Coroner's Finding: SPRINGGAY Mark Douglas

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 24th day of February 2010 and the 2nd day of December 2011, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Mark Douglas Springgay.

The said Court finds that Mark Douglas Springgay aged 40 years, late of the Glenside Campus of the Royal Adelaide Hospital, Fullarton Road, Eastwood, South Australia died at the premises of Transport SA, Warwick Street, Walkerville, South Australia on the 19th day of April 2008 as a result of multiple injuries. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Mark Douglas Springgay was 40 years of age when he died on 19 April 2008. At the time of his death Mr Springgay was detained on a continuing detention order issued by the Guardianship Board pursuant to section 13 of the Mental Health Act 1993.

The order was dated 24 May 20071. Mr Springgay was on approved leave of absence from detention at the time of his death. Mr Springgay suffered from schizophrenia.

1.2. At about 9:30pm on the evening in question, Mr Springgay was found deceased by his father in a garden area beneath the Transport SA building in Walkerville. Mr Springgay had apparently ascended an external fire escape attached to the building and had then fallen from the building causing fatal injuries. From this fact, and from the fact that Mr Springgay had a history of mental illness and self harm, it is open to the Court to conclude that Mr Springgay deliberately fell from the building with the 1 Exhibit C15

intention of taking his own life. I so find. I also find that no other person was involved in Mr Springgay’s death.

2. Cause of death 2.1. Following Mr Springgay’s death, a post-mortem examination was conducted by Dr John Gilbert, a forensic pathologist at Forensic Science South Australia. In his postmortem report dated 4 March 20092, Dr Gilbert expresses the opinion that the cause of death was ‘multiple injuries’. He stated: 'Death was attributable to multiple injuries. The pattern of injury was consistent with a fall from a substantial height.' 3 I find that the cause of Mr Springgay’s death was multiple injuries.

2.2. A toxicology report dated 19 June 2008 was prepared by Dr Joanna Rositano, forensic scientist4. In her report she stated that Mr Springgay’s post-mortem blood contained therapeutic concentrations of clozapine, amisulpride and valproate which is consistent with his prescribed medication regime.

3. Background 3.1. Mr Springgay was born in 1967 in the Queen Victoria Hospital. He had a younger brother, Matthew, who was 2 years his junior. He led a normal childhood until the age of approximately 18 years when he began expressing thoughts that he felt evil and that there was a ‘black cloud’ in his head. Mr Springgay’s parents consulted a general practitioner who referred him to Dr Brock, a psychiatrist. Between 1985 and 1990 Mr Springgay received regular outpatient treatment from Dr Brock. In 1990 Mr Springgay was diagnosed with chronic schizophrenia and admitted to Hillcrest Hospital. He spent the next 6 years in this facility. Upon the closure of that hospital, Mr Springgay returned home to live with his parents.

3.2. A short time later Mr Springgay was admitted to the Cedar Ward at Glenside Hospital, which is a self-contained unit, but again returned to his parents’ home.

Between 1997 and 2005 Mr Springgay continued to live with his parents and was under the psychiatric care of Dr Peter Norrie of Glenside Hospital. Between 2004 and 2 Exhibit C2a 3 Exhibit C2a, page 1 4 Exhibit C3a

2006 Mr Springgay was admitted to the psychiatric ward of the Royal Adelaide Hospital for short periods of detention.

3.3. In 2004 Mr Springgay was prescribed a new medication, Abilify. According to Mr Springgay’s mother, Mrs Margaret Springgay, this new medication brought about a change in Mr Springgay, bringing him more awareness and insight into his life5.

3.4. Mr Springgay’s first apparent attempt to take his own life occurred on 9 March 2005.

He walked from the pedestrian footpath of North East Road at Walkerville onto the south-west lane of North East Road and was struck by a car. He was not seriously injured, but was conveyed to the Royal Adelaide Hospital for assessment, whereupon he was released. He apparently told his mother that this was an accident, but later confirmed that it had been a suicide attempt6.

3.5. On 20 March 2007 Mr Springgay again walked in front of a motor vehicle on North East Road and was struck causing serious leg injuries. He was hospitalised and detained under section 12 of the Mental Health Act 1993 at the Royal Adelaide Hospital. Mr Springgay spent a month in the orthopaedic ward for his broken leg and then a further 15 weeks in Ward C3. During this period, and as a result of the two traffic incidents I have described, an application was made to the Guardianship Board of South Australia on 4 May 2007 by Mr Patrick Duigan of the Royal Adelaide Hospital. On 24 May 2007 a 12 month continuing detention order was made pursuant to section 13 of the Mental Health Act 1993.

3.6. Whilst under the continuing detention order, Mr Springgay made a further apparent attempt at suicide, this time by way of electrocution. He was then released from the Royal Adelaide Hospital and admitted to Glenside Hospital. During this time he came under the immediate care of Dr Roman Onilov and Dr Harry Hustig. He was initially accommodated in Banfield Ward but was moved to Glen South Ward in November 2007.

3.7. In October 2007 Mr Springgay was approved for regular weekend visits to his parents’ house. According to his mother, when Mr Springgay came to stay he would bring his medication with him. He was taking 1200mg of Amilsulpride, 2g Valproate and 800mg of Clozapine daily. There is no evidence to suggest that Mr Springgay 5 Exhibit C4a, page 3 6 Exhibit C4a

was non-compliant with his medication regime. Mr Springgay would submit to regular blood tests which confirmed this compliance.

3.8. The arrangements for Mr Springgay’s home visits were that he would stay one night during the weekend at his parents’ home. The periods of leave of absence were considered and approved by the treating psychiatrist on an individual, case by case, risk assessed basis. Dr Olinov in his statement to the Inquest7 explains the leave regime. He states that leave was arranged in consultation with Mr Springgay’s parents who were aware of their son’s illness, medication and ideation. The individual assessment relating to any proposed leave period was based upon the general impression of Glen South Ward staff. On one occasion, in March 2008, Dr Olinov cancelled Mr Springgay’s leave of absence due to comments made by Mr Springgay regarding his intention to commit suicide. However, according to Dr Olinov, Mr Springgay’s condition seemed to improve from this point and until his death. He stated: 'In the week leading up to Mark’s death there was no indication or active planning that was observed by staff towards a suicide attempt. Mark exhibited his normal demeanour and did not voice any out of the ordinary ideation. In fact, and surprisingly so, that week mark had shown minor signs of improvement evidenced by his decision to sign the consent form for influenza vaccinations that were voluntary and occurring within the Glen South Ward.' 8

4. Events leading to Mr Springgay’s death 4.1. On 19 April 2008 Mr Springgay was collected by his mother from Glenside Hospital and taken home on a leave of absence approved by Dr Olinov. According to his mother, Mr Springgay appeared as he normally did. In accordance with his usual routine he brought his washing with him and they picked up ten bottles of Coke from a nearby cafeteria. They went to Subway for lunch and then to Sefton Park Plaza to shop. Upon arriving home Mrs Springgay recalls that her son went to his room as he usually did. Later in the day Mr Springgay agreed to help his mother with some gardening. Whilst gardening Mr Springgay stated to his mother ‘I really, really, really wish you well’. He repeated this a number of times. He also stated that he believed in God. Mrs Springgay thought nothing of these comments as her son would often say strange things as a result of his illness.

7 Exhibit C5a 8 Exhibit C5a

4.2. At one point while gardening Mr Springgay broke a pot and he and his mother travelled to a nursery in Norwood to purchase a replacement. Upon their return Mrs Springgay continued gardening and then attended to some washing. Mr Springgay had a cigarette and spent some more time in his room. This was apparently normal.

4.3. At approximately 5:30pm Mrs Springgay was resting in the lounge room when her son walked past and indicated that he was going for a walk. He did not wish for his mother to accompany him, despite her offer to do so.

4.4. Mrs Springgay became concerned when it became dark and Mr Springgay had not returned. She spoke with her husband who went looking for their son in his car. Mr Springgay Snr returned a short time later having been unsuccessful in his attempts to find his son and both Mr and Mrs Springgay went out together to continue the search.

4.5. Mr and Mrs Springgay returned home for dinner and, as Mr Springgay still had not returned, his father once again went to search for him.

4.6. In Mr Springgay Snr’s statement9 he indicates that it was at about 9:15pm that he found his son lying on the ground near the western side stairwell of the Highways Department (now Transport SA) building in Walkerville. He believed from the way his son was lying that he was deceased. He rang his wife and then 000. When police arrived a short time later they came to the conclusion that Mr Springgay had fallen from the Transport SA building, based on his injuries and the fact that his body was found outside the stairwell which leads to the roof of the building. South Australia Ambulance Service members also attended the scene and pronounced life extinct.

5. Conclusion 5.1. A police investigation into Mr Springgay’s death was conducted. The Investigating Officer stated as follows: 'It was suspected that the deceased, owing to the severe and obvious injuries sustained, had jumped from the Transport SA building. There were no suspicious circumstances noted by the attending patrol members from Holden Hill or Major Crime Criminal Investigation Branches in relation to the deceased, immediate area or Transport SA building.' The Court endorses that conclusion.

9 Exhibit C1b

5.2. Although Mr Springgay had a clear history of attempted self-harm and suicidal ideation as part of his illness, there is nothing to suggest that his regime of regular leave of absence into the care of his parents, assessed as it was on a case by case basis, was anything other than appropriate. Nor is there any suggestion that the grant of leave in this particular instance was other than appropriate. The investigating police have not expressed any conclusion to the contrary.

6. Recommendations 6.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 2nd day of December, 2011.

Deputy State Coroner Inquest Number 6/2010 (0516/2008)