Bramble, Julie Anne

OFFICE OF THE STATE CORONER FINDINGS OF INQUEST CITATION: Inquest into the death of Julie Anne Bramble TITLE OF COURT: Coroners Court JURISDICTION: Bundaberg FILE NO(s): 2011/1128 DELIVERED ON: 6 December 2012 DELIVERED AT: Rockhampton HEARING DATE: 14 August 2012 FINDINGS OF: AM Hennessy, Coroner CATCHWORDS: Coroners: inquest, death at home from septicaemia, housemates did not seek medical attention, whether there was a duty owed by housemates to deceased (referral).

REPRESENTATION: Counsel Assisting: Ms A Martens For Mr Brien and Mr Martin: Mr Doug Winning (for submissions)

Introduction These findings seek to explain, as far as possible, how the death of Julie Anne Bramble occurred on 1 April 2011. Consequent on the court hearing the evidence in this matter, where learnings indicate that changes can be made to improve safety and changes to practices and procedures, recommendations may be made with a view to reducing the likelihood of a similar incident occurring in future.

I express my sincere condolences to the family of Ms Bramble for her tragic loss.

The Coroner’s jurisdiction

1. The coronial jurisdiction was enlivened in this case due to the death falling within the categories of section 8 of the Coroners Act 2003 (the Act) as Ms Bramble’s death was an ‘unnatural death’ and section 9 of the Act. A Coroner has jurisdiction to investigate the deaths under section 11(2), to inquire into the cause and the circumstances of a reportable deaths and an inquest can be held pursuant to section 28.

2. A Coroner is required under section 45(2) of the Act when investigating a death, to find, if possible:-

• the identity of the deceased,

• how, when and where the death occurred, and

• what caused the death.

3. An inquest is an inquiry into the death of a person and findings in relation to each of the matters referred to in section 45 are delivered by the Coroner which includes a finding about the circumstances in which the person died, as distinct from the means or mechanism by which the death occurred. The focus of an inquest is on discovering what happened, informing the family and the public as to how the death occurred, but not on attributing blame or liability to any particular person or entity.

4. The Coroner also has a responsibility to examine the evidence with a view to reducing the likelihood of similar deaths. Section 46(1) of the Act, authorises a Coroner to ‘comment on anything connected with a death investigated at an Inquest that relates to – (c) ways to prevent deaths from happening in similar circumstances in the future’. Further, the Act prohibits findings or comments including any statement that a person is guilty of an offence or civilly liable for something.

5. Due to the proceedings in a Coroner’s court being by way of inquiry rather than trial, and being focused on fact finding rather than attributing guilt, section 37 of the Act provides that the Court may inform itself in any appropriate way and is not bound by the rules of evidence. The rules of natural justice and procedural fairness apply in an inquest. The civil standard of proof, the balance of probabilities, is applied.

Findings of the inquest into the death of Julie Anne Bramble 1

6. All interested parties can be given leave to appear, examine witnesses and be heard in relation to the issues in order to ensure compliance with the rules of natural justice. In this matter, no parties sought leave to appear at the Inquest but Mr Martin and Mr Brien made submissions through a solicitor regarding the issue of referral to Director of Public Prosecutions (DPP).

7. I will summarise the evidence in this matter. All of the evidence presented during the course of the inquest, exhibits tendered and submissions made have been thoroughly considered even though all evidence or submissions may not be specifically commented upon.

8. At the time of her death, Ms Bramble resided with her eight year old daughter, Mr Wayne Brien and Mr Percy Martin at 31 Childers Road, Bundaberg. The four had resided together for over six years.

9. Both Ms Anderson and Mr Sitters (friends of Ms Bramble, Mr Brien and Mr Martin) believed Mr Martin and Ms Bramble may have been in a relationship due to the way they acted. Mr Brien and Mr Martin both gave evidence that Mr Martin and Ms Bramble had previously been in a romantic relationship however at the time of Ms Bramble’s death they were not in a romantic relationship.

10. Prior to giving evidence at the inquest, both Mr Brien and Mr Martin were granted immunity under section 39 of the Coroners Act 2003. Therefore, the evidence which they gave at the inquest cannot be used against them in any other proceedings.

Medical Records

11. Ms Bramble’s Medicare records were obtained. Ms Bramble appeared to attend Dr Abid Majid’s practice when she required medical assistance.

Ms Bramble’s medical records noted Ms Bramble’s current prescriptions as Biperiden hydrochloride, Lexapro and Ventolin inhaler. Ms Bramble’s last appointment was on 4 March 2011. On this occasion, Ms Bramble was feeling down, agitated and there was a relapse of her depression.

Ms Bramble was prescribed Lexapro for 4 days.

Evidence regarding Ms Bramble’s alcohol and drug use

12. Two of Ms Bramble’s close friends, Ms Anderson and Mr Sitters provided statements and gave evidence at the Inquest. Both witnesses had known Ms Bramble for a number of years and prior to her residing with Mr Brien and Mr Martin.

13. Ms Bramble was described by her friends as a heavy drinker and smoker. Ms Anderson and Mr Sitters gave evidence that Ms Bramble drank alcohol every day and would often consume an entire carton of beer in one day. Mr Sitters told the court that quantifying the amount of Ms Bramble’s drinking was difficult as she would drink from the time she woke up until the time she went to bed.

14. Ms Anderson noted that in the few years prior to Ms Bramble’s death, Mr Martin had assisted Ms Bramble reduce the amount of alcohol she consumed, helped Ms Bramble put on weight and she appeared healthier. Ms Anderson gave evidence that prior to her death Ms Bramble consumed approximately three – four tallies of beer a day, however on paydays she would consume more, between one to two cartons per day.

15. Mr Martin told the court that in the months prior to Ms Bramble’s death, she consumed at least four – five tallies per day. Mr Brien told the court that Ms Bramble consumed five – six tallies per day.

16. Mr Sitter had no direct knowledge that Ms Bramble consumed drugs however he believed she may have because she sometimes acted in a similar way to others whom he knew had taken drugs. He described Ms Bramble at times as having glassy eyes and an altered attitude and she would have different mood swings.

17. Ms Anderson understood Ms Bramble to have been a drug user prior to her daughter’s birth. She had no knowledge about whether or not Ms Bramble was a current drug user.

18. Mr Martin told the court that he believed Ms Bramble previously used drugs. He formed this view after he once saw Ms Bramble in her room injecting herself with a needle. When they were in a relationship, Ms Bramble ceased taking drugs. Mr Martin believed that Ms Bramble restarted using drugs approximately six months prior to her death based on her mood changes.

19. Mr Brien told the Police that attended on the day of her death, that Ms Bramble was a heavy amphetamine user. However, during evidence, Mr Brien told the court that Ms Bramble told him she had used speed and that for the last 6 months she was taking drugs. Mr Brien was unable to give any further assistance such as how much or how often Ms Bramble consumed drugs.

Evidence regarding Ms Bramble seeking medical/ambulance assistance

20. Mr Sitters stated that Ms Bramble would not seek medical attention or call an ambulance when she was sick. Ms Bramble did not want medical staff to find out about her drinking or illnesses as she was fearful that her daughter would be taken away from her. Ms Bramble often mentioned this to Mr Sitters and then stated that she thought doctors were a ‘bunch of idiots’.

21. Mr Sitters recalled an occasion approximately two years prior to her death when Ms Bramble had been drinking at Mr Sitters’ residence and was unable to get out of a chair as she had extreme lower back and kidney pain. Mr Sitters called an ambulance without Ms Bramble’s Findings of the inquest into the death of Julie Anne Bramble 3

knowledge and when the ambulance arrived, Ms Bramble was abusive towards paramedics and Mr Sitters and refused medical treatment.

22. Ms Anderson was able to recall a couple of occasions when Ms Bramble had previously been sick but was refusing to go to the doctor or have an ambulance called. Ms Anderson described Ms Bramble as being very stubborn. In evidence, Ms Anderson stated Ms Bramble did not like doctors. Ms Anderson recalled an occasion a year or two ago when an ambulance had been called for Ms Bramble and she yelled and screamed and refused to go with the ambulance officers. It is unclear whether this was the same occasion Mr Sitters also recalled or a different occasion.

23. Mr Brien gave evidence that he recalled calling an ambulance for Ms Bramble, without her consent, approximately 6 months prior to her death in relation to liver problems. Mr Brien recalls this occurred before he thought Ms Bramble recommenced using drugs. Whilst Ms Bramble initially refused to go with the ambulance, when they arrived she did go with them to seek medical attention.

24. Mr Martin was able to recall this incident but his version was that Ms Bramble had consented to the ambulance being called and that is why she went with the ambulance officers.

Circumstances leading up to Ms Bramble’s demise

25. Mr Sitters last saw Ms Bramble on 23 March 2011. On this occasion, Ms Bramble had a chest infection and cold symptoms and a very heavy smokers cough. In evidence Mr Sitters told the court he was told by someone else that Ms Bramble had a chest infection. He did observe Ms Bramble to have flu like symptoms. Mr Sitters was unaware of whether Ms Bramble was taking any medication. Despite this illness, Ms Bramble drank almost an entire carton of Victoria Bitter that day.

26. Mr Martin told police on the day of her death, that he had not observed her to have used drugs in the previous five days. When he gave evidence, Mr Martin said he had no explanation for Ms Bramble’s behaviour and physical appearance and assumed it was as a result of ceasing drugs however he had no direct knowledge of her using or withdrawing.

27. Mr Brien told police on the day of Ms Bramble’s death, that Ms Bramble last used drugs four days ago and that she ordinarily went away from the home to use drugs. When he gave evidence, Mr Brien stated he could not say for sure when Ms Bramble had last consumed drugs and/or whether Ms Bramble was attempting to give up drugs. He told police that Ms Bramble had complained of a sore body during that period of time.

28. Ms Anderson recalls visiting Mr Bramble at her residence about four or five days prior to her death. Ms Anderson recalls that Ms Bramble was sick at the time. Ms Bramble stated she had a chest infection and she

was coughing, Ms Anderson thought it was like a smokers cough. Ms Anderson also observed Ms Bramble to user her asthma puffer however her usage of the puffer was the same as what it ordinarily was, after every cigarette. During this visit, Ms Bramble gave advice to Ms Anderson, trying to persuade Ms Anderson to cease taking drugs and sort out her life.

29. Mr Brien gave evidence that in the days leading up to Ms Bramble’s death she appeared a bit sick and tired, like she had a hangover, however he did not notice any significant changes in her. Ms Bramble continued to smoke and drink as usual. Mr Brien did observe Ms Bramble to have some bruising on her arms which he believed may have been linked to intravenous drug usage.

30. Mr Martin told police on the day of Ms Bramble’s death that in the three to four days prior to her death, Ms Bramble had a little food and a little bit of water. Everything went straight through her. Mr Martin claimed Ms Bramble was urinating and defecating in the bed. This occurred on more than one occasion. Mr Martin would assist Ms Bramble wash herself. Mr Martin was concerned about Ms Bramble and wanted to call an ambulance. Ms Bramble said no and Mr Martin did not want Ms Bramble to be angry with him. Mr Martin gave evidence that he had never seen Ms Bramble in this condition before.

31. When he gave evidence Mr Martin stated that Ms Bramble was ‘pretty crook’ in the few days before her death. Ms Bramble was able to walk around but much slower than normal. He had to assist Ms Bramble to the bath and the toilet because she was so weak. Ms Bramble attempted to consume alcohol on the day prior to her death however she was only able to consume ¼ of a tallie.

32. Mr Martin stated that he asked Ms Bramble for four days straight to seek medical attention however she refused. He did not call an ambulance because he thought it would be a waste of time because Ms Bramble would refuse to go with paramedics.

33. There was some evidence that Ms Bramble may have been passing blood in the days prior to her death (this had also occurred on previous occasions, during one such occasion, Ms Bramble sought medical advice).

34. On 1 April 2011, Mr Brien and Mr Martin went into town at 9.30am. Prior to leaving, Mr Martin checked on Ms Bramble. Mr Martin observed Ms Bramble to be shaking. Mr Martin believed this was as a result of Ms Bramble ‘going cold turkey’ and not using drugs for four days.

35. Mr Martin asked Ms Bramble if she needed an ambulance. Ms Bramble indicated she did not.

Findings of the inquest into the death of Julie Anne Bramble 5

36. Mr Martin gave evidence that when he saw Ms Bramble before leaving the residence she was sitting on her bed. Both Mr Brien and Mr Martin tried to encourage Ms Bramble to come with them to the doctor they were seeing as the doctor was also Ms Bramble’s doctor.

37. Mr Brien says that up until their return from the doctors, he had not noticed any change in Ms Bramble. Despite this, he recalled that both he and Mr Martin tried to convince Ms Bramble to come with them to the doctors. Mr Brien recalls Ms Bramble sitting on her bed being argumentative about not wanting to go with her roommates.

38. Mr Brien and Mr Martin returned to the residence at approximately 11am. Mr Martin again checked on Ms Bramble. Ms Bramble was still shaking and she felt cold. Mr Martin asked Ms Bramble if he could ring an ambulance and Ms Bramble said no. Mr Martin said to Ms Bramble that her body was shutting down and she was getting cold.

39. Mr Martin discussed Ms Bramble’s situation with Mr Brien. Mr Brien stated that if Ms Bramble did not want an ambulance then they would not call an ambulance. Mr Brien denied this conversation as having occurred.

40. Ms Anderson recalls being called by Mr Sitter, her previous partner, about an hour or so prior to being told that Ms Bramble had died. Mr Sitter told Mr Anderson that Mr Martin had contacted Mr Sitter because Ms Bramble was sick and arguing with Mr Martin about going to the hospital and would not go or listen to Mr Martin. Ms Anderson left her friend’s house and returned home, intending to go to Ms Bramble’s residence however when she returned home, Ms Anderson was told that Ms Bramble had died. In evidence, Ms Anderson stated that Mr Sitters had asked her to come around and have a drink with Ms Bramble to calm her down and get her to the doctors. Mr Martin said he tried to get a hold of Ms Anderson as he believed she may have been the one person who may have been able to convince Ms Bramble to get medical attention.

41. After returning to the house and briefly speaking with Ms Bramble, Mr Martin watched TV and when he returned to Ms Bramble later he noticed she was ‘guzzling’. Ms Bramble was moving but not able to talk. Mr Martin identified that Ms Bramble was significantly unwell and because she could not talk, he asked Mr Brien to call an ambulance.

42. Mr Brien told police that after he and Mr Martin arrived home at 11am, Mr Martin went to speak to Ms Bramble. Mr Martin came out of the bedroom and told Mr Brien that Ms Bramble was not breathing properly.

Mr Brien called an ambulance and followed their directions. This was the first time that Ms Bramble had appeared like this.

000 call and QAS attendance

43. A 000 call was received by QAS at 12:41:55 pm. Mr Brien advised that Ms Bramble was getting off drugs and was not breathing properly. He stated that they had tried to wake Ms Bramble up but she did not comprehend what they were saying. Mr Brien was adamant Ms Bramble had not taken any drugs and was withdrawing. He confirmed that Ms Bramble was conscious and breathing (like an asthma type of breathing) however she was not completely awake and could not talk. Mr Brien described Ms Bramble as being cold, clammy and pale.

44. A unit was assigned to attend the scene at 12:44:17pm. This was the unit containing Advanced Care Paramedic (ACP) Becker and Student ACP Wilkinson. They departed for the scene, on code 1, at 12:45:14pm.

45. Mr Brien contacted 000 again at 12:48:13 to advise that Ms Bramble had deteriorated by passing out and she was currently unconscious. When Mr Brien was asked if Ms Bramble was breathing, he responded ‘no’.

He was then given some instructions to determine if Ms Bramble was breathing to which he replied ‘very slightly’. Mr Brien again indicated that Ms Bramble had not overdosed and she ‘hasn’t had anything’. Mr Brien was given instructions to perform CPR which he did until the paramedics arrived. Mr Brien noted immediately prior to the paramedics arrival that Ms Bramble was gurgling. He can be heard on the 000 call telling paramedics that Ms Bramble stopped breathing five minutes ago and he had been doing CPR for two minutes.

46. ACP Becker and Student ACP Wilkinson arrived at the residence at 12:51:51pm. Student ACP Wilkinson observed a male performing CPR on Ms Bramble who was lying on a bed. She observed that the mattress was springy and the CPR being performed appeared to be inadequate.

47. Student ACP Wilkinson asked how long Ms Bramble had not been breathing. The male stated that Ms Bramble had been short of breath and then stopped breathing. He had checked for a pulse but could not find one. The male then began doing CPR, which he had been doing for approximately three minutes prior to the arrival of the QAS. Student ACP Wilkinson and the male moved Ms Bramble onto the floor in the lounge room because the bedroom was extremely cluttered.

48. During the entire time of the involvement by paramedics, Ms Bramble remained unconscious with no obvious signs of life. Her pupils were bilaterally fixed and dilated with no respirations, no pulse and asystole.

Resuscitation efforts were ceased at 1.15pm and ICP Searle declared life extinct at 1.17pm.

49. The men told the ambulance officer that Ms Bramble had a history of drug use however she had been trying to stay clean for the sake of her daughter.

Findings of the inquest into the death of Julie Anne Bramble 7

Police attendance

50. Following Ms Bramble being declared deceased, police attended the residence. Both Mr Brien and Mr Martin provided information voluntarily to the police. These versions were noted in police notebooks. Both Mr Brien and Mr Martin signed the relevant notebooks. Mr Brien and Mr Martin were approached by police to provide a detailed statement of their knowledge of Ms Bramble’s death. Both Mr Brien and Mr Martin elected not to provide a statement to police.

Autopsy findings

51. An external and full internal post mortem examination was conducted by Dr Ashby on 7 April 2011. Dr Ashby noted that Ms Bramble was normally nourished. Dr Ashby observed hardened veins right brachial fossa (elbow crook) with one visible injection mark. Dr Ashby noted Ms Bramble’s tongue was dry, furred and cyanosed and her teeth were in poor condition. Dr Ashby reported Ms Bramble’s heart showed mild coronary artery atheroma. There is a myocarditis with abscess formation and areas of more diffuse inflammation. Micro-organisms were seen.

52. Dr Ashby noted that Ms Bramble’s lungs had suppurative pneumonia with areas of septic infarction. There were colonies of micro-organisms and foreign debris. Also, changes to suggest a smoking habit of cannabis, focal oedema. Adult respiratory distress areas. Dr Ashby observed Ms Bramble’s kidneys had abscesses and septic embolisation proximal renal tubule necrosis.

53. Toxicological analysis noted the following: Alcohol: Not detected (less than 10mg/100ml) Amphetamine: Detected (< 0.005mg/kg) Methylamphetamine: 0.05mg/kg Diazepam: Approx 0.02 mg/kg Nordiazepam: Approx 0.1 mg/kg Paracetamol: Detected (< 10 mg/kg) 11-nor∆9 tetrahydrocannabinol-9- Detected carboxylic acid:

54. Dr Ashby was of the opinion that Ms Bramble died from septicaemia due to or as a consequence of complications of attempted withdrawal from methylamphetamine. Dr Ashby believed that some of the withdrawal complications could have been increased parasympathetic activity with

diarrhoea and vomiting. Other possible causes of the septicaemia could be disseminated intravascular coagulation or residual problems from intravenous amphetamine use namely rhabdomyolysis.

Expert reports

55. An expert report was provided by Dr Hall, a Forensic Medical Officer from the Clinical Forensic Medicine Unit examining the toxicology results and Ms Bramble’s cause of death. Dr Hayllar, the Clinical Director of the Alcohol and Drug Service in the Metro North Health Service District also provided a report.

56. Dr Hall noted that the ratio between the amphetamine and methylamphetamine in Ms Bramble’s toxicology results indicate that the amphetamine was as a result of the breakdown of methamphetamine and the methamphetamine present is as a result of taking the drug itself.

Dr Hall reported that both methylamphetamine and amphetamine undergoes post-mortem redistribution and the levels found in Ms Bramble may have been lower. Dr Hall gave evidence that this suggested Ms Bramble had recently used methylamphetamine, probably 24 to 48 hours prior to her death.

57. Dr Hayllar noted that the concentrations of methamphetamine and amphetamine, having regard to the limitations in interpreting levels in post mortem samples suggest recent use with no evidence of intoxication or overdose.

58. Dr Hall indicated that amphetamines are taken by recreational drug uses for their stimulant effect on the central nervous system, namely euphoria, excitement, reduced fatigue, raised self-esteem, increased energy, increased alertness, increased attentiveness and greater concentration, but it can equally result in irritability, restlessness and aggression, as well as loss of appetite and insomnia. Mild to moderate use can be associated with a paranoid psychosis, with persecutory ideas, delusions, and hallucinations in the peripheral vision but these are more common at higher levels. These symptoms may persist for some time after the drug has cleared from the person’s body.

59. Dr Hall reported that as the effects of amphetamine use wear off, a rebound effect ensues with extreme fatigue and falling asleep, which may be potentiated by the effects of monotonous activities. In users habitually taking large doses with high blood levels, these rebound effects may occur while significant blood levels of the drug are in the system. Tolerant individuals have more severe withdrawal symptoms.

60. Dr Hayllar noted that the information provided about Ms Bramble’s amphetamine use is very limited: ‘heavy’ is a broad description and certain features of amphetamine use need to be considered. Typically, it is an intermittent pattern of use, characterised by between one and a few days of use followed by larger periods without use.

Findings of the inquest into the death of Julie Anne Bramble 9

61. Dr Hall noted that the literature does not refer to deaths as a result of amphetamine withdrawal. The effect of withdrawal from the amphetamines, or abstinence syndrome, is described as a ‘crash’ where the person experiences profound fatigue, often sleeping for days, followed by a period of ‘normality’, then developing craving for amphetamine. This often follows a period of relative ’bingeing’ on the drug, with repetitive dosing. Although there may be a potential risk of pneumonic aspiration, the subject is not intoxicated so there is no risk of protective reflexes being compromised, thus this outcome is unlikely.

Most subjects simply sleep the effects off and return to ‘normality’.

62. Dr Hayllar reported that amphetamine withdrawal is divided into three stages: crash, withdrawal and extinction. The crash typically may last 48 hours, withdrawal then lasts two - four days and extinction may endure for weeks. Symptoms of amphetamine withdrawal are typically fatigue, lethargy, appetite disturbance, depression, irritability, psychomotor retardation or agitation and strong craving.

63. Dr Hayllar also noted that in order of withdrawal severity across the substances, given an equivalent level of dependence, alcohol can be ranked as most severe, with potential life threatening complications of seizures and delirium tremens, sudden benzodiazepine withdrawal may also be complicated by seizures, next opioid withdrawal which is described as being like a severe dose of influenza, then come amphetamine and cannabis withdrawal which are generally accompanied by relatively mild physical symptoms, although mental distress may be considerable.

64. Dr Hayllar gave evidence alcohol withdrawal signs are a state of arousal, sweaty, hypertensive, agitated, vomiting, and diarrhoea. The worst symptoms occur two – three days after alcohol is ceased. Dr Hayllar stated that it is possible some of Ms Bramble’s symptoms may have been as a result of alcohol withdrawal however if she had been drinking up until the day she died then her symptoms would not fit with alcohol withdrawal.

65. Dr Hall noted that the presence of diazepam and nordiazepam could be explained by the use of diazepam alone (nordiazepam is the active metabolite of diazepam). He reported that diazepam exhibited postmortem redistribution thus making the interpretation problematic. As the levels were not high, Dr Hall opined that the ingestion was not recent.

66. Dr Hall reported that the level of paracetamol was low and unlikely to have contributed to Ms Bramble’s death.

67. Dr Hall noted the presence of 11-nor∆9 tetrahydrocannabinol-9carboxylic acid. He noted this tended to accumulate in the body with repeated use of cannabis and because of its long elimination half-life it may persist many days and even weeks after ceasing use.

68. Dr Hall opined that the history that Ms Bramble had last consumed amphetamines four days previously could be true however post mortem redistribution particularly with respect to cartoid blood (where the sample from Ms Bramble was taken) with the absence of urine levels makes estimation of time frames difficult.

69. Dr Hall noted that the description (provided by Mr Brien and Mr Martin to police following her death) of Ms Bramble’s general condition in the days preceding her death is such that it may be stated she was in the withdrawal phase after taking methylamphetamine, with lethargy, and appearing to be bed-bound for some days. This does not suggest she was ‘giving up’ amphetamines; it represented the abstinence syndrome commonly seen with amphetamine use.

70. Dr Hayllar reported that the very limited lay description of Ms Bramble’s state over the four – five days prior to her death made it difficult to comment definitively on the nature of her experience, however the impression Dr Hayllar gained was that Ms Bramble had a progressive and catastrophic illness rather than the crash and withdrawal described by someone ceasing amphetamine use. He also gave evidence that the symptoms fit more with an infective process than alcohol withdrawal.

71. The different versions provided by Mr Brien (that Ms Bramble was tired appeared ‘hung-over’ but otherwise fine up until the ambulance was called) and Mr Martin (that Ms Bramble was deteriorating over a number of days) were put to Dr Hall and Dr Hayllar. Both agreed that Mr Martin’s version was more consistent with Ms Bramble suffering from septicaemia. Both Dr Hall and Dr Hayllar gave evidence it would be difficult to explain the sudden deterioration as suggested by Mr Brien.

Dr Hall commented that a person would not deteriorate rapidly within two hours unless they were suffering from meningococcal.

72. Dr Hayllar stated that the version provided by Mr Martin would not fit with the pattern of either alcohol or methylamphetamine withdrawal.

73. Dr Hall believed Ms Bramble was suffering from an infective process, with possible diarrhoea and perhaps even a urinary tract infection as she was incontinent of urine and faeces. The description provided by Mr Martin of ‘cold and shaking’ may represent rigors secondary to fever.

74. Dr Hall noted Ms Bramble’s appearance at autopsy was of dehydration with a dry, furred mouth and desiccated tissues. The presence of a ‘bone marrow needle’ (or interosseous cannula) suggests that QAS personnel could not access a vein, either due to previous damage and scarring from long-term intravenous drug use, or because of venous shut down secondary to dehydration and/or septic shock or a combination of both.

75. Dr Hall was of the view that the histological findings at autopsy strongly suggest septicaemia, with widespread infection and abscess formation, Findings of the inquest into the death of Julie Anne Bramble 11

particularly involving heart, lung and kidneys. There is no suggestion as to primary focus, however in intravenous drug users there is a high risk of sepsis as a result of unhygienic injection practices and no guarantee that drugs are contaminant-free. Ms Bramble was also noted to have poor dentition which could contribute as a potential infective source.

Other sources of septicaemia include urinary tract infection, gastroenteritis.

76. Dr Hayllar reported that there was little doubt from the autopsy findings that Ms Bramble’s cause of death was septicaemia and injection drug use is the most plausible antecedent. Poor dental hygiene is a remote possibility as is pneumonia, either primary or secondary to orthostasis (lying in bed contributing to poor clearance of secretions) or aspiration with regurgitation of gastric contents into the lungs.

77. Both Dr Hall and Dr Hayllar agreed that the evidence of Ms Bramble passing blood in the last week could have been haemorrhoids or infective causes. They also agreed that if Ms Bramble had a chest infection this could also have developed into septicaemia.

78. Dr Hayllar was of the opinion septicaemia provided a coherent explanation for Ms Bramble’s illness leading up to death. She suffered a devastating process with prostration, anorexia, incontinence, shaking and coldness as she developed circulatory collapse. Dr Hayllar was surprised Ms Bramble was able to respond to the question of whether she wanted an ambulance called in the hours leading up to her death.

79. Dr Hall reported that it was difficult to state that the infective processes occurred as a result of withdrawal from amphetamines, when there is little available in the literature to point to toxic reactions from acute amphetamine withdrawal, indeed, in the clinical picture there is little to suggest anything different from normal amphetamine use, and the ‘crash’ phase associated from short term abstinence.

80. Dr Hall noted in his report that his opinion was that the cause of death should not be due to or as a consequence of withdrawal but instead ‘complications of intravenous methamphetamine abuse’ would be more appropriate.

81. Dr Hayllar suggested that the phrase ‘amphetamine withdrawal’ creates an expectation of an illness that is unlikely to be of relevance in Ms Bramble’s death, and a withdrawal state, if it existed, played a minimal role in her death.

82. Both Dr Hall and Dr Hayllar were critical of the lack of action taken by Ms Bramble’s roommates. Dr Hayllar was of the view that Ms Bramble was unable to care for herself and little or no regard should have been paid to her own wishes. He was also of the view that if the ambulance had been called earlier and the right treatment been provided, Ms Bramble may have survived.

83. Both Dr Hall and Dr Hayllar gave evidence that any person wishing to cease taking alcohol or drugs should seek professional help. Initially a person should approach their general practitioner or hospital for assistance and referral to various programs. At the very least, a medical practitioner can provide information about what symptoms to expect and signs to be aware of suggesting further medical attention should be sought.

Findings on the evidence

84. There is little evidence regarding Ms Bramble’s drug use. No witness was able to offer any information about Ms Bramble recent use and the amount consumed. There is also very little evidence that Ms Bramble was attempting to ‘detox’ from drugs. Mr Martin’s version regarding Ms Bramble’s deterioration is preferred over Mr Brien’s in light of the medical evidence.

85. It would appear that Mr Brien and Mr Martin did little to ascertain the cause of Ms Bramble’s deterioration. They both appear to have made an assumption that Ms Bramble was detoxing from drugs because Ms Bramble had never presented like this previously. It is very likely that Ms Bramble was actually suffering the severe effects of an infective process that was spreading throughout her body.

86. There is no doubt that medical assistance should have been sought prior to Ms Bramble’s death. Seeking such assistance may very well have prevented her death.

87. There was evidence that an ambulance had, previous to this week, been summonsed for Ms Bramble and she had refused to receive medical treatment however on at least one other occasion she had received medical attention from an ambulance. There is also evidence that Ms Bramble saw her general practitioner for numerous ailments over the years.

88. Mr Martin was concerned and wanted to call an ambulance for Ms Bramble for a number of days. Both Mr Brien and Mr Martin attempted to have her attend her general practitioner which suggests both were aware her deteriorating condition required medical attention and that she was known to attend her general practitioner when needed.

89. Given Ms Bramble’s deteriorating state, her wishes for an ambulance not to be called should have been disregarded and an ambulance called.

At the worst, if Ms Bramble had then refused medical attention then the position would have been the same however there was the real potential that Ms Bramble may have accepted medical attention when it arrived.

90. There is no evidence to suggest that Ms Bramble’s septicaemia was caused as a result of withdrawing from drugs. There are a number of possible causes of Ms Bramble’s septicaemia, such as poor dental Findings of the inquest into the death of Julie Anne Bramble 13

hygiene, a possible chest infection, a possible bowel infection and unhygienic injection practices. There is no way to ascertain now, which of these possibilities, or whether a combination of these possibilities, was the cause of the septicaemia.

Findings required under section 45 I make the formal findings: a. The identity of the deceased was Julie-Anne Bramble; b. The date of death was 1 April 2011; c. The place of death was at 31 Childers Road, Bundaberg; d. The formal cause of death was septicaemia; and Ms Bramble died as a result of suffering from an infective process that was untreated. The cause of the infective process is unable to be identified. Had Ms Bramble received appropriate medical attention, her death may have been prevented. An underlying circumstance was likely complications of intravenous methamphetamine abuse.

Referral

91. Section 48(2) of the Act gives a coroner discretion to give information to the Director of Public Prosecutions (DPP) if the coroner reasonably suspects a person has committed an indictable offence. The threshold provided for in section 48(2) of the Coroners Act 2003 is reasonably low.

From the information obtained whilst investigating Ms Bramble’s death, a coroner only needs to reasonably suspect a person has committed an indictable offence.

92. The evidence Mr Brien and Mr Martin gave at the inquest has not been considered in determining whether or not they should be referred to the

DPP.

93. A coroner does not need to be satisfied that the elements of the offence have been met; the standard for a referral to the DPP is much lower than that. A coroner’s state of mind does not need to be such that they are satisfied of an offence having been committed, or convinced that an offence has been committed. The coroner need only have a reasonable suspicion that an offence has been committed. A reasonable suspicion must be based on grounds that are reasonable in the circumstances.

94. Legislation provides sanctions for the failure to supply necessaries and negligent acts causing harm however both of these offences require a person to have a ‘duty’ to the person injured and do not relate to death, they relate more to harm or permanent injury at best.

95. The relevant criminal offence in the circumstances of Ms Bramble’s death, if a duty is established, is manslaughter (sections 302 and 303 of the Criminal Code Act 1899).

96. The negligence necessary to establish a criminal charge is greater than that required in a civil case. The test as to criminal liability is set out in R v Bateman (1925) 94 LJKB 791 where Hewart LCJ said: In explaining to juries the test which they should apply to determine whether the negligence in the particular case amounted or did not amount to a crime, judges have used many epithets, such as culpable, criminal, gross, wicked, clear, complete. But, whatever epithet be used, and whether an epithet be used or not, in order to establish criminal liability the facts must be such that, in the opinion of the jury, the negligence of the accused went beyond a mere matter of compensation between subjects and showed such disregard for the life and safety of others as to amount to a crime against the State and conduct deserving punishment…..It is desirable that, as far as possible, the explanation of criminal negligence to a jury should not be a mere question of epithets. It is in sense a question of degree and it is for the jury to draw the line, but there is a difference in kind between the negligence which gives a right to compensation and the negligence which is a crime.

97. In order to establish manslaughter by criminal negligence, it is sufficient if the prosecution shows that the act which caused the death was done by the accused person consciously and voluntarily, without any intention of causing death or grievous bodily harm but in circumstances which involved such a great falling short of the standard of care which a reasonable man would have exercised and which involved such a high risk that death or grievous bodily harm would follow that the doing of the act merited criminal punishment: Nydam v R [1977] VR 430.

98. In R v Pesnak [2000] QCA 245 a husband and wife (the Applicants) were charged with the manslaughter of their friend on the basis of criminal negligence in not obtaining medical assistance. The deceased came to stay in a caravan in their backyard where she voluntarily commenced a 21 day spiritual cleansing program conducted by the husband with the assistance of his wife. It involved a fast of seven days without food or fluid followed by 14 days with some fluid. While she was undergoing this program she suffered a stroke, acute renal failure and ischemia of the right foot which led to pneumonia from which she died.

The husband and wife were criminally negligent in not obtaining medical assistance for the victim until it was too late. The absence of any intention was irrelevant. The 'criminal negligence' was that the victim was in their care. The Court said Findings of the inquest into the death of Julie Anne Bramble 15

Whilst intention is relevant to sentence, a major criminal factor in criminal negligence manslaughter cases is the extent of the departure from reasonable community standards which constitutes the criminal negligence. The Applicants did not intend to harm the deceased through their failure to obtain medical assistance for her; they believed her serious symptoms were caused by spiritual struggle. Nevertheless their failure to respond to her obvious and increasingly serious symptoms constituted an extremely grave departure from reasonable community standards.

99. The Court noted that the husband and wife were tertiary educated, well respected in the community and that the husband had undertaken some form of first aid course.

100. In R v Miller [2011] QCA 160 a daughter was charged with the manslaughter of her elderly mother. The mother had been living with the daughter for a period of time. Police and paramedics who attended the residence found the living conditions to be squalid. The autopsy revealed the mother had sepsis as a consequence of bed sores (there was evidence that a number of bed sores were extensive and maggots were found within some of the infected bed sores). The Court found that the mother had gradually deteriorated to a point where incapable of making decisions about her own care, and as such the daughter was required to make decisions for her. Despite the difficulty in their relationship and the mother’s previous history of refusing medical assistance, as the daughter became overwhelmed, she was obliged by law to obtain assistance.

101. The Court referred to an unreported decision of R v Cramp, unreported, Supreme Court of Queensland, White J, 30 January 2008. This matter involved a mother whose three year old daughter was in the shower by herself and knocked her head sustaining a laceration and acute leftsided subdural haemorrhage. The mother went to a neighbour and asked for advice on concussion however because she did not want to lose her children (they had previously been in foster care) she did not call an ambulance until it was too late and the child was dead. White J said: This is a serious case of neglect. It would have been so easy to dial triple 0 and call an ambulance immediately.

There was no question of implicating anyone else in the injury.

102. In all of the above cases, the deceased person was incapable of making their own decisions about their care and was in the care of the accused.

103. Mr Martin’s version to police was that he wanted to call an ambulance for Ms Bramble however he did not because Ms Bramble was refusing

medical assistance. This would suggest that Ms Bramble was able to communicate her views. The issue is whether Ms Bramble was in a position to make decisions regarding her care given her deteriorating state and the clear concerns Mr Martin held.

104. According to the evidence of Mr Brien and Mr Martin, Ms Bramble only became incapable of making decisions at around about the time the ambulance was called. This evidence with respect to Ms Bramble’s capacity to make decisions is questionable, when coupled with the evidence of her very poor physical state.

105. It is unclear whether Ms Bramble could be said to be ‘in the care of’ Mr Brien and/or Mr Martin and therefore whether they could have owed a duty to her.

106. However, the case law dictates that one of the major factors in criminal negligence manslaughter is the extent of the departure from reasonable community standards. The reasonable community standards in this case being, that any reasonable person in the same position as Mr Brien and Mr Martin, would have not accepted Ms Bramble’s refusal of medical care and would have called an ambulance. It is clear that in this matter, the men did depart from reasonable community standards.

107. The submission made on behalf of Mr Brien and Mr Martin relies on the absence of evidence of a duty existing between the men and Ms Bramble. The duty identified in Section 285 of he Criminal Code arises in three ways: It is the duty of every person having charge of another who is unable by reason of age, sickness, unsoundness of mind, detention, or any other cause, to withdraw himself or herself from such charge, and who is unable to provide himself or herself with the necessaries of life, whether the charge is undertaken under a contract, or is imposed by law, or arises by reason of any act, whether lawful or unlawful, of the person who has such charge, to provide for that other person the necessaries of life; and the person is held to have caused any consequences which result to the life or health of the other person by reason of any omission to perform that duty.

108. The only possible ground under which the duty might arise in these factual circumstances would be the third in the section ‘arises by reason of any act’. Neither man was in a situation of holding a charge under contract or imposed by law. The relationship between the parties was, at best, housemates. The circumstance in which a duty might be argued to exist really arose for the illness of Ms Bramble rather than any act of either man, towards her or otherwise. Whilst it is objectively obvious with the benefit of hindsight that the men should have acted sooner to obtain medical assistance for Ms Bramble and their reticence to do so Findings of the inquest into the death of Julie Anne Bramble 17

along with their lack of understanding of what her medical condition actually was (and the seriousness of it) have all contributed to the tragic outcome.

109. Despite the apparent departure from reasonable community standards which is evident in this case, I cannot hold a reasonable suspicion that Mr Brien and Mr Martin may have been criminally negligent as there does not seem to have been a relationship between them and Ms Bramble which could give rise to a duty of care being owed to her. As such, I do not intend to refer this matter to the DPP for consideration.

Recommendations/Comment

110. Both Dr Hall and Dr Hayllar were supportive of information being conveyed to the public about seeking medical assistance when withdrawing from alcohol and/or drugs and the public being reminded to be aware when others might need medical assistance and to seek medical assistance irrespective of their views

111. I intend to provide the Chief Health Officer with a copy of these findings in order to determine whether a statement might be able to be issued to further inform the public on the issues identified in the previous paragraph.

A M Hennessy Coroner 6 December 2012