Coroner's Finding: VELKOS Basile

CORONERS ACT, 2003 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 17th day of June 2008 and the 9th day of December 2009, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Basile Velkos.

The said Court finds that Basile Velkos aged 39 years, late of 17 Bolivia Crescent, Paralowie, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 12th day of June 2006 as a result of multi organ failure complicating acute paraquat and diquat toxicity. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Mr Basile Velkos, aged 39 years, died at the Royal Adelaide Hospital (RAH) on Monday 12 June 2006. Prior to his death he had been detained pursuant to the Mental Health Act 1993 (the MHA) and had been taken in the first instance to the Lyell McEwin Hospital (LMH) from where he was transferred to the RAH. I am uncertain on the evidence whether the detention was ever confirmed within 24 hours of the initial order. Mr Velkos died more than 24 hours after the initial detention. It is a legal requirement that within 24 hours of the initial detention if practicable, a psychiatrist has to give consideration as to whether the detention should be confirmed or revoked1. It is not entirely clear what the status of Mr Velkos’ detention was at the time of his death. To my mind, the issue is moot because there is no question of Mr Velkos ever being discharged from hospital given, as we will see, the manifest seriousness of his medical predicament.

1 Section 12(3) and (4) of the Mental Health Act 1993

2. Cause of death 2.1. A post-mortem examination was conducted by Dr John Gilbert, a Forensic Pathologist at Forensic Science SA. The cause of Mr Velkos’ death, as revealed in Dr Gilbert’s post-mortem report2, is multi organ failure complicating acute paraquat and diquat toxicity. Blood samples taken on Mr Velkos’ admission to the RAH prior to his death revealed potentially lethal levels of the herbicides paraquat and diquat. Both of these agents are highly toxic even in small quantities. I will deal with the circumstances of Mr Velkos’ ingestion of those toxic substances in a moment. Mr Velkos’ admission bloods also showed a blood alcohol concentration of 0.153%, which is a very high reading consistent with a marked degree of intoxication at the time of his admission to hospital.

2.2. I find the cause of Mr Velkos’ death to have been as stated in Dr Gilbert’s report, namely multi organ failure complicating acute paraquat and diquat toxicity.

3. Background and the events leading to Mr Velkos’ death 3.1. Mr Velkos was married with one child. He resided at 17 Bolivia Crescent, Paralowie.

Since the beginning of 2006, Mr Velkos had been treated for depression by his general practitioner, Dr Singh, at the All Health Medical Centre on Waterloo Corner Road, Paralowie. Mr Velkos also had a significant drinking problem which, according to statements given by Mr Velkos’ wife to police3, had become a bone of contention between them. There had been arguments over the few days prior to the weekend of Saturday 10 June and Sunday 11 June 2006 about this and other issues.

In fact the police were called during the afternoon of Saturday 10 June 2006 following one particular altercation between Mr and Mrs Velkos. Mr Velkos had been to work as usual during that Saturday morning but when he returned home at about 2pm it was obvious that he had been drinking. When the police attended later that afternoon Mrs Velkos left the home and took her daughter to another residence. Mr Velkos, who was already significantly intoxicated with alcohol, then became somewhat unhinged.

Police left the premises without taking any further action.

3.2. At some point during the course of that same afternoon of Saturday 10 June 2006 Mr Velkos had attended at the premises of his next door neighbours, Mr and Mrs Elliott.

He was drunk. Several months prior to this Mr Elliott had borrowed a bottle of weed 2 Exhibit C3a 3 Exhibits C1a and C1b

poison and a spray pack from Mr Velkos. The poison was contained in a Coca Cola bottle and the substance inside was black in colour, not dissimilar to Coca Cola itself or, according to Mr Elliott, engine oil. Mr Elliott had wanted it to poison weeds in his front yard but in the event had not used the poison and had put it in his shed where it remained until the Saturday afternoon in question. When Mr Velkos came over to the Elliott’s that afternoon he asked Mr Elliott if he could have his poison and spray pack back because he was moving to another address and was giving the house in Bolivia Crescent to his wife. Mr Velkos was slurring his words and seemed nervous. He was wandering around and seemed to have difficulty standing still. Mr Elliott retrieved the poison and spray pack and, as he was getting it out of the shed, Mr Velkos said ‘this stuff would be good to drink’. Needless to say Mr Elliott thought he was joking.

Mr Velkos then left with the poison in the Coca Cola bottle but left the spray pack behind saying that Mr Elliott could later pass it over the fence. Later that afternoon Mr Velkos knocked on the dividing fence. He asked Mr Elliott to go and buy him some tobacco because his wife had called the police and he believed they were on their way to arrest him. Mr Elliott obliged and when he returned about 15 minutes later the police were already at Mr Velkos’ premises. He gave the tobacco to the police. In the event the police did not arrest Mr Velkos.

3.3. Later that same afternoon Mr Elliott again heard a bang on the fence. Mr Velkos was calling out to him and when Mr Elliott went to speak with him Mr Velkos told him that he had ‘blacked out’. He also asked Mr Elliott whether he had earlier asked him to obtain some tobacco for him. Mr Elliott naturally told him that he had but that he had handed the tobacco to the police.

3.4. At some point in time that afternoon or early evening Mr Velkos drank some of the contents of the Coca Cola bottle that contained the herbicide. The bottle was later found on the back lawn. Some of the contents had spilled on the lawn. It is not known for certain whether Mr Velkos had consumed the poison deliberately or with any intent to harm himself or to take his own life. The matter is complicated by the fact that there was another Coca Cola bottle found in the vicinity which apparently was true to label. Mr Velkos was also to tell paramedics that he had drunk what he thought was Coca Cola, but then went on to say things from which it might be inferred that he had consumed the poison knowingly. The fact that Mr Velkos was significantly intoxicated with alcohol precludes any meaningful determination as to what Mr Velkos’ intention was.

3.5. It appears that Mr Velkos himself rang an ambulance. An ambulance crew arrived at the Bolivia Crescent premises at approximately 5:39pm that afternoon. The ambulance officers noticed a male person walking within the house towards the rear of the house. At that stage there was no indication from the way that the male person was behaving that there was anything wrong. The crew yelled out to the man, whom we now know to be Mr Velkos, and he replied that he was around the back. The ambulance officers went to the rear of the premises. By then Mr Velkos was lying on the floor inside the rear sliding door. They asked Mr Velkos what had happened and he replied that he had been poisoned with weed spray. It was at that stage that he said that he had accidentally drunk the spray which he thought was his Coca Cola. When the officers asked him specifically how much of the poison he had consumed, he said that he had taken two mouthfuls. This of course begged the obvious question as to why he did not realise after the first mouthful that he had drunk something other than Coca Cola. Upon being asked that question Mr Velkos became abusive and uncooperative and would not comply with any of the ambulance officers’ directions.

Eventually the officers managed to get Mr Velkos on to a gurney and then into the ambulance.

3.6. Mr Velkos was uncooperative en route to the LMH Emergency Department where they arrived shortly after 6pm. At the LMH Mr Velkos continued in the same vein.

At that stage, from all of the circumstances as they were known it was not unreasonably believed that Mr Velkos had deliberately ingested the poison. He was uncooperative and aggressive within the LMH Emergency Department and it was also clear that he required urgent medical treatment. Dr Geoffrey Oddie, whose statement was tendered to the Inquest4, formed the view that it was in the interests of Mr Velkos’ health and safety to detain him under the Mental Health Act 1993. He signed a Form 1 under the Mental Health Regulations for that purpose, the grounds for his detention being as stated in the form that Dr Oddie was satisfied that Mr Velkos had a mental illness that required immediate treatment, that the treatment was available within the LMH and that Mr Velkos should be admitted and detained in the centre in the interests of his health and safety and for the protection of other persons. Dr Oddie has recorded the grounds of his opinions as: 'Intentional overdose of paraquat, high lethality toxin, uncooperative and aggressive.' 4 Exhibit C15a

The observations of a number of police officers as recorded in statements tendered to the Inquest confirms that within the Emergency Department of the LMH Mr Velkos was very agitated and required restraint.

3.7. A decision was made that Mr Velkos could more appropriately be treated at the RAH.

To that end he was transferred there that evening, still under detention of course. Mr Velkos remained at the RAH under detention and he died at approximately 12:50am on Monday 12 June 2006 from the cause that I have identified. Mr Velkos’ treatment at the RAH prior to his death is described in the statement of Dr Anna Louise Sullivan5.

4. Conclusion 4.1. Mr Velkos’ initial detention was lawful and appropriate. It was manifestly in his interests that he be admitted to, and kept within, the RAH at all material times. There is no suggestion that the medical treatment that Mr Velkos was accorded was anything other than appropriate and in keeping with what any voluntary patient within the hospital would have received. Unfortunately clinical staff at the RAH were not able to save his life.

5. Recommendations 5.1. I have no recommendations to make in this matter but would observe, irrespective of Mr Velkos’ actual intentions, that this case provides a reminder that it is a highly undesirable practice to store poisons in other than accurately marked containers suitable for that purpose.

Key Words: Death in Custody; Poisoning; Paraquat In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 9th day of December, 2009.

Deputy State Coroner Inquest Number 19/2008 (0821/2006) 5 Exhibit C2a