Coroner's Finding: SABINO Joseph Manuel

CORONERS ACT, 1975 AS AMENDED SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 29th day of November, and 11th day of December, 2000, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Joseph Manuel Sabino.

I, the said Coroner, do find that Joseph Manuel Sabino, aged 36 years, late of Unit 1, 195 Young Street, Unley, in the State of South Australia, died at the Lyell McEwin Hospital, Elizabeth on the 21st day of December, 1999 as a result of cardiac failure associated with intravenous methylamphetamine abuse and exertion. I find that the circumstances of death were as follows:-

1. Introduction 1.1 At about 11.00a.m. on Tuesday 21 December 1999 Tracey Lawrence was confronted by an unknown man in the laundry of her house in McCabe Avenue, Parafield Gardens. He asked for a glass of water, then went into her lounge room. He asked to use her bed, and when she refused he offered her one of the rings on his finger. She refused. He then asked to lay down on her verandah.

1.2 While the man was laying down on the verandah, Ms. Lawrence called a friend, who sent her boyfriend over. By the time the boyfriend arrived, the man had gone. Ms.

Lawrence called the police at about 11.50a.m. She described the man as “agitated and nervous”. She added:- “.... I was very scared and just wanted him to leave”. (Exhibit C.12a, p2).

1.3 At about 1.40p.m. the same day, the same man was seen by Samantha Tanner, another resident of McCabe Avenue, climbing on her back fence. When her two Rottweiler dogs began barking at him, he ran away. She called the police.

1.4 Constable Rodell and Probationary Constable McMahon attended at about 1.50p.m.

They spoke to Ms. Tanner, then drove around looking for the man. They found him crouched behind a bush behind a nearby house. He jumped the back fence of the house when the police approached him. They chased him and he ran away and they lost sight of him.

1.5 The man ran back to near Ms. Tanner’s house. He approached her in the driveway of her house and said:- “Fucking cops. Don’t tell them where I am”. (Exhibit C.9a, p1).

1.6 The man then hid behind a rubbish bale in the driveway of the house next door. When the police arrived, they asked the witnesses where the man was. One of the children pointed to where he was hiding. When the officer approached, the man stood up. He was described again as “agitated and nervous” (Exhibit C.11a, p2). The police officer tried to calm him down but the man turned, jumped the locked gates at Number 11 McCabe Avenue, and ran into the back yard.

1.7 Constable Rodell saw the man astride the fence between Numbers 9 and 11 McCabe Avenue. There were two German Shepherd dogs in the yard of Number 11, and two Rottweilers in Number 9. He made his way along the top of the fence and then jumped over the back fence into a laneway and disappeared. The officers continued to search the area for a few minutes and then resumed their patrol.

2. Final collapse 2.1 Joseph Sabino had stayed the night of 20-21 December 1999 at 3 McCabe Avenue with a friend, Sylvia Sherif. His defacto wife, Chelsea Miller, and daughter, Marisa Sabino, aged 15, had also been with him. Ms. Miller left at about 5.30 or 6.00a.m. on 21 December. She said:- “About 5.30-6.00a.m. on Tuesday, 21st December I left the house. When I left Joe he was still stressed out because he didn’t want me to go. I know Joe is an amphetamine user. He hadn’t ever used (it) in front of me.

When I left him in the morning he said he would catch a train and meet me in town to fix my car”. (Exhibit C.13a, p2-3).

2.2 Ms. Sherif gave the following statement to police:-

“At about 1.00p.m. today I was in the kitchen when I heard someone yelling out for help.

I looked out and saw Marisa’s dad, Joseph. Marisa was standing in the kitchen and as I looked at her Joseph came through the back door and he was staggering around in the laundry. I noticed that he was wearing a pair of black and white track pants and no shirt.

He was continually yelling ‘help, help’. He appeared to be very scared and he was shaking and freaking out.

It looked as though he thought someone was chasing him and he was panicking. Joseph was falling over and as he fell he was hitting his head really hard on the laundry wall.

He fell a couple of times and each time he hit his head as he went to the ground. Joseph was unsteady on his feet as though he was drunk or something. I cant remember seeing any open wounds or cuts but there was blood on one of his hands, on the back of his hand. We didn’t know what to do so Marisa called an ambulance. Joseph was unconscious and his eyes rolled back in his head. His arms started to turn blue and his mouth was open.

While we were waiting for an ambulance I was feeling for a pulse, but I couldn’t find one. I tried to give him mouth to mouth and CPR but he didn’t respond. Marisa was helping me but she was upset and crying.

The ambulance took about 2 minutes to arrive and when they arrived they attempted to revive Joseph. Joseph was taken to the Lyell McEwin Hospital and that is all I know”.

(Exhibit C.7a, p1-2).

2.3 Ms. Veronica Steeds, a neighbour, went to Number 3 at Marisa’s request. She commenced cardiopulmonary resuscitation (“CPR”), and continued until the ambulance arrived.

2.4 Ambulance officers McGregor and Brealey received the call at 2.15p.m., and attended at 2.24p.m.

2.5 The ambulance officers took over resuscitation efforts. The heart monitor showed that Mr. Sabino had no heart output. CPR was continued while he was transported “under full emergency conditions” to the Lyell McEwin Hospital (Exhibit C.5a, p2).

2.6 The ambulance arrived at Lyell McEwin Hospital at 2.42p.m., and Mr. Sabino was examined by Dr. Jeffrey Goh. Dr. Goh noted that he had no pulse or respiration, and his eyes were fixed and dilated. Notwithstanding this, further efforts were made to resuscitate him, including CPR, intubation, and medication, but these were unsuccessful and Dr. Goh pronounced him deceased at 2.57p.m. (Exhibit C.2a).

3. Cause of death 3.1 A post mortem examination was carried out on the body of the deceased by Dr. R.A. James, Forensic Pathologist, on 22 December 1999.

3.2 Dr. James found the cause of death to have been:- “Cardiac failure associated with intravenous methylamphetamine abuse and exertion”.

(Exhibit C.3a, p1).

3.3 Dr. James found “an obvious injection site” in the left inner elbow (Exhibit C.3a, p2).

Toxicological analysis carried out by Mr. Peter Harpas, Senior Forensic Scientist, on 11 February 2000 disclosed the presence of the following in the blood:-

• 0.65mg methylamphetamine per litre (excess but not fatal);

• approximately 0.1mg amphetamine per litre (non-toxic/therapeutic).

• tetrahydrocannabinol (THC) and its major metabolite 11-nor-9-carboxy-THC.

(Exhibit C.4a, p1).

3.4 Dr. James commented that the levels of amphetamine and methylamphetamine were “less than one would expect for most reported fatal cases from methylamphetamine alone”. He added:- “Fatalities from amphetamine and amphetamine derivatives are infrequent. Deaths have been associated with cardiovascular (acute left ventricular failure and ventricular fibrillation), cerebrovascular (subarachnoid haemorrhage), intracerebral haemorrhage, cerebral oedema and hyperthermia causes. Patients who die of cardiovascular causes often have predisposing factors such as co-administration of stimulants, hypocalcemia or pre-existing cardiovascular disease. In one series two thirds of amphetamine related fatalities resulted from violence including accidents, suicide and occasionally homicide.

Intravenous drug abusers are of course also subject to potentially fatal complications of illicit intravenous administration such as septicaemia, hepatitis, bacterial endocarditis and AIDS.

Acute cardiovascular deaths may be associated with cardiomyopathy, mitral valve disease, the results of raised cardiac output with complicating cardiac failure, hypotension and pulmonary oedema.

Sudden deaths have commonly occurred during physical or emotional stress probably from cardiac dysrhythmias.

In this case the described violent physical activity while under the influence of a large blood level of recently injected methylamphetamine is considered to be causally related to his death. The viral hepatitis noted at post mortem is considered to be a complication of his chronic intravenous drug abuse. The superficial injuries including linear parallel abrasions reflect the described activities before his death. The coincidental finding of cannabis (THC) in the blood is considered unrelated to his death”. (Exhibit C.3a, p5-6).

3.5 Dr. James also noted a number of superficial bruises and abrasions to the left arm, lower left rib margin, back and right shoulder. These can obviously be accounted for by the manner in which Mr. Sabino was acting before he collapsed, and the number of times he fell down in the laundry and hit his head severely at 3 McCabe Avenue.

There is no suggestion that there was any physical contact with the police officers that day which may have caused any of these injuries.

4. Why did Mr. Sabino run away?

4.1 On 12 December 1999 a particularly vicious home invasion and robbery with violence took place at a private house at Springfield.

4.2 Acting on information received, on 14 December 1999 Detective Senior Constable Cunningham and a number of other police officers attended at 1/195 Young Street, Unley, the residence of Mr. Sabino, and his defacto wife and child. The police searched the premises. During the search, three items of jewellery, valued at about $8,500, were located and later identified as having been stolen in the home invasion.

The police also found $1,850 in cash. Detectives later learned that Sabino had purchased a motor vehicle for $2,000 cash on 15 December 1999.

4.3 On the basis of this evidence, Mr. Sabino was a prime suspect for these serious criminal offences. He was clearly concerned about this. Ms. Miller said:- “He was freaking out. The police were after him”. (Exhibit C.13a, p2).

4.4 In a recent letter, Marisa Sabino described how she and her father and two friends had been walking to catch a train from Parafield Gardens on the morning of 21 December 1999 when they saw what they thought were “detectives in a blue Magna”. They panicked and ran away. Mr. Sabino and Marisa hid in a tree in the yard of a house, where they stayed for about an hour. When they left the tree, she said her father began “freaking out”, he jumped another fence and ran away and left her. This obviously led to the sequence of events in McCabe Avenue which led to Mr. Sabino’s eventual collapse and death.

4.5 I agree with the conclusions of Detective S.J. Duval, who investigated this matter on my behalf, when he reported:- “It is evident from the statements that Sabino was suffering some form of paranoia or delusions. It is likely his substance abuse is a contributory factor in his mental state. His cause of death is also closely related to his substance abuse.

...

I found that the death of Sabino was entirely of his own volition, and his cause of death closely relates to his illicit drug use. His decision to flee I believe was largely due to his paranoid state and just merely Police presence on the day of his death made him run. As

previously stated, he would have run from Police at any time given his state of mind”.

(Exhibit C.19a, p6-7).

4.6 Certainly, no criticism of the actions of the police on 21 December 1999 in relation to Mr. Sabino is justified. The police pursued him because he had committed several offences, and frightened several female people in their own homes. He was described as agitated, and may have been a danger to himself or others. They had no way of knowing that he was at risk of a fatal heart arrhythmia as a result of amphetamine abuse.

5. Other issues arising at inquest 5.1 Response of the ambulance service In her letter, Marisa Sabino alleged that she and Ms. Sherif had to telephone twice for an ambulance and that “they turned up with no lights on and they seemed to be in no hurry”. This allegation seems to be at odds with the fact that the ambulance took only nine minutes to get from the Salisbury Ambulance Station to Parafield Gardens.

5.2 The affidavit of Mr. Keith Driscoll, Clinical Manager of S.A. Ambulance Service (“SAAS”), which is based on the SAAS records, indicates that the call was treated as a Priority 1. The first call was received at 2.14p.m., the crew responded at 2.15p.m., and they were already mobile by the time the second call was received at 2.18p.m.

Further, the lights and sirens on an ambulance are used to warn traffic, and are not used when it is unnecessary, particularly in suburban streets.

5.3 Finally, ambulance crews are taught not to rush - experience has shown that fewer accidents, quicker responses, and better treatment is achieved if the officers remain calm and composed (see Exhibit C.21a).

5.4 On the material before me, there is no ground upon which to criticise the response of the SAAS.

6. Recommendations 6.1 I have already quoted Dr. James’ comments about the risks associated with amphetamine abuse, particularly when combined with exercise. I note that fatalities from amphetamine and amphetamine derivatives are infrequent. However, it is widely known that the use of amphetamines in the community, both as a stimulant and

as a recreational drug, is increasing, and it may be that users are not aware of the dangers of such use.

6.2 I consider that it would be useful to issue a public warning to those who take amphetamines, particularly intravenously, that:-

• amphetamine use may cause cardiovascular death, cerebrovascular death, and hyperthermia (this is particularly the case if the subject has predisposing factors such as co-administration of stimulants, hypocalcemia, or pre-existing cardiovascular disease);

• use of amphetamines has been shown to increase the risk of violent death, including accident, suicide and homicide;

• amphetamine use associated with physical or emotional stress may lead to death, probably from cardiac disrhythmia;

• intravenous drug users are also subject to potentially fatal complications including septicaemia, hepatitis, bacterial endocarditis and HIV/AIDS.

6.3 In view of the above, I recommend pursuant to Section 25(2) of the Coroners Act that a public warning be given.

Key Words: amphetamines; police investigation; public warning In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 11th day of December, 2000.

……………………………..……… Coroner Inq.No.46/2000