Coroner's Finding: STORRIE Victor James

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 12th day of June 2009 and the 18th day of August 2010, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Victor James Storrie.

The said Court finds that Victor James Storrie aged 38 years, late of the Glenside Campus of the Royal Adelaide Hospital, Fullarton Road, Eastwood, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 4th day of October 2007 as a result of terminal respiratory failure due to chronic obstructive lung disease on a background of severe chronic schizophrenia and ischaemic heart disease. The said Court finds that the circumstances of his death were as follows:

1. Reason for Inquest and cause of death 1.1. Victor James Storrie was 38 years of age when he died on 4 October 2007 at the Royal Adelaide Hospital. The cause of death was given by Dr Iain McIntyre as terminal respiratory failure due to chronic obstructive lung disease on a background of severe chronic schizophrenia and ischaemic heart disease1 and I so find. At the time of his death Mr Storrie was detained on a continuing detention order pursuant to section 13 of the Mental Health Act 1993. The order was dated 6 June 20072. Mr Storrie’s death was therefore a death in custody within the meaning of the Coroners Act 2003 and an Inquest was required to be held into his death under section 21(1)(a) of that Act.

1 Exhibit C3a 2 Exhibit C13

2. Background 2.1. Mr Storrie had a long history of severe mental illness dating from the age of 21 years.

From that age he had many admissions to mental health facilities within the State.

Initially he was diagnosed as suffering from schizophreniform psychosis. He had a number of suicide attempts over the years and was addicted to cannabis. He frequently abused alcohol and was a heavy smoker. Mr Storrie was not compliant with his medications.

2.2. In 2003 the medical practitioners who were treating him at that time noted a worsening of a respiratory complaint. He was then smoking 40 cigarettes per day.

Mr Storrie was diagnosed as having chronic obstructive lung disease and it was noted that, if he continued to smoke, his condition would worsen. During his various periods of detention efforts were made to reduce Mr Storrie’s smoking, but this was a source of irritation to him and a constant theme throughout his detention was his desire to smoke and the efforts of staff to limit his smoking. He continued to suffer delusions of a paranoid nature and his delusions and psychosis became worse in periods of respiratory distress.

2.3. Mr Storrie was admitted to the Royal Adelaide Hospital on 29 September 2007 from Glenside Hospital where he was detained. He was in severe Type 2 respiratory failure and was admitted to the Intensive Care Unit. On 1 October 2007 it was noted that his condition had deteriorated overnight. A chest X-ray was performed which showed no evidence of reversible pathology. The medical opinion was that there was little likelihood of recovery, even with intubation. At this point Mr Storrie was regarded by the treating medical practitioners as being in the terminal phase of respiratory failure.

He was discharged from the Intensive Care Unit on 2 October 2007 to a ward to be managed palliatively. His condition continued to deteriorate and his next of kin were notified. In the evening of 3 October 2007 he was noted to have low oxygen saturations at 55% and was developing Cheyne-Stokes breathing. He ceased respiration just after midnight on 4 October 2007 and was declared life extinct that morning.

3. Conclusions 3.1. A very thorough investigation has been performed by Detective Senior Constable Phillips in this matter3. I consider that Mr Storrie’s detention was lawful and his treatment at all relevant times was appropriate.

4. Recommendations 4.1. I have no recommendations to make.

3 Exhibit C11

Key Words: Death in Custody; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 18th day of August, 2010.

State Coroner Inquest Number 14/2009 (1441/2007)