Coroner's Finding: AMOS Mark Geoffrey

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 23rd day of June 2011 and the 25th day of September 2012, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Mark Geoffrey Amos.

The said Court finds that Mark Geoffrey Amos aged 37 years, late of 1B Stevens Close, Somerton Park, South Australia died at Somerton Park, South Australia on or about the 20th day of April 2009 as a result of morphine toxicity. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Mark Geoffrey Amos died on or about 20 April 2009, he was aged 37 years. At the time of Mr Amos' death he was subject to home detention bail conditions for two counts of illegal interference with a motor vehicle and one count of aggravated assault. As Mr Amos died whilst he was subject to home detention bail conditions, he was deemed to be in custody at the time of his death and this Inquest was held as required by section 21(1)(a) of the Coroners Act.

2. Cause of death 2.1. An autopsy was performed by Dr John Gilbert, Forensic Pathologist at Forensic Science South Australia. He gave the cause of death as morphine toxicity in his post mortem report1, and I so find.

1 Exhibit C2a

3. Background 3.1. Mr Amos had a longstanding medical and mental health history beginning with the diagnosis of encephalitis at the age of 15 which is believed to have affected his learning development. Mr Amos had an extensive history of polysubstance abuse and prescription drug abuse; he used both amphetamines and heroin intravenously and began the methadone program in 2005.

3.2. Mr Amos had an extensive criminal history, primarily made up of dishonesty offences and he had been imprisoned on numerous occasions. On 28 January 2009 he was arrested for the charges of illegal interference of two motor vehicles in neighbouring houses in Somerton Park. In the course of this offending the 83 year old victim who owned one of the vehicles attempted to stop Mr Amos from stealing his vehicle.

There was then a scuffle which resulted in the victim being injured. Other residents from nearby houses heard yelling and came to the victim's aid. They held Mr Amos until the police arrived and arrested him.

3.3. On 11 February Mr Amos was granted home detention bail to reside at an address in Somerton Park. The conditions of his bail were standard for home detention bail conditions. They including wearing an electronic monitor, residing at the Somerton Park address, agreeing to undergo psychological assessment and undertaking a victim's awareness program amongst other conditions.

4. Events leading to the discovery of Mr Amos 4.1. On 21 April 2009, Mr Amos failed to attend a scheduled appointment. His case manager, Gloria Sanchez, was notified the following day. On 22 April 2009 a phone call was made to Mr Amos by his home detention officer, Andrew Peacock, with no response. The monitoring device showed that Mr Amos was at home. A notation was made in the case management notes for the case manager to follow up. Three days later, on 25 April 2009, Andrew Peacock made calls at both 12:05pm and 2:45pm to Mr Amos' landline phone with no response. Mr Peacock then called his mobile telephone, which was not answered.

4.2. Mr Peacock then called Mr Paterson, another home detention officer who was in the area, and asked him to undertake a welfare check. Mr Peacock also called Mr Amos'

parents to see if he had the right mobile phone number. Mr Amos’ mother commented that her son was a very heavy sleeper and that he may not have heard the phone ring.

4.3. Mr Paterson was unable to rouse Mr Amos when he arrived so they called Mr Amos’ parents who attended a short time later with a spare key. Unfortunately Mr Amos was found deceased in the front main bedroom in a decomposed state.

4.4. The monitoring device that was worn by Mr Amos did not record movement within his house. Therefore it was not possible for those monitoring Mr Amos to know that he was in the same position for an unusually long time, thus triggering concerns for his welfare earlier.

4.5. It is apparent from the evidence that one of the drugs Mr Amos was known to consume was Kapanol, which is a slow release morphine agent. However, it can be crushed and dissolved for use in a syringe, and it appears that this was the source of the morphine that led to Mr Amos’ death. There were used syringes and Kapanol capsules found at the scene.

4.6. I find that Mr Amos died as a result of an accidental overdose of morphine derived from Kapanol capsules obtained by him from an unknown source. Under the terms of his home detention he was permitted to leave the house in order to attend appointments and go shopping. It is likely that he obtained the Kapanol while absent from the house on one of those occasions.

5. Recommendations 5.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Morphine Toxicity In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 25th day of September, 2012.

State Coroner Inquest Number 18/2011 (0696/2009)