Clarke, Jon Edward Norman

OFFICE OF THE STATE CORONER FINDINGS OF INQUEST CITATION: Inquest into the death of Jon Edward Norman Clarke TITLE OF COURT: Coroner’s Court JURISDICTION: Maroochydore FILE NO(s): COR 634/07(7) DELIVERED ON: 9 February 2009 DELIVERED AT: Maroochydore HEARING DATE(s): 4 & 5 December 2008 FINDINGS OF: CJ Taylor, Coroner CATCHWORDS: CORONERS: Inquest – chronic schizophreniaparanoid type, heatstroke, effects of Clozapine

REPRESENTATION: Mr Cottersby, the solicitor for the next of kin, Mr Allan, counsel for STEPS Employment, Ms Rosengren, counsel for Queensland Health, Mr Lippett, counsel for the Trolley Boys Queensland Pty Limited

CORONER: Now, as previously arranged, I firstly intend to deliver my findings in relation to this death in accordance with section 45 of the Coroner's Act 2003.

I find on the evidence before me as follows.

(A) The name of the deceased person to be Jon Edward Norman Clarke.

(B) The deceased person collapsed on the 27 January 2007 at Woolworths Marketplace Buderim, where he was employed as a part-time trolley boy. The deceased was ultimately transported to the Nambour General Hospital on that date and medically treated until life support was removed on the 8 February 2007.

(C) The deceased person died at 1.40am on Thursday the 8 February 2007.

(D) The deceased person died in the Intensive Care Unit at the Nambour General Hospital in the State of Queensland.

(E) The cause of death as certified by Dr P Ellis, Pathologist, to be: (1a) multi organ failure, (1b) heatstroke.

It should be said by way of background that in 1998 the deceased at the age of 14 years was diagnosed with chronic schizophrenia-paranoid type and as part of his treatment he was administered medications of Olanzapine, Risperidone, and Quetiapine orally and Flupenithixol.

The deceased was commenced on the medication Clozapine, an atypical antipsychotic drug in Newcastle, New South Wales in 2001, and in approximately March 2006 the deceased, who had by that stage returned to live on the Sunshine Coast with his father, was also taking Efexor XR, 255 milligrams per day, and Solian, another atypical antipsychotic drug, 200 milligrams per day, in addition to Clozapine, 600 milligrams per day, which was ultimately reduced to 500 milligrams per day on the 23 November 2006.

When on the Sunshine Coast and in particular from the 1 April 2003, the deceased was under the effective treatment and care of Dr Evan Nichols from the Adult Mental Health Services, a very experienced medical practitioner in the area of mental health.

The deceased was also the subject of a Clozapine monitoring scheme which included routine blood tests to guard against agranulocytosis, together with the checking of weight, blood pressure and pulse rate.

It was Dr Nichols' evidence, amongst other things, that he'd never had another patient who had engaged in work as a trolley boy or other manual type occupation, die from heatstroke whilst on Clozapine, or in combination

with the drug Solian, and he was also not aware of any other medical practitioner who had reported such an outcome.

Dr Nichols also conducted extensive research from published literature both in Australia and overseas, into the subject matter of Clozapine and heatstroke and he could only find one case of a patient in the United Kingdom on Clozapine suffering heatstroke, however, that patient subsequently recovered.

Otherwise the prevailing medical and scientific view overwhelmingly was that heatstroke was not an attributable adverse side effect of the use of Clozapine.

It was also Dr Nichol's opinion the sufferers of mental illness tend to have a higher rate of mortality and morbidity than that of the general population and that some people, by virtue of their genetic makeup, are more susceptible to heatstroke than others.

The events leading up to the death of the deceased, put as simply as the case permits, were that on the 17 January 2007 the deceased met with his employment consultant, Mr Jerome Robert Tueta-Nicholls from STEPS Employment, a non-profit based organisation funded by the Commonwealth Department of Employment and Workplace Relations, to assist people with disabilities to gain employment in the general workforce.

That particular person was aware that the deceased was suffering from schizophrenia and was taking 100 milligrams of Clozapine. He met with Ms Shorter from Trolley Boys Queensland Pty Limited. The role played by Ms Shorter in that organisation was, curiously, that of a part-time unpaid volunteer, overseer/supervisor emanating, it would seem, from the fact that her two younger sons were employed as the main trolley boys at Woolworths Marketplace in Buderim and she was frequently in attendance at that small store complex.

In any event, after the meeting on the 17 January 2007, the deceased successfully trialled as a trolley boy. As a consequence, the deceased commenced paid employment on the basis of what should have been a sixhour day on the 24 January 2007 at 8am and that the deceased was monitored during the course of the day on three occasions by Mr TuetaNicholls, he being aware of the deceased's mother's concern about the capacity for her son to perform the requisite tasks because he was overweight.

On the 29 January 2007, which was a humid and overcast day, Mr TuetaNicholls transported the deceased to his workplace. At the time the deceased was wearing shorts, highly visible shirt, work boots and socks and a cap on his head. He also had with him an esky with two water containers inside.

At this stage the deceased was monitored from 8 till 8.30am. Mr TuetaNicholls then left, returning at approximately 11.30am and remained for some 30 to 45 minutes. During this time he observed the deceased collecting trolleys and when he asked the deceased if he had been regularly drinking fluid the deceased replied, "Yes."

The deceased, however, had informed Mr Tueta-Nicholls that he had not eaten lunch but that he would have something later. Mr Tueta-Nicholls again left, returning next at approximately 2.50pm and observed that the deceased appeared to be functioning well, both cognitively and physically at his work, albeit that the deceased did inform him that he was hot.

At this stage, both the deceased and Mr Tueta-Nicholls had occasion to attend at the corner of Ballenger Road and King Street Buderim, to retrieve two trolleys. They returned to the supermarket where upon the deceased informed Mr Tueta-Nicholls that he wanted to sit down and consequently the deceased sat on a bench outside Woolworths.

Shortly thereafter, Mr Tueta-Nicholls observed the deceased to be pale. He asked the deceased if he wanted any water but he declined. It was at this juncture that Mr Tueta-Nicholls called for an ambulance and administered a form of first aid by pouring some water over the deceased's head to cool him down and laid him down on the cement path in the recovery position.

Very shortly after making a second call for an ambulance, paramedics attended at the scene and the deceased was transported unconscious with a high temperature, to the Caloundra Hospital, but because of the serious nature of his condition he was then transported to the Intensive Care Unit, Nambour General Hospital, where, during the course of his hospitalisation from the 27 January 2007 to the early hours of the 8 February 2007, he received appropriate medical care including being placed on life support as he was comatose and had suffered multiple organ failure.

At approximately 12.40pm life support was removed with the consent of the deceased's father after he had taken appropriate medical and other advice, such that the deceased passed away at 1.40am.

The evidence also discloses that Dr Nichols, when discussing the issue of diet and exercise with the deceased, particularly on the 22 December 2004, 16 March 2005 and 23 August 2006, informed him contextually that he should dress appropriately, avoid long periods in the sun on very hot days and to keep well hydrated. He did this, as a person suffering schizophrenia can sometimes become somewhat disorganised, thus such commonsense heatstroke prevention strategies needed to be mentioned.

Ms Shorter, on the 17, and again on the 24 January 2007, emphasised to the deceased, amongst other things, the importance of drinking plenty of water due to the risk of fainting, becoming dehydrated and becoming unwell. She also informed him of the location of drinking water taps, the need for appropriate headwear and to take drink breaks as needed.

Mr Tueta-Nicholls, on the 29 January 2007, also reinforced to the deceased that he should maintain his water intake.

Now, I've taken into account the main submissions made by Mr Cottersby, the solicitor for the next of kin, Mr Allan, counsel for STEPS Employment, Ms Rosengren, counsel for Queensland Health, Mr Lippett, counsel for the Trolley Boys Queensland Pty Limited.

It must firstly be said that the state of the evidence is such that I am not prepared to find either medically or scientifically that Clozapine/Clozaril played any major part in the deceased's death from heatstroke, and of course it cannot be excluded that unfortunately the deceased was one of those individuals who had a susceptibility to heatstroke.

Dr Nichols alluded to a theoretical risk or compromise to the heating regulating system, but as I understood his evidence, that related to studies conducted with animals rather than humans and in the only case worldwide where there was some linkage between Clozapine and heatstroke, the patient in that instance recovered.

Secondly, I find on the evidence that the assessment and subsequent supervisory role undertaken by STEPS was appropriate in the circumstances based upon, and amongst other things, information supplied to that organisation by the Adult Mental Health Services at Cottontree, and in that regard Dr Nichols' advice would have been, in reality, no different from that given by the Clozapine Clinic Coordinator, save, perhaps, that he would have recommended or suggested that the deceased start off working a-half day shift to assess his work coping ability and then if appropriate, increase his work hours over time.

In that regard, the only comment I wish to make in accordance with section 41(1A) and to a lesser extent perhaps, subsection (C), is that I will recommend, which would seem in all respects to accord with the general practice of the Adult Mental Health Service, that the request for assessment information form and/or any attended report, see Exhibit 4, attachments 8 and 9, should be completed in all respects by the patient's treating doctor, who, in my view, would be better placed to make comment on the patient's medical circumstances in the context of a working environment. For example, suggesting the type and hours of work that may be suitable.

The Inquest will now be closed.