no suspicious circumstances, particularly given that: a) There was no motive established for anyone to harm Fazan.

b) The young people at the party included some of Fazan’s close friends, who had known him for many years, and there was no evidence to suggest there had been a disagreement between Fazan and any other person.

c) There is ample evidence that Fazan had been using illicit and prescription drugs for some time.

d) A number of witnesses saw Fazan voluntarily consume MDMA on the evening of 27 January 2018.

e) A number of witnesses were present around the time that Fazan was discovered to be deceased in the morning of 28 January 2018 and they gave accounts that were consistent with respect to all salient details.

f) There was no sign of any physical injuries on Fazan.

g) The findings at autopsy were not suspicious and were clearly explained by Dr Marianne Tiemensma.

h) I heard testimony from witnesses who were credible and forthcoming about the circumstances of the party. I accept the evidence of the host of the party that he was numb and shocked on finding his friend deceased.

27. Consistent with the evidence of a friend who saw him drowsy but alive when he went to bed, I am satisfied that Fazan died sometime between 12am and a few hours before 10am in the morning, on 28 January 2018, when his body was located with signs of rigor mortis.

28. After the ambulance officers had arrived at 10.20am, police were soon at the home and conducted their duties to preserve the scene and commence their investigations. There were dozens of officers in attendance, including four detectives. Officer Merwan Kazeem arrived at 10:28 am and switched on a body-worn camera that he used to record footage of the house and relevant contents. Detective Senior Constable First Class Natasha Wood located some drug paraphernalia in the first room which included scales and clipseal bags, and in the second room, she located an amount of cannabis and some cash.

29. Police identified that Fazan had possessions at the house, including a black bag in which there was $160 in notes. Although Fazan’s family members had heard that Fazan had about $2000 on him that day, there was no evidence from Fazan’s friends that he had carried that much money on him at the party, and there was no evidence to suggest that anyone had known he had money or had stolen it from him. There was nothing to link the money that was found by police in a bedroom of the house with Fazan.

30. As part of the investigations Police reviewed Fazan’s internet history on his phone to see if he had any phone calls or searches of relevance. On the night

of 27 January 2018, one of the searches that he conducted was “what to keep you going hard after a big party”. Also on the phone was a search history with respect to purchasing prescription drugs, as well as images of drugs, and conversations and messaging about drugs, both prescription and illicit. There were messages between Fazan and others in relation to the sale and purchase of drugs.

31. After Fazan’s body was found, a number of persons were transported from the house to the police station to assist with the inquiries.

Conclusions

32. Fazan’s tragic death is another reminder of the dangers of illicit drug use, and the particular dangers of mixing drugs and of mixing drugs and alcohol. I accept what I was told by the young people who gave evidence in Court that the host of the party and Fazan were very close friends, who had known each other since they were children, loved laughing together and having a good time, and genuinely cared for each other.

33. When asked about Fazan’s character, one his friends who had known him for many years said this: He's a great guy, very down to earth, willing to help whenever needed.

Just very kind, respectful, wouldn't hurt a fly and very, very close to [the party host]. They've been best friends since primary school.

34. Fazan’s siblings and step-father prepared a beautiful family statement that was read in Court. It included this: The death of Fazan Khan has majorly affected the family. He took up an enormous space in everyone's heart around him. He showed nothing but love and care towards all his family and friends. He had a bright personality and was always making his family laugh. His support towards them all was amazing and anything they needed or wanted he would never fail to provide. He never thought about himself but always put his family and friends first and always ensured that everyone around him was happy. The word “no” was never in his vocabulary. He was one of a kind. The emotional and financial support was there for as long

as Fazan was around. Fazan was always so happy to do anything for his family and friends and no matter what he was only ever one call away.

35. Fazan’s Aunty said: Fazan was an intelligent, caring and responsible young man who loved life and was expressing future goals for his family. Fazan held his close and extended family in high regard and was loving of all family members, within the social context Fazan presented as a trusting and loyal friend.

He showed much self-respect, firm religious values, a strong work ethic and appeared to be progressing well in his life.

36. Fazan was a vibrant, caring and hard working young man who loved his family and was loved in return. It is an absolute tragedy that he was lost so young.

37. Pursuant to section 34 of the Coroner’s Act, I find as follows:

(i) the identity of the deceased person is Fazan Khan; (ii) the time of death was between 2am and 10am on 28 January 2018, and the place of death was 16 Ridgehaven Circuit, Leanyer.

(iii) the cause of death was accidental multi-drug toxicity, predominantly oxycodone and 3,4-methylenedioxymethylamphetamine (MDMA), in keeping with overdose after oral ingestion; (iv) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act are:

1. The deceased was Fazan Khan, a male born 7 May 1995 in Darwin.

2. The deceased was not of Aboriginal descent.

3. The deceased was employed at Seat City in Winnellie the time of his death.

4. The death was reported to the Coroner by Police.

5. The cause of death was confirmed at autopsy by Forensic Pathologist, Dr Marianne Tiemensma.

6. The deceased’s mother was Farah Khan and his father was Yasin Khan.

38. I do not make any formal recommendations.

Dated this 20 day of June 2019.

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JUDGE GREG CAVANAGH TERRITORY CORONER