Coroner's Finding: DOBRIJEVIC Sofija

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 8th, 9th, 10th and 11th days of September 2009 and the 7th day of May 2010, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Sofija Dobrijevic.

The said Court finds that Sofija Dobrijevic aged 73 years, late of 18 The Parade, Blair Athol, South Australia died at the Glenside Campus of the Royal Adelaide Hospital, 226 Fullarton Road, Eastwood, South Australia on the 16th day of August 2007 as a result of neck compression by ligature. The said Court finds that the circumstances of her death were as follows:

1. Introduction and reason for Inquest 1.1. Mrs Sofija Dobrijevic was aged 73 years when she died on 16 August 2007. At the time of her death she was a detained patient in the Rosewood Closed Ward at Glenside Hospital.

1.2. At about 7:40pm on the day of her death Mrs Dobrijevic was found unconscious and unresponsive on her bed in her room within the Rosewood Ward. She had a garment tied tightly around her neck. The member of the nursing staff who located Mrs Dobrijevic removed the garment, called for assistance and commenced cardiopulmonary resuscitation (CPR). Additional staff assisted and members of the South Australian Ambulance Service (SAAS) attended. CPR was continued until 8:14pm when her life was pronounced extinct by a SAAS Intensive Care Paramedic.

1.3. The garment that had been tied tightly around Mrs Dobrijevic’s neck was to prove to be the instrument that caused her death. It is clear that the garment had been

deliberately tied around Mrs Dobrijevic’s neck. A number of handwritten notes were located in Mrs Dobrijevic’s room. They consisted of 10 pages1. The writing was in the Croatian language and was clearly the product of Mrs Dobrijevic’s authorship.

The notes in part evinced an irrational belief on Mrs Dobrijevic’s part that her son, Duro Dobrijevic, had been assassinated in the Modbury Hospital (MH), but certain of the notes referred to matters that strongly suggested that Mrs Dobrijevic was, at the time the notes were written, contemplating her own death. For example, one note refers to her ‘leaving for eternal rest’ as translated from the Croatian to the English.

Another note referred to her burial by the United Church of Christ. There was a further note expressing a desire that she have no funeral feast, but that she be commemorated by a priest of that religious denomination.

1.4. It is apparent from the evidence, some of which I will discuss in these findings, that Mrs Dobrijevic had been experiencing a period of emotional if not mental instability for several years. More recently her instability had acutely manifested itself in what was believed to be among other things a depressive episode.

1.5. On 17 August 2007 Dr John Gilbert, a forensic pathologist employed at Forensic Science South Australia, performed a post-mortem examination which included a full autopsy in respect of Mrs Dobrijevic’s remains.

1.6. Dr Gilbert identified certain features that were consistent with an asphyxial mode of death resulting from neck compression sufficient to at least impair venous drainage from the head. The neck showed no external signs of recent injury to indicate either manual or ligature strangulation by another person.

1.7. Dr Gilbert was of the view that death could have resulted from the deceased applying a ligature in the form of the garment that was found around her neck and had done so with sufficient pressure to at least interrupt the venous drainage of the head.

1.8. Dr Gilbert assigns as Mrs Dobrijevic’s cause of death ‘neck compression by ligature’.

I find that to be the cause of Mrs Dobrijevic’s death.

1.9. There is no evidence, and indeed no suggestion, that any person other than Mrs Dobrijevic herself had tied the garment around her neck. In the light of Mrs Dobrijevic’s mental instability and recent depressive presentation, and having regard 1 Exhibit C23g

to the contents of the notes that she left in her room prior to her death, the conclusion that Mrs Dobrijevic tied the garment around her own neck with an intention to end her life is a compelling one. I find that Mrs Dobrijevic intentionally tied the garment around her own neck and did so with the intention to end her own life.

1.10. The detention that Mrs Dobrijevic was experiencing within the Glenside Hospital was that imposed by virtue of the Mental Health Act 1993 (MHA). Mrs Dobrijevic had originally been detained in the early hours of the morning of Sunday, 12 August 2007.

This detention was originally imposed at the MH. Its confirmation, as required by law, had also taken place at the MH. Mrs Dobrijevic was subsequently transferred pursuant to the provisions of the MHA to the Glenside Hospital and was accommodated, to begin with, in the open section of the Rosewood Ward. A further period of detention was ordered once she was at Glenside. In circumstances that I will describe below, it was necessary for Mrs Dobrijevic to be transferred from the open section of Rosewood Ward to the closed section. At the time of her death on Thursday 16 August 2007, Mrs Dobrijevic was still detained in the closed section of Rosewood pursuant to the provisions of the MHA.

1.11. Because of Mrs Dobrijevic’s status as a MHA detainee at the time of her death, her death was a death in custody as defined in the Coroners Act 2003. Accordingly, it was mandatory for an Inquest to take place into the cause and circumstances of Mrs Dobrijevic’s death.

1.12. In any event, it would have been considered necessary and desirable for an Inquest to be held into the cause and circumstances of Mrs Dobrijevic’s death owing to the fact that she was able to take the necessary steps to end her own life without detection, notwithstanding her confinement and detention within a closed ward of a major acute psychiatric institution. In the course of this Inquest I examined how it was that such an event could have come to pass.

2. The relevant provisions of the Mental Health Act 1993 2.1. Before discussing the circumstances of Mrs Dobrijevic’s hospitalisation and death, I should briefly explain the regime of detention that the MHA provides for. Section 12(1) of the MHA enables a medical practitioner to make an order for the immediate admission and detention of a person in an approved treatment centre where the medical practitioner is satisfied of a number of matters: firstly that a person has a

mental illness that requires immediate treatment, secondly that such treatment is available in an approved treatment centre and thirdly that the person should be admitted as a patient and detained in an approved treatment centre in the interests of his or her own health and safety or for the protection of other persons. Section 12(2) of the Act provides that such a detention order expires 3 days after the day it is made unless it is earlier revoked. A person so detained must be examined by a psychiatrist within 24 hours of the patient’s admission to the approved treatment centre or, where that is not practicable, as soon as is practicable after that admission. The examining psychiatrist must consider whether the continued detention of the patient is justified or not. If the psychiatrist is not satisfied that the continued detention of the patient is justified, the psychiatrist must revoke the order. Otherwise, the psychiatrist will confirm the order. If the psychiatrist confirms the order, this has the effect of continuing the 3 day period that had been activated by the original detention order.

Before the expiry of that 3 day period, a further order for detention for another period of up to 21 days may be imposed. A second 21 day order may be imposed upon the expiry of the first such order. Mrs Dobrijevic had been subjected to the regime of detention that I have just described and at the time of her death was detained pursuant to a first 21 day order.

3. Background 3.1. Mrs Dobrijevic had exhibited histrionic behaviour for several years. Her son, Mr Duro Dobrijevic, provided a detailed statement concerning his mother’s demeanour and behaviour and also gave evidence in the Inquest2. Mr Dobrijevic describes his mother’s troubled behaviour from a time very early in his own life. Such behaviour included threats to injure herself with a knife and the self-placement of numerous tablets in her mouth. This latter behaviour on some occasions required Mr Dobrijevic to ring poison hotlines when the tablets were swallowed and on other occasions forcefully to remove them from his mother’s mouth. There were times when Mrs Dobrijevic was required to stay in a private hospital for the purposes of respite. There were also other periods of hospitalisation in the Royal Adelaide Hospital (RAH) in respect of her histrionic behaviour. A discharge summary from the RAH relating to an admission in 1988 refers to a 10 year history to that point in time of recurrent depression, histrionic personality disorder and a number of overdose attempts.

2 Exhibit C29

3.2. According to Mr Dobrijevic, the 1990s was a relatively calm period for his mother.

In 1998 Mrs Dobrijevic’s husband died and, as I understood the evidence, there was a large measure of continuing and unresolved resentment on Mrs Dobrijevic’s part in respect of the fact that her husband did not leave the family home to Mrs Dobrijevic but had willed it to a grandson leaving Mrs Dobrijevic with the right merely to reside in the premises during her lifetime.

3.3. In the year 2002 a very unfortunate event occurred in Mrs Dobrijevic’s life. She suffered a fall which caused an injury that resulted in chronic pain that persisted for the rest of her life. It was said in the evidence in various quarters that there was a possible hysterical or somatic component to Mrs Dobrijevic’s pain, but it seems obvious that her pain was genuine, chronic and persistent. She was in possession of a device that was referred to in the evidence as a TENS (Transcutaneous Electrical Nerve Stimulation) machine that assisted with pain management. This instrument and its whereabouts appeared to be the subject of a fixation on Mrs Dobrijevic’s part during the course of her hospitalisation in Glenside Hospital in August 2007. Since 2002 Mrs Dobrijevic had consulted numerous specialists, such as orthopaedic surgeons and back specialists, about her pain and there were several instances in 2007 where Mrs Dobrijevic would ring the ambulance service to collect her and take her to the Emergency Departments of hospitals. Mr Dobrijevic states that the fall seemed to have been the turning point in his mother’s life and was the catalyst and trigger that made her even more prone to histrionic behaviour. However, he said that her behaviour for the few years afterwards did not actually become bizarre or delusional until close to the time of her death.

3.4. Mr Dobrijevic describes his mother’s ongoing attempts to obtain relief from her pain during the period from 2002 until the beginning of 2007. There were occasions when she consulted psychiatrists about it.

3.5. During all of this period Mrs Dobrijevic continued to live on her own in the family home at Blair Athol.

3.6. During the period from 2002 to 2007 there are a number of references in Mrs Dobrijevic’s medical history to ongoing depression connected with her husband’s death in 1998 and the bequeathing of the home to a grandson. There is also reference to Mrs Dobrijevic experiencing panic attacks and an anxiety disorder. In 2004 a letter

written by Dr Matthew Green, the Senior Registrar of the Pain Management Unit of the RAH, to Mrs Dobrijevic’s then general practitioner sums up Mrs Dobrijevic’s dilemma as follows: 'In view of Mrs Dobrijevic’s presentation today, she presents with cervical, lumbar, and lower leg neuropathic symptoms, which appear to be substantially amplified by her ongoing psychiatric condition. There is little doubt she has a history of depression, possibly with some psychotic features, as she frequently described rather vivid dreams.

She has maladaptive behavioural management strategies, and abnormal illness behaviours associated with her presentation today.' 3 In the event the pain management strategy was for the most part based on the use of the TENS machine and analgesia. An examination of the competence of Mrs Dobrijevic’s pain management during her life was beyond the scope of this Inquest.

3.7. Mrs Dobrijevic appears not to have come to terms with the suggestion that she had a mental illness or instability and believed at all material times that she did not require any psychological or psychiatric assistance for the same. She appears to have held the belief that all of her difficulties and behaviours were due to her ongoing pain and the fact that nobody seemed to be able to do anything for her about that.

3.8. Mrs Dobrijevic’s rejection of the notion that she might have required psychological assistance is exemplified in a letter that she wrote, or had written on her behalf in English, in apparent response to the letter of Dr Green to which I have referred. In her letter Mrs Dobrijevic asserts that there was no reason for her present condition other than her fall that occurred in 2002. She asserted in the letter that she was not insane or confused. She also asserts that notwithstanding that Dr Green had written that she had expressed thoughts of suicide if substantial relief for her pain was not obtained, she had no intention of committing suicide either at the time of the writing of the letter or at any time in the future. She said that she was: '… simply using exaggerated language to make the point that as far as possible I want to be in control of my faculties.'4 Mrs Dobrijevic in another letter once did say that sometimes she wished she were dead, especially when her pain was intense, because she knew that there was no cure for her condition5.

3 Exhibit C26, page 171 4 Exhibit C26, page 178

3.9. Notwithstanding the history that I have just described, Mr Dobrijevic states that his mother nevertheless, in the period leading up to the beginning of 2007, enjoyed very good mental health. However, from that point onwards until Mrs Dobrijevic’s detention under the MHA in August of that year, Mrs Dobrijevic appears to have gone into decline.

3.10. In June 2006 Mrs Dobrijevic had been referred to community nursing staff at the Central Northern Adelaide Health Service (CNAHS) following a presentation at the Queen Elizabeth Hospital with acute chronic pain and an abnormal pain response and issues with depression. Ms Jane Williams is a mental health nurse employed by CNAHS. Ms Williams provided a statement to the Inquest6. Ms Williams essentially oversaw Mrs Dobrijevic’s community interaction with the mental health services. Ms Williams’ statement states that her initial assessment of Mrs Dobrijevic was that, although she was very animated and dramatic and did not see the full implications of her actions, she did not see Mrs Dobrijevic as being at risk of self-harm and did not at that time require urgent intervention or detention. Mrs Dobrijevic was primarily concerned with her pain issues from the fall. She also appeared to be preoccupied with obtaining legal redress both in respect of her fall and in relation to the issue about the bequeathment of the family home. There was an improvement in her presentation in late 2006 and early 2007 which is in line with Mrs Dobrijevic’s son’s statement. Ms Williams’ statement suggests that Mrs Dobrijevic remained adamant that she did not have a mental illness and did not really require their services.

3.11. In an addendum statement prepared by Ms Williams, there is reference to Mrs Dobrijevic threatening self-harm on or about 3 August 2007. On contact, however, Mrs Dobrijevic denied any such threats and presented in a normal and generally organised fashion and animatedly reported words to the effect: 'If I wanted to kill myself why would I ring anyone?'

3.12. Mrs Dobrijevic was also referred to Uniting Care Wesley (UCW) which conducted a community mental health program the coordinator of which was Ms Emilija Jovanovic. Ms Jovanovic provided a statement to the Inquest7. The referral to UCW occurred in late February 2007 and came from Ms Williams. The goal of the referral was said to be to increase social contact and to reduce the number of presentations 5 Exhibit C24, page 76 6 Exhibit C14a 7 Exhibit C13a

that Mrs Dobrijevic was making to hospital emergency departments and to the Acute Crisis Intervention Service (ACIS). According to Ms Jovanovic’s statement she first was introduced to Mrs Dobrijevic in March 2007 and Mrs Dobrijevic made it clear that she did not think she had a mental illness but made it equally clear that she had problems with back pain. There was some initial reluctance on Mrs Dobrijevic’s part to have anything to do with the UCW care worker who was assigned to her, but Ms Jovanovic herself, over the ensuing months, had regular interaction with Mrs Dobrijevic because the latter would call her. Ms Jovanovic describes the ongoing preoccupation with legal matters concerning her husband’s will and her fall.

3.13. There is no evidence to suggest that Mrs Dobrijevic expressed any suicidal ideation to staff of UCW. However, in one of Mrs Dobrijevic’s client reports, which is contained in the UCW file8, it is recorded that after Mrs Dobrijevic had received a spinal injection, she had said that instead of it helping her, it had had the opposite effect.

She had said that she could not cope with the pain anymore and would prefer not to have any feeling from the waist down rather than having to live in pain constantly. It is reported that she said that she did not want to live.

3.14. Dr Marko Zuvela, who provided a statement to the Inquest9, became Mrs Dobrijevic’s general practitioner in February 2007. Dr Zuvela was obviously aware of Mrs Dobrijevic’s pain difficulties. As well, his statement explains that Mrs Dobrijevic complained of being depressed for a long time. He initiated a care plan for her that involved referrals to a number of community resources to assist with her day to day functioning. The referrals that he made were in addition to the community services to which Mrs Dobrijevic had already been connected. In his statement Dr Zuvela makes it plain that at no time during his treatment of Mrs Dobrijevic did he think that she was acutely suicidal or in need of detention under the MHA. He saw Mrs Dobrijevic on 31 July 2007 and he noted on that occasion that she ‘wanted to die’. However, she was not presenting as being acutely suicidal or at risk of self-harm. As it transpired Dr Zuvela was to make contact with a psychiatric registrar at Glenside Rosewood Ward during the week of Mrs Dobrijevic’s detention there in August 2007. However, there is no evidence to suggest that Dr Zuvela discussed any question regarding suicidal ideation with that Registrar.

8 Exhibit C27, pages 15-16 9 Exhibit C28a

3.15. On 5 August 2007 Mrs Dobrijevic presented by ambulance at the MH where it was noted in the triage record10 that she presented with acute psychotic episodes and was upset about ongoing medical treatment. She felt that her medications may be causing her sickness issues. There was a notation to the effect that she might be unable to cope fully at home on her own. There was a statement recorded, as made by her, to the effect that within five years all the doctors will be killed by God. Mrs Dobrijevic was kept overnight for observation. A psychiatric examination took place the following morning, 6 August 2007, in which the reporting intern at the RAH Emergency Department states in his letter addressed to Dr Zuvela: 'It is unclear as to why she presented today other than that she feels that we care, although she recognises that we cannot help her with her pain.' 11

3.16. On 6 August 2007 Mrs Dobrijevic was examined by a psychiatric nurse, Mr Paul Richards, who provided a statement to the Inquest12. During his examination it was established through Mrs Dobrijevic herself that the reason that she had presented to the MH was because she was unhappy with her pain management elsewhere. The overall assessment of Mrs Dobrijevic was that psychiatrically she did not present as psychotic, manic or depressed and that there was no notable cognitive impairment.

She denied any self-harming, suicidal or homicidal ideation. She expressed no themes indicative of delusion and denied any perceptual disturbances and none were objectively evident. There was no evidence of confusion or delirium. An assessment was made that Mrs Dobrijevic was not detainable and that there were sufficient resources available to manage her in the community. On 1 August 2007 Mrs Dobrijevic’s son, Duro, had noticed a deterioration in his mother’s level of pain. He became aware of Mrs Dobrijevic’s presentation at the MH on 5 August 2007 as he happened to be in the hospital visiting a family that had just received a new addition to their family. He was told that his mother was in the Emergency Department and when he saw her he found her to be in a distressed condition. She screamed at him.

He understood that she was being psychologically assessed. He went to the hospital the next day to pick her up upon her release. When he spoke to her on this occasion she told him that if he had arrived 10 minutes later he would have found her dead.

She was talking about how the people at MH were trying to kill her. There does not 10 Exhibit C25, page 188 11 Exhibit C24, page 98 12 Exhibit C12a

appear to be any evidence or any hint within the Modbury notes that she was genuinely thinking that.

3.17. In the MH notes13 there is an element of uncertainty as to whether or not Mrs Dobrijevic should be discharged home on 6 August 2007. However, it appears to have been considered appropriate that she be discharged to her home with her supports in place. After discussion with her son Duro she was discharged. When her son took her home that day she indicated to him that she wanted him to find someone to stay with her as she did not like being home alone at night. Nevertheless, for the most part she remained alone at the Blair Athol premises during the course of the ensuing week, although visited by her son from time to time.

4. Mrs Dobrijevic’s detention under the Mental Health Act 1993 4.1. The circumstances in which Mrs Dobrijevic came to be detained are to a large extent explained by her son Duro and by the Uniting Care Wesley Coordinator, Ms Jovanovic. On Thursday 9 August 2007 Ms Jovanovic received a call from Mrs Dobrijevic who said that she was worried that one of her doctors was going to send someone to go to her premises and kill her. Mrs Dobrijevic had spent the night at a friend’s place as a result of this belief. Ms Jovanovic explains that in the ensuing days she had numerous contacts with Mrs Dobrijevic and concluded that Mrs Dobrijevic’s thoughts were becoming increasingly disturbed and that she was not looking after herself. On Friday 10 August and Saturday 11 August 2007 Ms Jovanovic received constant calls from Mrs Dobrijevic at intervals of approximately every half hour. Ms Jovanovic concluded that Mrs Dobrijevic required hospitalisation and to this end she contact Mr Duro Dobrijevic.

4.2. Duro Dobrijevic himself had been contacted on the Saturday by a friend who had advised him that Mrs Dobrijevic had called him in the middle of the night and that her conversation was bizarre. When Mr Dobrijevic went to his mother’s premises that day she was screaming words to the effect ‘I’m dying, I’m dying, they’re trying to kill me’. His friend who had been contacted during the night confirmed to Mr Dobrijevic that his mother had also been talking to him about dying and that if they had not turned up they would find her deceased. Ms Jovanovic attended and, after some 13 Exhibit C25, page 126

discussion during which Mrs Dobrijevic evinced the belief that the hospitals were trying to kill her, she was persuaded to go to the Modbury to be assessed.

4.3. In the early hours of the morning of Sunday 12 August 2007 a medical practitioner at the Modbury detained Mrs Dobrijevic pursuant to the MHA on the basis of her psychotic and erratic behaviour. As seen earlier, this detention required re-evaluation within the first 24 hours. The detention was confirmed later on the morning of 12 August 2007. The confirming psychiatrist was Dr Sally Rischbieth. Dr Rischbieth gave evidence in the Inquest and explained the basis upon which she confirmed Mrs Dobrijevic’s detention. When Dr Rischbieth assessed Mrs Dobrijevic, Mrs Dobrijevic voiced the belief that her problem was related to her pain and that she did not want to have any mental health service involvement. But she admitted to Dr Rischbieth that she had a low mood, had been sleeping poorly, that her appetite was reduced. She would also not give a clear answer with respect to whether or not she had suicidal thoughts. Dr Rischbieth explained in evidence that she was unclear whether or not Mrs Dobrijevic posed a suicide risk but she was concerned enough regarding her presentation and her previous behaviour over the preceding few days that she could have had suicidal ideation. Dr Rischbieth concluded that although Mrs Dobrijevic clearly had significant pain issues, she also had a past history of depression and anxiety which seemed to have acutely reoccurred and she felt that Mrs Dobrijevic had a histrionic personality style. Dr Rischbieth was aware that Mrs Dobrijevic’s son Duro was supportive of Mrs Dobrijevic’s admission to hospital on this particular occasion. Dr Rischbieth was convinced that Mrs Dobrijevic had significant neurovegetative features and was satisfied that she had a mental illness. Dr Rischbieth was concerned that Mrs Dobrijevic was at risk of harming herself either by deliberate action or by virtue of her histrionic behaviour such as the irrational phone calling of other people which placed her vulnerable to harm. She also viewed Mrs Dobrijevic as being at some risk of harm partly because of her impulsive behaviour and by her lack of organisation in her behaviour. She felt that Mrs Dobrijevic needed to be in a place where she could be watched more closely and had concluded that even with the support that the community provided for her Mrs Dobrijevic was still at risk. Dr Rischbieth believed that Mrs Dobrijevic’s remaining in MH as a voluntary patient was not feasible and also believed that the alternative of being discharge to her home was

also a very difficult proposition14. Dr Rischbieth signed the necessary form confirming Mrs Dobrijevic’s detention. This confirmation meant that the 3 day order that had originally been enlivened in the early hours of the morning of Sunday 12 August 2007 was confirmed and would remain extant until the early hours of the morning of 15 August 2007. In my view, and no one has suggested anything to the contrary, this detention was both lawful and appropriate in all of the circumstances.

4.4. Mrs Dobrijevic was transferred to the Glenside Campus Rosewood Ward on Sunday 12 August 2007.

4.5. On 13 August 2007 Mrs Dobrijevic was examined for the first time by Dr Bridget Warnes, a psychiatric registrar. Dr Warnes would essentially remain responsible for Mrs Dobrijevic’s care together with Dr Sarojena Hapuarachchi, a psychiatrist. On 13 August Dr Warnes identified evidence of delusional thinking on Mrs Dobrijevic’s part including an expressed belief that her nephew may have been killed. However, at that time she did not give the impression of being acutely severely depressed or at risk of self-harm. In fact, according to Dr Warnes, Mrs Dobrijevic was adamant that she did not have suicidal thoughts and denied any past suicidal gestures or attempts. Dr Warnes spoke to both of Mrs Dobrijevic’s sons as part of her assessment and also spoke to Dr Zuvela. Dr Warne’s initial assessment was that there were a number of possible diagnoses that included major depressive disorder, early dementia, a late onset psychotic illness, underlying medical condition and a somatoform disorder related to her chronic pain. Dr Warne felt that she required more time for observation, in particular, looking for signs of paranoia, perceptual disturbance and affective symptoms. She also wished to gather further collateral information from Mrs Dobrijevic’s GP, from the pain clinic at the Royal Adelaide Hospital and from the community mental health team.

4.6. On Tuesday 14 August 2007 a further 21 day order was imposed in respect of Mrs Dobrijevic’s detention. This order was imposed by Dr Hapuarachchi, the psychiatrist.

Dr Hapuarachchi is a consultant psychiatrist employed at Glenside and has been so employed since May 2000. Since April 2001 her work at Glenside has exclusively involved psycho-geriatric practice. Dr Hapuarachchi also practices privately in general psychiatry. Dr Hapuarachchi explained that Rosewood Ward at Glenside was an acute psychiatric hospital that catered for the aged. Dr Hapuarachchi first became 14 Transcript, pages 100-103

aware of Mrs Dobrijevic’s presence in the Rosewood Ward on Monday 13 August 2007 when she discussed Mrs Dobrijevic’s case with the psychiatric registrar, Dr Warnes, who had already assessed Mrs Dobrijevic. Dr Hapuarachchi herself, with Dr Warnes in attendance, assessed Mrs Dobrijevic on 14 August 2007. This assessment was conducted in order to determine whether further detention was indicated. Dr Hapuarachchi explained to me in her evidence that when she examined Mrs Dobrijevic on this occasion Mrs Dobrijevic’s presentation included obvious paranoid behaviour and ideation15. She explained her decision to extend Mrs Dobrijevic’s detention in the following way: 'Yes, my decision to extend the detention on Mrs Dobrijevic was based on the comprehensive history and assessment by Dr Warnes, the senior registrar, on the 13th of the eighth. Secondly, on my assessment of Mrs Dobrijevic on the 14th of the eighth 2007 at 11.45 a.m. when I observed her behaviours, her mood and speech, to be that of a lady who was sad, depressed, agitated, lacking insight into her condition and a judgment clouded by her emotional state at that point in time. Thirdly, on the observations that were on record by the staff and in discussion with a staff member on the 14th of the eighth '07, the behaviours that were displayed by Mrs Dobrijevic was denoting lack of self control and impulsivity. She refused her medication, she refused her breakfast on that day. Hence, these behaviours of lack of self control, impulsivity, in the context of her mental state, at that lack of insight and impaired judgment at the point in time was sufficient evidence for me to believe that Mrs Sofija Dobrijevic was placing herself at risk. I was concerned for her physical and emotional health and safety and therefore I made the decision to detain her further under form 3.' 16 Dr Hapuarachchi explained in her evidence that Mrs Dobrijevic was placing herself at risk by refusing medication and food. In addition, physical aspects of Mrs Dobrijevic’s presentation, such as her blood sugar levels, were very labile and Dr Hapuarachchi was concerned about Mrs Dobrijevic’s ability to take care of her physical health which would thereby endanger her overall wellbeing and safety. The mental illness that in Dr Hapuarachchi’s view triggered Mrs Dobrijevic’s difficulties was her depressed and sad emotional state which had manifested itself in weeping, crying aloud, a lack of insight into her condition and blaming it all on physical symptoms17. Dr Hapuarachchi was of the view that Mrs Dobrijevic’s pain could have been due to a real injury but that her depression was expressed in an exacerbated symptom of pain. Either way, Dr Hapuarachchi related the depression to her pain.

15 Transcript, page 214 16 Transcript, page 214 17 Transcript, page 218

4.7. As part of her examination Dr Hapuarachchi considered whether Mrs Dobrijevic would have stayed in Rosewood voluntarily. She not unreasonably concluded that she would not have done so. Dr Hapuarachchi knew that Mrs Dobrijevic had already tried to leave the ward. Mrs Dobrijevic had no understanding as to why she was there and why she had been detained. Dr Hapuarachchi also viewed Mrs Dobrijevic as not being able to cope in her home environment because she had a very strong impression that Mrs Dobrijevic would inevitably be back in hospital for help in the light of her many attempts to approach Emergency Departments and seek treatment through them.

The other matter of concern was Mrs Dobrijevic’s mental state deterioration over the previous week and a decline in her behaviour over that period of time. Although Dr Hapuarachchi did not believe that Mrs Dobrijevic was at risk of self-harm, there were concerns about Mrs Dobrijevic placing herself at risk by refusing medication and food. She believed that Mrs Dobrijevic lacked insight and was clouded in her judgment because of her depression. This gave rise to a concern as to whether she had the capacity to manage her medications and food intake in the context of her distressed and acutely depressed emotional state. Dr Hapuarachchi was concerned that her lack of insight and her clouded judgment would have definitely led her to being quite unsafe at home despite all of the supports in the community. She said: 'I would really question her health and safety in the context of her behaviours.' 18

4.8. As to what psychiatric assistance may have been provided in Rosewood, Dr Hapuarachchi believed that it was necessary to firstly establish a rapport with Mrs Dobrijevic and to endeavour to win her confidence and to educate her on the depressive symptoms. Her plan was to commence her on a very small dose of a safe anti-depressant, to follow her progress very carefully and to engender a belief in Mrs Dobrijevic that she could be helped. At the time of her death Mrs Dobrijevic had not yet been placed on anti-depressant medication as her presentation was still agitated and she was still refusing medication. The initial plan, therefore, was to treat Mrs Dobrijevic symptomatically which explains why an anti-psychotic, Risperidone, was administered in the first instance.

4.9. Again, the appropriateness of Mrs Dobrijevic’s further detention as ordered by Dr Hapuarachchi was not brought into question during the course of the Inquest. I find 18 Transcript, page 222

that the 21 day order that was made by Dr Hapuarachchi was both lawful and appropriate.

5. Events leading to Mrs Dobrijevic’s death 5.1. It was necessary for Mrs Dobrijevic to be transferred from the open section of Rosewood to the closed section owing to an attempt on her part to abscond from the open section. Within the open section Mrs Dobrijevic had been subject to observations every 15 minutes due to the risk of her absconding, not because of any perceived risk of self-harm. When Mrs Dobrijevic was transferred to the closed section, the need to prevent or deter absconding was no longer a major concern and so observations were limited to hourly. Mrs Dobrijevic occupied her own room within the closed ward. According to Dr Hapuarachchi she and Dr Warnes, the registrar, deemed such an observation regime to be appropriate as they were not aware of any risk of self-harming behaviour.

5.2. In the ensuing days of Mrs Dobrijevic’s detention no firm diagnosis appears to have been made. The plan as explained by Dr Warnes19 was that Mrs Dobrijevic would be observed, managed and investigated during the period of her detention. Dr Warnes herself explained in her evidence before the Inquest that she did not assess Mrs Dobrijevic as being at risk of self-harm. Dr Warnes noted that Mrs Dobrijevic had denied suicidal ideation. Like Dr Hapuarachchi, Dr Warnes did not view Mrs Dobrijevic as being at risk of harming herself or anyone else, but that Mrs Dobrijevic had become quite fearful that people were ‘out to get her’20 and that she was acting on those beliefs to the extent that her persecutory ideas were significantly affecting her quality of life and in that respect there was a chronic long term risk which needed to be addressed. In short, as Dr Warnes said: 'There was nothing to lead me to believe that she had any intent to harm herself.' 21

5.3. During the course of that week Mrs Dobrijevic was visited by her son Duro on a number of occasions. On the Tuesday Mrs Dobrijevic complained about the fact that she did not have access to her TENS machine. As I understood the evidence it could not be established where the machine was at that point in time and whether it was at Glenside or still at the MH. Apparently the machine was later to be located.

19 Transcript, page 157 20 Transcript, page 168 21 Transcript, page 173

Discussion about Mr Dobrijevic going to the MH to make enquiries about the whereabouts of the TENS machine elicited a reaction from Mrs Dobrijevic to the effect that if her son were to attend at MH they might kill him. Mr Dobrijevic’s impression was that his mother was very serious and had genuinely believed that he would be killed if he went to the MH. This belief seems to have formed the basis of what Mrs Dobrijevic was to write on the pieces of paper that were found in her room after her death, documents to which I have referred earlier in this finding.

5.4. Wednesday 15 August was the day preceding Mrs Dobrijevic’s death. Dr Warnes reviewed Mrs Dobrijevic during that morning. Dr Warnes noticed that Mrs Dobrijevic was different from previous interactions in that she was more agitated and less communicative. She was refusing to take any medication and would not give a valid reason for her attitude. Dr Warnes enquired of her whether Mrs Dobrijevic thought that they were poisoning her. Mrs Dobrijevic denied any such belief. Dr Warnes made an entry in her note of her review of 15 August 2007 as follows: 'Also intimated that she was going to die ‘My nerves are dying. I want to be with my family when I die’.' 22 Although Dr Warnes has recorded throughout this long progress note entry that Mrs Dobrijevic made a number of utterances to the effect that she was going to die, Dr Warnes also specifically noted that Mrs Dobrijevic in terms denied any suicidal ideation. As a result of her review, Dr Warnes discussed Mrs Dobrijevic’s presentation with Dr Hapuarachchi and it was agreed that she be commenced on antipsychotic medication, Risperidone. It was felt that the one-hourly observations in a closed ward would still be sufficient.

5.5. That same day Mr Dobrijevic visited his mother and describes her behaviour and conversation as bizarre on this occasion. She asserted that the staff of Glenside were trying to kill and poison her and she begged him to arrange for her to be taken out of the ward. She spoke of conspiracy theories and a fear for her own life and, in a begging manner, said words to the effect that if her son did not get her out of there, he would find her dead tomorrow and that he would be planning her funeral tomorrow.

At one point she tried to prevent her son from leaving the ward by barricading the door to her room.

22 Exhibit C25, Pages 57 and 58

5.6. When Mr Dobrijevic managed to extricate himself from the room he not unnaturally wanted to share what his mother had told him with members of the ward staff. What was then said between Mr Dobrijevic and members of the staff is the subject of some dispute, and indeed lack of clarity. Nevertheless, the conversations are important as they could have shaped the manner in which Mrs Dobrijevic was subsequently cared for on the ward.

5.7. According to Mr Dobrijevic’s police witness statement that was taken on 28 October 200723, he approached a member of the Rosewood staff who was at that time in the corridor adjacent to his mother’s room. He believed this man to have been an orderly as he had seen him earlier in possession of a drinks trolley. This individual was subsequently identified as an enrolled nurse, Mr John Frundt. Mr Dobrijevic’s statement records that he told the man we now know to be Mr Frundt that he had experienced a ‘very spooky visit’ with his mother and told him that Mrs Dobrijevic had said that he would find her dead tomorrow if he did not get her out of there.

According to Mr Dobrijevic’s statement Mr Frundt asked him if Mr Dobrijevic wanted to speak to one of the medical staff and he then went and obtained a doctor.

According to both Mr Dobrijevic’s statement and his evidence during the Inquest, this was Mr Frundt’s sole reaction to the information that he had imparted to him. Mr Frundt did not engage Mr Dobrijevic in any conversation about what the latter had told him, although according to Mr Dobrijevic, it was obvious that the unusual piece of information that he imparted to this man hit home as his ‘eyes widened’24. Mr Frundt gave evidence at the Inquest. Mr Frundt was not a mere orderly, although Mr Dobrijevic would have been forgiven for thinking that he was because Mr Frundt had earlier, during the course of Mr Dobrijevic’s visit, come into the room and supplied them with refreshments.

5.8. There is no question but that Mr Frundt did go and fetch a doctor because a Dr Babar Malik then came and spoke to Mr Dobrijevic. Dr Malik at that time was a junior medical officer working within the Acacia and Jacaranda Wards at Glenside. He only had a loose association with Rosewood Ward as one of his supervising registrars, Dr Warnes, was attached to Rosewood. He happened to be in Rosewood Ward at the time of Mr Dobrijevic’s conversation with Mr Frundt. Dr Malik was not a psychiatrist nor trainee psychiatrist. His work for the most part was concerned with 23 Exhibit C29 24 Transcript, page 72

the medical issues of patients within Glenside. Dr Malik obtained his medical degrees in Pakistan in December 2001. He had worked in Pakistan as a medical practitioner for approximately six years before coming to Australia in February 2007. He joined the professional staff at Glenside in August 2007. Dr Malik gave evidence in the Inquest. I found Dr Malik’s comprehension and speech in the English language to be excellent although, according to Dr Malik, as of August 2007 he had not been very fluent at that time and had experienced some difficulty with the novelty of the Australian accent. That said, Dr Malik told me that he did not have any trouble understanding Mr Dobrijevic during their conversation. I mention all of this because there is a marked divergence between the accounts of Mr Dobrijevic and Dr Malik about what was said in their ensuing conversation.

5.9. According to Mr Dobrijevic’s statement he told the doctor essentially what he had told Mr Frundt. In addition, as he was talking to the doctor he began to think that perhaps his visits to his mother were causing his mother additional stress.

Accordingly, he also asked the doctor whether he should be visiting her every day or whether he should be coming less frequently in order to minimise her distress.

According to Mr Dobrijevic the doctor was not able to answer that question and said that he would go and speak to a psychiatrist. Dr Malik left that location and returned a few minutes later. Mr Dobrijevic was not party to, nor witnessed, any conversation that Dr Malik had conducted with another practitioner. We know that Dr Malik in fact spoke to Dr Warnes.

5.10. Mr Dobrijevic told me in evidence that what he had said to Dr Malik about his mother saying that he would be planning her funeral tomorrow did not seem to make any impression on Dr Malik as he maintained the same facial expression throughout the conversation. The overall feeling of Mr Dobrijevic was that Dr Malik did not really understand what he was being told, except to the extent of the enquiry about how frequently Mr Dobrijevic should visit his mother.

5.11. Mr Dobrijevic told the Court that when the doctor ultimately returned he told Mr Dobrijevic that he could refrain from visiting the following day or visit on Friday or, alternatively, visit tomorrow and miss Friday. Mr Dobrijevic does not claim at that stage to have engaged the doctor in further conversation about his mother’s utterances about planning for her funeral. According to Mr Dobrijevic’s statement, he was convinced that the message in that regard had been passed on to a psychiatrist. This

claim seems a little odd as it is difficult to see how Mr Dobrijevic could have been confident about that in the light of Dr Malik’s apparent casual or non-comprehending attitude to what he had been told. Be that as it may, Mr Dobrijevic asserts that he had the impression that the psychiatrist must not have been unduly concerned about what Doctor Malik had passed on, and the impression that he received was that he should therefore not be concerned himself. He then left the ward and, based upon the conversation he had with Dr Malik, did not attend the following day which was the Thursday of that week. It was on the Thursday evening that Mrs Dobrijevic met her death.

5.12. None of the Glenside staff members who were involved in this chain of communication, namely Mr Frundt, Dr Malik and the psychiatric registrar, Dr Warnes, acknowledged that there had been anything said by Mr Dobrijevic about his mother saying that they would find her dead the following day or that Mr Dobrijevic would be planning her funeral.

5.13. Mr Frundt, the enrolled nurse, both in his statement25 and in his evidence in the Inquest, said that what Mr Dobrijevic had asked him to do was simply to obtain a doctor which he did by fetching Dr Malik. Although he said that Mr Dobrijevic appeared to be concerned when he came out of his mother’s room, he did not ask him what his concern was. In his evidence Mr Frundt at first denied that Mr Dobrijevic had said to him that his mother had said that he would find her dead the following day if he did not get her out of there. He also denied that Mr Dobrijevic had told him that his mother had said that they would be planning her funeral. In short, Mr Frundt denied that Mr Dobrijevic had said anything to him that suggested that his mother had made a threat of self-harm. Mr Frundt said that if Mr Dobrijevic had used the words ‘very spooky’ to describe his visit he did not recall it. When questioned by counsel assisting as to whether it was possible that Mr Dobrijevic had said something to him in addition to simply requesting the presence of a doctor, he said that it was possible but that if he had been made aware that Mrs Dobrijevic had been threatening selfharm he would certainly have recalled that and written it down. However, Mr Frundt did go on to agree that if it had been the case that Mr Dobrijevic had said something about his having to arrange a funeral, he may not have interpreted that as being an indication of potential self-harm. Mr Frundt also acknowledged that Mr Dobrijevic 25 Exhibit C31

had told him something that was important enough to be conveyed to a doctor, but he could not remember what it was. The following passage in Mr Frundt’s examination by counsel assisting is pertinent: 'Q. We heard some evidence yesterday that Mr Dobrijevic remembers clearly telling you that his mother had said to him 'If you don't get me out of here, you'll be planning my funeral tomorrow'. Do you say he's mistaken about that.

A. I say I don't remember that conversation. He didn't say it to me.

Q. Is it possible that he did say that to you but that you just don't remember.

A. It's possible, I guess.

Q. I'm sorry, I didn't hear.

A. It's possible.

Q. Perhaps because you were busy and in the middle of something at the time.

A. Yes.' 26 I found these concessions to be puzzling in the light of Mr Frundt’s original unequivocal statement that the only conversation that had taken place between himself and Mr Dobrijevic was a simple request that he obtain a doctor for Mr Dobrijevic to speak to. Such an uncluttered account of this exchange would have been quite believable, particularly having regard to the fact that Mr Dobrijevic believed Mr Frundt merely to be an orderly. In those circumstances it would not have been surprising if all Mr Dobrijevic had imparted to an orderly was a mere request to get a doctor without providing any detail as to why he wanted to speak to a doctor.

Yet Mr Frundt in his evidence equivocated as to whether something further had been said and I found him to be a wholly unreliable historian as far as this conversation was concerned. In the event, Mr Frundt’s evidence did not really advance the issue one way or the other as to whether or not Mr Dobrijevic imparted any information to Mr Frundt about his mother’s intentions or statements regarding the possibility of selfharm. Mr Frundt’s evidence certainly was incapable of refuting the thrust of Mr Dobrijevic’s evidence that he had mentioned these things to Mr Frundt.

5.14. Dr Malik denied that anything had been said by Mr Dobrijevic about Mrs Dobrijevic having made utterances concerning her funeral or being found dead the following day.

Dr Malik said in his witness statement27 that Mr Dobrijevic gave no indication that he was worried that his mother would hurt herself. Dr Malik’s denials that Mr 26 Transcript, pages 125-127 27 Exhibit C33

Dobrijevic had said anything along those lines were at all times unequivocal and consistent. He said that he would have regarded the information as ‘substantial’28 and would definitely have consulted his registrar, who was only a matter of feet away, about such an issue. Dr Malik’s account of the conversation, as recorded in his witness statement, was that Mr Dobrijevic told him that his mother wanted to use him as an instrument for her escape and that he was concerned that his visits were upsetting her. Mr Dobrijevic had added that he thought it would be more appropriate that he did not visit for the next few days and asked Dr Malik whether he agreed with that strategy. Dr Malik repeated this account on oath in his evidence. Having been asked this by Mr Dobrijevic, Dr Malik went and spoke to Dr Warnes about it. At that time Dr Warnes was on the ward but was having a meal in another area.

5.15. Dr Warnes provided a statement to police29 and also gave evidence at the Inquest. In her statement she describes Dr Malik’s enquiry of her. All Dr Malik told her was that Mrs Dobrijevic’s son was concerned that his mother had become acutely distressed by his visit and was insisting that he take her home. The question that was posed to her was whether he should continue to visit daily or whether it might be prudent to take a day off. There was nothing said about the question of self-harm at all.

5.16. Dr Warnes in her evidence told me that the question of the frequency of Mr Dobrijevic’s visits had been a matter that he had raised with her earlier in the week and the issue seemed to be in the forefront of his thinking. She believed that on the Monday of that week he had asked her whether he should be visiting on a daily basis.

She had consistently informed him that the frequency of his visits was really a matter for him, that he should make the decision for himself and that Glenside would support him in whatever decision he made.

5.17. Mr Dobrijevic’s wife, Ms Anna-Maria Bassani, provided a statement to the Inquest that was supported by affidavit30. In that statement she describes her husband coming home at the end of this particular day and being very distressed about his mother. He told her that he had experienced a distressing visit with his mother and had mentioned the fact that his mother had attempted to barricade him in the room. Ms Bassani confirms that Mr Dobrijevic told her that Mrs Dobrijevic had said that if her son did not get her out of Glenside he would find her dead the next day would be planning her 28 Transcript, page 151 29 Exhibit C34a 30 Exhibits C15 and C15a

funeral. She states that her husband told her that he had then approached a doctor and had told the doctor what his mother had said but that he did not think that the doctor had fully understood the thrust of what he was saying. She said that her husband told her that he had told Glenside staff what Mrs Dobrijevic had said and that he had also asked the doctor whether his visits were causing his mother distress. Ms Bassani said that her husband told her he was advised by the doctor that he could take a day off if he wanted. This account as given by Ms Bassani is naturally self serving in a sense, but it does confirm that on the very day in question, and at a time before Mrs Dobrijevic’s death, Mr Dobrijevic had made a statement that was in all senses consistent with what he was eventually to say in his police statement and to tell this Court. Accepting as I do what Ms Bassani’s has stated on her oath, I find that Mr Dobrijevic made a statement that was consistent with his evidence and made it at a time when he did not have an apparent motive to fabricate any account of what his mother had said to him or what had subsequently been said to Glenside staff about the issue. Ms Bassani’s evidence certainly would refute any suggestion that Mr Dobrijevic had later fabricated his account in the light of the tragic events that were to involve his mother the following day.

5.18. In my view Mr Dobrijevic’s evidence of what his mother told him about finding her dead the following day and planning her funeral was truthfully given. I find that his mother did say those things to him. It would therefore be surprising if Mr Dobrijevic did not mention this to at least one of the persons to whom he then spoke. I find that Mr Dobrijevic did impart this information to Mr Frundt. Mr Frundt’s half-hearted denials, if they can be characterised as such, were unconvincing. When pressed about the matter he was quite hesitant and acknowledged that something may well have been said by Mr Dobrijevic that had given rise to concern.

5.19. The difficulty in my view was whether or not Mr Dobrijevic also told Dr Malik about his conversation with his mother and if he did, whether Dr Malik really took it on board. It is worthwhile observing that according to Mr Dobrijevic, Dr Malik did not appear to fully comprehend what he told him about his mother’s utterances. Mr Dobrijevic told the Court that he had the distinct impression that Dr Malik did not register the information and it is also pertinent to observe in this regard that Mr Dobrijevic had said the same thing to his wife later that day. The conversation with Dr Malik, as described by Mr Dobrijevic, was complicated by the fact that in addition

to the conversation about what his mother had said, there was a question raised about the frequency of his visits. This to me seems to have been the operative part of the conversation as far as Dr Malik was concerned because it was in respect of this inquiry that he spoke to Dr Warnes and it is in respect of this inquiry that he came back to Mr Dobrijevic with the general advice about frequency of visits. On any version of events, at that point there was no further conversation between them about Mrs Dobrijevic’s utterances. There would have been nothing unusual in Dr Malik wanting to obtain an opinion from one of the psychiatrically trained medical practitioners as to whether or not Mr Dobrijevic should continue to visit. I am not surprised that Dr Malik would not have wanted to answer that particular question himself. The fact that Dr Malik went and consulted Dr Warnes about Mr Dobrijevic’s concerns is quite in keeping with an understanding on Dr Malik’s part that Mr Dobrijevic simply wanted to obtain the doctor’s view about the frequency of his visits. I accept Dr Warne’s evidence that the only matter that Dr Malik raised with her was the frequency of Mr Dobrijevic’s visits. I found Dr Warnes to be a manifestly truthful witness in every respect.

5.20. There seems to have been in Dr Malik’s mind a greater emphasis on the issue concerning the frequency of visits than on what may have appeared to his untrained eyes to have been coincidental information about what Mrs Dobrijevic had said. In my view, while I accept Mr Dobrijevic’s evidence that he told Dr Malik what his mother had told him, there was much greater emphasis in this conversation on the question of the frequency of visitation. It may well be that Dr Malik, in spite of his more recent recognition of the importance of Mr Dobrijevic’s information about his mother’s state of mind, did not at the time appreciate the significance of Mrs Dobrijevic’s utterances and has simply forgotten that part of the conversation because of its then comparative lack of significance. Its lack of significance in Dr Malik’s mind is reflected by the fact that he said nothing about Mrs Dobrijevic’s utterances to Dr Warnes.

5.21. This lack of meaningful communication between Mr Dobrijevic and Dr Malik on the one hand and between Dr Malik and Dr Warnes on the other, was most unfortunate.

It would have been far better if Mr Dobrijevic had insisted on speaking to Dr Warnes or if Dr Warnes had of her own motion come and spoken personally to Mr Dobrijevic.

6. The events of Thursday 16 August 2007

6.1. As of Thursday 16 August 2007 any diagnosis concerning Mrs Dobrijevic’s mental state remained provisional, although a diagnosis of depression was considered likely having regard to her cultural background, age and the presence of chronic pain. There was also a history that suggested the presence of persecutory delusions. The complicating feature of her presentation was that Mrs Dobrijevic had multiple vascular risk factors and a cognitive impairment with behaviour disturbance and psychotic features could not be ruled out.

6.2. Dr Warnes reviewed Mrs Dobrijevic at around midday. She noted that Mrs Dobrijevic was much more settled that day and was reasonably cheerful and was accepting of the proposition that discharge at that time was not possible. That said, Mrs Dobrijevic also remained adamant that psychiatric services were not necessary and it is noted that she felt ‘quite ashamed about being here’. There was no suggestion in Mrs Dobrijevic’s presentation of any suicidal ideation and no hint of what she was to do later that day.

6.3. According to other notes made in her progress notes that day, she was seen by a physiotherapist who observed that Mrs Dobrijevic had her TENS machine and knew how to use it. The machine was provided with a new battery and pads. In a note timed at 1845 hours it records that she attended a meal in the dining room but had refused a shower.

6.4. Although Mrs Dobrijevic was not visited by her son on this day, he had telephoned to find out how she was and was told that she was better than the day before, which is in keeping with Dr Warnes’ observations. He had asked staff to pass on a message as he did not want to talk to his mother and stir her up. He says in his statement that he was very relieved by the telephone conversation. I do not know whether Mr Dobrijevic’s message was passed on. The note about his call as contained in Mrs Dobrijevic’s progress notes merely records that Mr Dobrijevic had requested that only immediate family members should be permitted to speak to his mother on the phone.

6.5. Whatever her ultimate diagnosis would have turned out to be, there is no evidence that would have alerted Glenside staff to any acute suicidality on her part on the day of her death. The conversation with her son had unfortunately not been effectively passed on and there was nothing else in Mrs Dobrijevic’s presentation during her time in the ward that would have indicated an active intent on her part to end her own life.

It is, however, most unfortunate that the communication between her son and staff on the ward in respect of the incident the day before had broken down or had lacked proper comprehension. Certainly in my view those utterances were not communicated either to the psychiatric registrar, Dr Warnes, or the psychiatrist, Dr Hapuarachchi. I say this was unfortunate because in her very frank evidence to me Dr Hapuarachchi made no bones about the fact that she would have been very concerned about those statements, would have taken them very seriously and would have taken the necessary action. Dr Hapuarachchi told me that because Mrs Dobrijevic was very likely depressed, the utterances may have said something about her true intent and a suicidal plan or a desire to self-harm would be a matter that would need to be seriously taken into consideration. If the utterances had been communicated to Dr Hapuarachchi she would have firstly spoken to the son herself to find out exactly what had been relayed to him and she would then have assessed Mrs Dobrijevic in respect of her mental state to see how intense the suicidal intent, plans and ideas were.

Depending on her evaluation, Dr Hapuarachchi told me that she would have considered implementing a high-risk management strategy in respect of Mrs Dobrijevic as well as endeavouring to reassure Mrs Dobrijevic. A high-risk category management strategy would be implemented for the first 24 hours. Management strategies, she told me, could have included organising a special nursing arrangement which I understood to be a one-on-one interaction. There would be constant observations for 24 hours. There would have been an effort to minimise opportunities for self-harm, for example to ensure that there were not any items or objects in her room that she might use to self-harm. There would also be other strategies considered such as the administration of sedating medication. In short, what Dr Hapuarachchi described would have significantly minimised the opportunity for, and the risk of, Mrs Dobrijevic doing what she did.

6.6. When Mrs Dobrijevic’s presentation is properly evaluated, in my opinion although as of 16 August 2007 Mrs Dobrijevic had said things in recent times that may have indicated a weakened desire on her part to continue living, there was no indication that had been communicated properly to any person in authority on the Rosewood Ward that she would take deliberate steps to end her own life. Nevertheless, the conclusion is available that Mrs Dobrijevic’s decision to end her own life was a reflection of her weakened desire to live in a state of constant pain and discomfort. In my view one does not need to have psychiatric training to conclude that this was

something that was not entirely unforeseeable. As Mr Homburg, who appeared for and on behalf of the Central Northern Adelaide Health Service that encompasses the Glenside Hospital, himself pointed out in his final address there was clear past evidence of depression and a reduced will to live if not active suicidal ideation from time to time. All this in my view raises a question as to whether in any assessment that involves an analysis of risk of self-harm or suicide, a patient’s longitudinal history is sufficiently taken into consideration. The emphasis in Mrs Dobrijevic’s case seems to have been focussed more on evidence, or lack of it, of acute and vocalised suicidal ideation when in reality her whole history, both longitudinal and recent, suggested that Mrs Dobrijevic, as of the week of 13 August 2007, may finally have just been giving up. The view seems to have been taken that Mrs Dobrijevic’s denials of an intent, desire or inclination to end her own life in and of themselves were conclusive evidence that she did not have, nor would have at any time, any such frame of mind.

6.7. In the event, on 16 August 2007 there was no change to Mrs Dobrijevic’s regime of observation or supervision and her level of scrutiny was of no greater intensity than that of any other patient on the ward. The hourly observations were maintained in her case and this level of infrequency enabled Mrs Dobrijevic to take the necessary steps to end her life.

6.8. At approximately 6:45pm Mrs Dobrijevic was seen by a registered nurse, Jocelyn Richards31, to be walking in the corridor. She was dressed. At about that time Mrs Dobrijevic knocked on the door to the nurses’ station and requested some antacid. A mental health nurse by the name of Robert Hill32 describes this interaction. About 10 minutes later, Mr Hill went around the ward and conducted checks. At that time Mrs Dobrijevic was by then in her room lying on her bed. She was still wearing her day clothes. She was facing the door and she acknowledged Mr Hill’s presence. By this stage the time was about 7pm. At approximately 7:40pm, which of course is less than 1 hour later since her last sighting by Mr Hill, an enrolled nurse by the name of Gail McMaster33 endeavoured to locate Mrs Dobrijevic in the day room with the intention of measuring her blood sugar levels. Not finding her there she went to her room. Mrs Dobrijevic was lying on her bed on her back. It was at that time that Ms McMaster 31 Exhibit C9a 32 Exhibit C10a 33 Exhibit C5a

found that Mrs Dobrijevic had a purple sweater around her neck. She was unresponsive. Ms McMaster called for assistance and unwound the garment which was tightly around the neck. CPR was commenced and other assistance was provided. An ambulance was called. Mrs Dobrijevic at no stage regained any respiration or heartbeat in spite of thorough resuscitative measures taken by both Glenside Rosewood staff and the South Australian Ambulance Service. I am satisfied that all that could be done for Mrs Dobrijevic was in fact done. Unfortunately Mrs Dobrijevic died as a result of the placement of the garment around her neck.

7. Mrs Dobrijevic’s risk assessment 7.1. Throughout the duration of Mrs Dobrijevic’s time in Rosewood Ward a pro-forma document entitled Mental Health Risk Assessment was maintained. It formed part of her clinical record34. The document purports to record the patient’s perceived level of risk in a number of identified risk categories. The document is updated on a daily basis. The document describes a number of categories of risk including the following: Risk of harm to self (suicidality) Risk of harm to others Risk of absconding Individual risk (in Mrs Dobrijevic’s case, falls) Within each category there are 5 levels of risk in descending order of seriousness, namely ‘extreme’, ‘significant’, ‘moderate’, ‘low’ and ‘none’. On the reverse side of the form a guideline description is given for each level of risk within the categories of ‘risk of harm to self (suicidality)’ and “risk of harm to others”. The definitions are not materially different in respect of both categories of risk. A ‘moderate’ risk is described in the following terms: 'Current thoughts / distress / past actions without intent or plans / moderate substance misuse' ‘Significant’ risk is described as: 'Current thoughts / past impulsive actions / recent impulsivity / some plans, but not well developed / increased substance misuse'

7.2. The level of risk determines the frequency of observations of a particular patient.

34 Exhibit C25, page 24

7.3. In Mrs Dobrijevic’s case there is a recorded daily risk assessment for each day from 12 August to 16 August 2007 inclusive. It has been recorded that her risk assessment in each of the 4 categories of risk was ‘moderate’ on each and every day.

7.4. In Mrs Dobrijevic’s case this document, insofar as it purports firstly, to reflect a competently considered risk assessment and secondly, to be a serious risk management device, is a most unconvincing document. In my view the integrity of the document is destroyed by the fact that her risk of harm to others is at all times described as moderate when there was little or no evidence to suggest that Mrs Dobrijevic was at any risk of harm to others. As well, her risk of absconding must have been considered to have been at least significant having regard to the fact that she was, at first, placed on 15 minute observations because of that very risk and secondly, had to be moved to the closed section of the ward because of that same risk.

7.5. Of course, the pertinent category of risk in Mrs Dobrijevic’s case, as far as the issues in this Inquest are concerned, was her ‘risk of harm to self (suicidality)’. Her categorisation as being at moderate risk of self-harm, unconvincing as it is in the light of her other questionable categorisations, only dictated an hourly observation regime in any event. All that said, there was no evidence that would have suggested from what was known within the four walls of the Glenside Rosewood Ward about Mrs Dobrijevic’s recent presentation that her risk of harm to self was to be characterised as significant in accordance with the definition. If her utterances to her son had been passed down the line, things probably would have been different. However, to be categorised as having a significant risk according to the definition, past impulsive actions were a relevant matter and we know from Mrs Dobrijevic’s history that such actions were part of her makeup.

7.6. The risk management document stated that any risk identified as moderate or of a higher category required a management plan that detailed a plan to ‘mitigate’ each of those risks. As to the nature of the plan to manage Mrs Dobrijevic’s perceived moderate level of risk of harm to self, I heard evidence from Ms Janine Buob who was the clinical nurse consultant in the Rosewood Ward in August 200735. Ms Buob explained to me that in effect the major component of Mrs Dobrijevic’s risk assessment was her risk of absconding. I do not need to repeat what the underlying basis of that assessment was and what action was taken to minimise it. As far as risk 35 Exhibit C36

of harm to self was concerned, Ms Buob stated as follows when asked to describe the management plan: 'From my recollections of Sofija when she was with us, she was not voicing suicidal intent to the nursing staff. From my recollection of the information provided to us by the medical staff that Sofija was not verbalising to us that she was wishing to harm herself this also I think reflects the score of perhaps past issues, that when she presented to the ward she was not making any attempt by trying to find something to hurt herself with.

She wasn't talking to the nursing staff about wanting to harm herself. When we hear that as nursing staff the alarm bells would ring and as a consequence we would change the amount of observation we give that patient. As I recall for this lady the time that she was with us, this was something that we weren't hearing. We were also guided by the assessments that were being done by the registrar that was seeing her on the ward and by the psychiatrist's review. If they had at any time found that there was any cause for concern that they felt that she was a significant risk to herself we would have changed her sightings, most definitely.' 36 In that regard, Ms Buob’s assessment did not differ from that of the medical practitioners concerned with Mrs Dobrijevic’s assessment and treatment. Naturally Ms Buob did not know anything about Mrs Dobrijevic’s statements to her son that were made on the afternoon of Wednesday 15 August 2007. In any event, Mrs Dobrijevic’s assessment as being at moderate risk of self-harm does not appear to have had any significant impact on her level of care.

7.7. Mr Homburg who appeared for and on behalf of the Central Northern Adelaide Health Service, arranged for the Court to be furnished with an affidavit compiled on behalf of his client that describes changes that were scheduled to take place as far as risk management was concerned in April of this year37. Among the relevant changes is a recognition that risk factors and their assessment and management should not be confined to an assessment of a patient at a particular point in time. Rather, in reality the factors that influence a patient’s risk should be recognised as being both static and dynamic38. The new risk assessment strategy also recognises that risk factors can change from hour to hour. In addition, historical information may indicate areas of future risk. The document recognises that a comprehensive assessment of risk might also require that information be obtained from the patient’s family. In this regard I observe that Dr Warnes did indeed speak to both of Mrs Dobrijevic’s sons about their mother’s longitudinal history. On 13 August 2007 Dr Warnes recorded that Mr Duro 36 Transcript, page 265 37 Exhibit C37, Affidavit of Margaret Edith Katherine Honeyman, Director of Mental health Policy, Dept Health, dated 7 October 2009 38 Exhibit C37, paragraph 10

Dobrijevic told her that when his mother was younger she would say she was going to commit suicide and described the episodes involving pills in her mouth as well as instances in which she threatened to jump out of a moving car. However, there was nothing in the content of this information that appears to have placed Mrs Dobrijevic within a higher risk category, and her recent presentation within Glenside was not suggestive of suicidal intent on her part.

7.8. The affidavit tendered on behalf of the Department of Health also describes a procedure whereby when a patient is admitted to an acute mental health unit, such as Rosewood, the patient’s risk would initially be assessed by a multidisciplinary team including a mental health nurse, a consultant psychiatrist, a medical officer and a social worker. Subsequent risk assessments would be undertaken by the multidisciplinary treating team and acknowledged by the team on a daily basis. The risk assessment would be discussed at each multidisciplinary team meeting and at handovers and would be reviewed daily by nurses and handed over by them each shift. The management strategy has been described as ‘The Standard Mental Health Assessment and Risk Assessment’ tool. The affidavit describes an expectation that the tool would provide a comprehensive approach to mental health and risk assessment designed to achieve a number of benefits including better sharing of information between service agencies, better coordination of care, adult patients receiving a comprehensive, holistic assessment of their needs and that decision making will be based on a team process. As at the time of the writing of these findings I have no information as to whether the new system has been implemented.

8. Recommendations 8.1. Pursuant to Section 25(2) of the Coroners Act 2003 I am empowered to make recommendations that in the opinion of the Court might prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the Inquest.

8.2. I recommend that the Department of Health continue to develop and implement risk management strategies that, in an assessment of risk of self-harm, take into account the patient’s entire mental health history as it is known at the time of assessment.

8.3. I also recommend that the Chief Executive Officer of the Department of Health instruct clinical staff employed in acute and chronic mental health facilities that

concerns expressed by members of a patient’s family or by a patient’s associates should be comminicated to, and be properly evaluated by, the patient’s treating psychiatrist or psychiatric registrar.

Key Words: Death in Custody; Psychiatric/Mental Illness; Suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 7th day of May, 2010.

Deputy State Coroner Inquest Number 23/2009 (1173/2007)