Coroner's Finding: JORKOWSKI Natassja Alexandra

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 10th, 14th, 15th and 20th days of June 2011, the 12th day of July 2011 and the 18th day of June 2012, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Natassja Alexandra Jorkowski.

The said Court finds that Natassja Alexandra Jorkowski aged 19 years, late of 53 Greenridge Court, Wynn Vale, South Australia died at Wynn Vale, South Australia on the 10th day of June 2009 as a result of asphyxiation. The said Court finds that the circumstances of her death were as follows:

1. Introduction 1.1. This case is about a 19 year old university student called Natassja Jorkowski. One day at university Natassja informed a counsellor that she intended to commit suicide.

She produced a typewritten two page document running to some 1,500 words which expressed this intention and explained her reasons. It also set out her preferred method of suicide, being helium asphyxiation. The counsellor was naturally very concerned and contacted the Mental Health Triage Service which in turn contacted the Assessment and Crisis Intervention Service (ACIS). Natassja was contacted by counsellors from ACIS but was never assessed by a qualified psychiatrist. She died at her own hand by asphyxiation using helium just 3 weeks and 1 day after presenting her plans to the counsellor. This Inquest examined the circumstances leading up to Natassja’s death.

2. Background 2.1. Natassja’s parents separated when she was about 6 years old. After that she lived with her mother. When Natassja was in Year 11 she developed problems with her eyes which were diagnosed by an opthamologist as Uveitis. The opthamologist prescribed cortisone and noted that it was a very severe presentation. In the end, she was placed on a course of cortisone injections to the eyes. She had ongoing medical care throughout Year 12 which had an impact on her ability to perform her studies.

Notwithstanding this, she did extremely well in Year 12. Eventually, Natassja developed full cataracts in both eyes. She had to undergo an operation to recover her vision but subsequently the position was reached by the clinicians, and the treating opthamologist, that her condition was not curable. From that time the treatment was geared to managing the damage and delaying further deterioration for as long as possible.

2.2. After Year 12 Natassja took a gap year and, for the second part of the year, travelled to Cambridge University. She attended ecology classes at the University, took up fencing and performed volunteer work with four separate organisations.

2.3. Natassja moved to Adelaide in January 2009 in order to commence her tertiary education at Flinders University. At this time she was living with her father in the northern suburbs of Adelaide.

3. Natassja’s interactions with counselling services at Flinders University 3.1. On 2 April 2009 Natassja saw Ms Williams, the disability support officer, at Flinders University to discuss how she could manage her studies in a university environment with chronic bilateral Uveitis. Natassja informed Ms Williams that she ‘might be a bit depressed about her vision’1. The disability adviser suggested counselling and an appointment was made with the Flinders University Health Counselling and Disabilities Service.

3.2. On 15 April 2009 Natassja attended a counselling appointment with Ms Bretag of that service. She reported distress relating to her visual problems and they discussed the possibility of depression as a consequence of that medical condition. She was referred by Ms Bretag to the University’s general practitioner for assessment. An 1 Exhibit C18b, Page 7

appointment was made that day with the Flinders University Health Counselling and Disabilities Service general practitioner, Dr Douglas. Dr Douglas appeared, as a result of her discussions in that first session, to have suspected a reactive depression as a result of Natassja’s eyesight and that this was affecting her concentration and her mood. She provided Natassja with a sample of an antidepressant called Lexapro and made an appointment to see her a week later. On 22 April 2009 Dr Douglas saw Natassja to follow-up on the previous appointment. Natassja reported having headaches and broken sleep and feeling angry. Dr Douglas increased the dose of Lexapro to one whole tablet and provided a script. It was noted that counselling was continuing with Ms Bretag.

3.3. A further appointment with Dr Douglas occurred on 29 April 2009. Natassja reported that her sleep remained disrupted and her attention focus, concentration and motivation were low. She said that she was experiencing what she described as some disassociation. On the other hand, Natassja reported a significant improvement of her depressive symptoms. Dr Douglas explained that it took 4 to 6 weeks for antidepressant medication to properly take effect. Natassja told Dr Douglas that she had had suicidal thoughts in the past. This was the first time that she mentioned suicidal thoughts to Dr Douglas. Natassja said that she had been having these thoughts since the age of 13 but had never made any attempt to act on them. Dr Douglas discussed protective factors with Natassja and Natassja referred to assisted suicide in Switzerland. Dr Douglas took some comfort from the fact that although Natassja expressed a suicidal intent, it was planned for a date well into the future and at a place overseas. Dr Douglas did not think she was an immediate risk. Natassja told Dr Douglas that she had a further counselling session scheduled with Ms Bretag the following week and an appointment scheduled with her opthamologist shortly after that. At the conclusion of the consultation Dr Douglas recommended that Natassja see her in two weeks and thereafter, monthly.

3.4. On 30 April 2009 Natassja saw Ms Bretag again. Ms Bretag noted that Natassja had commenced antidepressant therapy and was feeling less anxious. They had a general discussion about stress management strategy.

3.5. On 19 May 2009 Natassja again presented for counselling with the Flinders University counselling service. On that occasion she was unable to see Ms Bretag who was away. Instead she saw Mr Andrew Wood who is the Head of Department,

Flinders University Health Counselling and Disabilities Service. Natassja asked Mr Wood what his thoughts were on suicide. She informed him that she had been considering suicide on and off since she was 13 years of age. She produced to him the two page typewritten document about suicide, to which I have already referred.

That document is two pages in length and runs to some 1,500 words2. The document contains the following observations by Natassja:

1. It is a mostly utilitarian approach that leads me to want to suicide;

2. In the past I have come to the conclusion that over the period of being 35 to 40 years of age I will be at an optimum stage of my life to end my life;

3. Recently I have discovered the relative ease with which an optimal death (helium based asphyxiation) can be achieved;

4. I have reconsidered my circumstances and on some consideration the timing and circumstance is optimal as well;

5. I am presently at a very good time of life;

6. On the other hand I have had recent (over the past month and a half or so) problems with depression;

7. At times I have a very strong irrational, morbid or self-harm desire;

8. Because of my depression I am sometimes frightened that I will do something stupid or painful;

9. I experience long periods of disassociation;

10. I have an eye condition that has persisted for two years and does not appear to have any reason for abating, has no known cause and no plan for treatment. It causes me great emotional stress and reduces the quality of my life;

11. ‘I have the opportunity to obtain resources and am confident in my ability to conduct suicide safely. It should take some time to set up and this should provide time for reconsideration. On consideration of these points I believe myself to be at a circumstantially good position to undergo a suicidal act’.

Mr Wood read this document. He asked Natassja if she had planned a day to carry out her plan and she said that she did not have a particular day planned but would do it in her own good time. Mr Wood said that he could tell that she was adamant about 2 Exhibit C18c

committing suicide3. As a result of this he contacted the Mental Health Triage Service and faxed the call taker a copy of the document provided by Natassja. He also contacted Natassja’s father advising him of his concerns about Natassja. He informed Natassja of his intention to make these notifications.

4. Mental Health Triage Service 4.1. Ms Rosenberg was the call taker at the Mental Health Triage Service. Ms Rosenberg immediately contacted Northern ACIS as a result of her call from Mr Wood. She made an entry in the Mental Health Triage Service records of the call from Mr Wood.

The conversation lasted for 20 minutes and Ms Rosenberg made detailed notes about Natassja and her presenting issues. Ms Rosenberg assessed the risk to Natassja as a Level 2 moderate risk. The effect of that was that she was prioritised as non-urgent but to be seen within 72 hours. Ms Rosenberg attempted to call Natassja twice but was unable to get through to her. She then referred the matter through to ACIS.

5. ACIS 5.1. At 12:45pm Ms Lloyd from ACIS called Natassja on her mobile phone and managed to get through. Natassja was not surprised by the call and stated that her suicidal ideas were with her constantly. As she was at university at that time and there was a lot of background noise Ms Lloyd, having established Natassja’s immediate safety, informed her that someone from ACIS would call her that night to arrange a face to face meeting.

5.2. At 7:10pm that night, 19 May 2009, Ms Moseley from ACIS called Natassja. Ms Moseley recorded4 that Natassja was agreeable to a face to face assessment but was only available after 7pm weekdays or on the weekend. A tentative arrangement was made to see Natassja the following Saturday. Ms Moseley agreed with Natassja that she would call Natassja on the preceding afternoon to confirm the details of the home visit on that next Saturday. Ms Moseley called again on the Friday afternoon as arranged and an appointment was made for Ms Moseley and Ms Lloyd to attend Natassja’s home at 2:30pm on the following Saturday afternoon.

3 Exhibit C18a 4 Exhibit C14, Page 14

6. The home visit 6.1. Ms Moseley duly attended with another ACIS worker, Ms Byrne, for the home visit on the Saturday afternoon, 23 May 2009. They were met at the door by Natassja’s father who introduced them to Natassja. He wished to remain present during the interview, however it was agreed after consultation with Natassja that he would leave the room and allow the interview to proceed in his absence. The mental state examination appears quite thorough as recorded by the ACIS workers5. They note that Natassja reacted appropriately with them but was of a flat effect. She denied having a low mood and reported feeling the best she could recall. She displayed very little emotion and remained factual regarding her history. She denied any auditory or visual hallucinations and displayed clarity of thought. She was oriented to person, time and place and showed no evidence of psychosis. She did not report any problems with her appetite, concentration, memory recall and her motivation was intact as she was attending university and socialising. As to her suicidal ideation, she reported consistent passive thought and intent of suicide. She denied that she was an immediate risk saying that she was safe until the next month, until the exams were over. She denied self-harming behaviours and thoughts. She confirmed that she had been taking Lexapro antidepressant for the last two months and was seeing a psychologist at Flinders University. Natassja assured the workers that she did not intend to suicide at that time. She said that she was awaiting a response from others as to what she perceived as her rationale, or her philosophical argument, namely ‘why live?’. Natassja told them that she would like to choose to die at the height of her happiness and not at a low.

6.2. I note that this sentiment is consistent with the two page document provided by Natassja to M Andrew Wood.

7. Natassja’s further involvement with Dr Douglas 7.1. On 20 May 2009, the day after Natassja saw Mr Wood and was put in touch with the Mental Health Triage Service and ACIs, she saw Dr Douglas. Prior to that consultation Dr Douglas had been informed of the outcome of the counselling session Mr Wood had conducted the previous day with Natassja. Dr Douglas reviewed Mr Wood’s notes and the two page document that Natassja had given him. Mr Wood’s 5 Exhibit C14

had informed Dr Douglas that he had contacted ACIS to arrange a psychiatric assessment for Natassja and that he had informed Natassja’s father of this and the reasons for it. Dr Douglas informed Natassja of her knowledge of these issues and her discussions with Mr Wood. They discussed the contents of Natassja’s document at length. During the discussion Natassja told Dr Douglas that she was happy with her life at the present and felt well prepared for her exams the following month. She said that she was happy living with her father. However, she said that she did wish to die and, according to Dr Douglas, she ‘expressed core beliefs that were inconsistent with her living’6. Natassja appeared clear, articulate and reasoned. This was a lengthy session and Dr Douglas spent a considerable amount of time with Natassja.

Dr Douglas said that she suggested to Natassja not to try to find a rational reason for living but just to experience it for awhile. She also suggested that Natassja might benefit from psychotherapy. Dr Douglas told her that she needed the help of a specialist psychiatrist and they discussed Natassja’s involvement with ACIS. Dr Douglas did not consider Natassja to be at immediate risk of self-harm because of her plans with regard to her upcoming exams. Dr Douglas expected that Natassja would be assessed by a specialist psychiatrist through ACIS. Because of her expectations in this respect, Dr Douglas did not arrange or recommend a follow-up appointment. She was however aware that Natassja was scheduled to see Mr Wood again on 29 May

2009. She did reassure Natassja that she would be prepared to see her at anytime.

That was the last time that Dr Douglas saw or spoke with Natassja.

8. Further appointment with Andrew Wood 8.1. Natassja saw Mr Wood again on 29 May 2009. On that day she told him that there had been a mix up in an appointment arranged with the ACIS psychiatrist but that she had been seen by the ACIS counselling team the previous weekend. She reported that she had less suicidal thinking in the previous 10 days and was confident with her impending examinations. She felt less depressed overall since starting the Lexapro.

She did however say to Mr Wood that she felt that she had the power to choose whether to live or die and that no one could stop her or choose for her. She had plans to return to Melbourne to see relatives over the impending university holidays. Mr Wood was left with the expectation that Natassja would have a psychiatric assessment and that further appointments would be made to see him thereafter7.

6 Exhibit C23 7 Exhibit C18b and Transcript, pages 39-41

9. Natassja’s dealings with ACIS – the missed appointment with Dr Toh 9.1. On Monday 25 May 2009, being two days after the home visit by Ms Moseley and Ms Byrne, Ms Moseley reported on the home visit to the consultant psychiatrist with ACIS, Dr Toh. Later that same day Ms Moseley contacted Natassja by telephone to advise her of an appointment with Dr Toh on ‘Thursday, 1400 29-05-09’. Now unfortunately, that day and date did not match. Thursday was 28 May 2009, not 29 May 2009. In fact the appointment was for the Friday and not the Thursday.

9.2. On Thursday 28 May 2009 Natassja presented to Northern ACIS. Unfortunately Dr Toh was with another patient at that time and, although he was made aware of Natassja’s presentation, he was unable to leave his patient to attend to her. Dr Toh informed the receptionist to apologise on his behalf and request that Natassja keep the appointment for the following day and he would see her then8. Dr Toh said that he had booked a two hour appointment for the Friday afternoon9.

9.3. Unfortunately Natassja did not attend the appointment with Dr Toh on Friday 29 May

2009. A telephone call was made that morning from Dr Toh’s office to confirm the arrangement and Natassja’s father had answered the home telephone to advise that Natassja had gone to university. Natassja’s father said that she would not be back until 5pm and that she could not afford to take anymore time off from university. The ACIS caller advised her father that they would contact Natassja to book a further appointment with Dr Toh.

9.4. The following day, Saturday 30 May 2009, the ACIS office attempted to contact Natassja at 1100 hours by both landline and mobile. However there was no response.

A recorded message was left.

9.5. On the following day, Sunday 31 May 2009, the ACIS office contacted Natassja at 1510 hours offering an appointment with Dr Toh on Tuesday 2 June 2009. It was noted that Natassja declined the appointment and indicated that she was willing to wait for another time in a week or so. She was noted as saying that everything was ‘okay’ at the moment. The notation records: 'Difficult to establish a risk, however Natassja feels that she can wait two weeks to see the doctor – no risk currently.' 10 8 Transcript, page 258 9 Transcript, page 259 10 Exhibit C14, page 23

9.6. The following day, Monday 1 June 2009, Dr Toh reviewed Natassja’s casenotes. He wrote in the notes that Natassja had chronic dysthymia11 and suicidal ruminations since the age of 13 years. He said that he concluded that there was certainly a plan, but that it was a future risk factor and he thought that it was a reasonable assumption that ACIS had a timeframe in which to work with Natassja at that stage12. Dr Toh said that at no time in his dealing with the matter did he regard Natassja as being subject to detention under the Mental Health Act. He said that he did not think that there was an imminent threat such as to justify detention13. He was of the view that it was important for Natassja to engage with an experienced therapist in the longer term14.

9.7. On 5 June 2009 Ms Moseley contacted Natassja to attempt to arrange an appointment with Dr Toh on 22 June 2009. Natassja requested that she be able to have a psychiatric appointment closer to Flinders University.

9.8. On 9 June 2009 Ms Moseley contacted a Dr Allan Nelson concerning an opportunity for referral to him. That same day Ms Moseley called Natassja and she indicated that she would be willing to engage with Flinders Medical Centre Psychiatry as this would be easier for her to attend. She said that she was continuing medication as prescribed and did not feel depressed for the main part. She told Ms Moseley that her thoughts of suicide remained noticeable but she identified that her protective factors to minimise harm to others, namely her father and friends, were reducing her desire to act upon her intention to suicide. She was currently studying for her exams which were in two weeks. It was Ms Moseley’s plan to contact Dr Nelson’s rooms for a follow-up appointment.

10. 10 June 2009 10.1. Unfortunately the following day, 10 June 2009, Natassja attended at the premises of Peter Van The Party Man and stated that she wanted to hire a cylinder of helium gas.

She stated on her final post that she had intended simply to find out how long it would take to order the helium, but was told that the helium was available immediately. She decided to take the opportunity then and there. She told the shop assistant that she already had balloons and she paid for the gas and the deposit on the cylinder. She asked the shop assistant if she would be likely to be allowed to take the cylinder on 11 Dysthymia is a low grade depressed state of mind that is not a clinical major depression 12 Transcript, page 263 13 Transcript, page 265 14 Transcript, page 267

the bus. The assistant did not think she would be able to and helped Natassja call a taxi. At 10:40am that morning a taxi transported Natassja to her home address arriving at 11:40am. At 1:22pm Natassja posted her final post on her Live Journal web page. At 4:20pm that day a friend of Natassja’s read the blog and contacted others, as a result of which police attended the house shortly after 5pm and located Natassja deceased. She had placed herself in a cupboard, sealing it, with the helium gas and died from asphyxiation.

11. Expert opinion - Professor Robert Goldney 11.1. Professor Goldney was asked by counsel assisting to provide an expert opinion15.

Professor Goldney is a distinguished psychiatrist. He has provided many medicolegal opinions in the field of psychiatry and is currently Emeritus Professor in the Discipline of Psychiatry at the University of Adelaide. Professor Goldney was of the view that Dr Douglas’ diagnosis was correct. He agreed with Dr Douglas’ prescription of Lexapro. He was asked whether he accepted that an increased risk of suicidality was a side effect of the prescription of antidepressants such as Lexapro.

He agreed that it is a potential side effect but that the aggregate data shows that the overall effect of antidepressants is almost invariably beneficial. He agreed that an idiosyncratic response is sometimes to be found. He noted that the subject is controversial but that on balance there are some people who can experience suicidal thoughts with antidepressants16. Professor Goldney noted that Natassja had been experiencing thoughts of suicidality since the age of 13, which suggested that the Lexapro may not have been responsible for her committing suicide. He was of the view that the decision to prescribe antidepressants was the appropriate treatment in the circumstances17.

11.2. Professor Goldney was concerned about the way in which ACIS handled Natassja’s case. He said that the two page document prepared by Natassja rang alarm bells for him as it indicated that Natassja was feeling very unsafe and that she was in need of urgent psychiatric treatment18. Professor Goldney said that his expectation after Mr Wood contacted the Triage Service and then ACIS, was that there would be an immediate referral to a psychiatrist. He said that it disappointed him that a Director of 15 Exhibit C26a 16 Transcript, page 298 17 Transcript, page 299 18 Transcript, page 301

a student health service might ring up ACIS and spend almost 20 minutes describing what was, in his opinion, an urgent risk of suicide and the result would be that the call taker would classify the situation as not being urgent. He said ‘it just doesn’t seem right to me’19.

11.3. Professor Goldney commented that the way ACIS works, he accepted that that was probably as good a service as they could deliver, but that he did not think it adequate20. He said he thought someone in Natassja’s situation should have been seen very, very soon21. Professor Goldney likened Natassja’s situation to a person presenting at an Emergency Department who is bleeding22.

11.4. Professor Goldney was informed of Dr Toh’s view that he did not classify Natassja’s risk as imminent. Professor Goldney said that simply by referring to Natassja’s written comments he regarded her as demonstrating severe psychopathology which needed to be acted on very soon and very promptly. He interpreted it as being a very significant cry for help23. Professor Goldney was of the opinion that there should be some mechanism whereby a responsible clinician, and is this respect he was referring to Mr Wood, could arrange for a psychiatrist to see the person directly. He noted that that is not the way ACIS runs24.

11.5. It is fair to say that Professor Goldney was particularly struck with the content of Natassja’s two page document: '… very rarely does one get a description such as this that I read out recently.' 25

11.6. Professor Goldney summarised the matter as follows: 'But somebody to have seen so many people and not to have seen the person who is probably in the best position to do something about it, I mean, it just shouldn't happen - just shouldn't happen.' 26 In this passage Professor Goldney is referring to the fact that throughout the period leading to her death, Natassja never saw a consultant psychiatrist.

19 Transcript, pages 302-303 20 Transcript, page 304 21 Transcript, page 304 22 Transcript, page 306 23 Transcript, page 308 24 Transcript, page 309 25 Transcript, page 310 26 Transcript, page 311

11.7. Professor Goldney accepted that, on his reading of the situation, it may well have been his view that Natassja was detainable27. He accepted that ACIS were in the process of working towards obtaining psychiatric assessment for Natassja, but that in the meantime ‘she’s bleeding psychologically’ and ‘I don’t think that’s good enough’28. Professor Goldney disagreed with Dr Toh’s assessment that Natassja’s risk was not imminent. He said that it was not safe to accept Natassja’s assurances about exams and so on and so forth. His comment was that ‘how could one rely on her to stay alive for another month when she was speaking in this manner’ as described in the two page document and averting to the possibility of ‘having no control over myself’. Professor Goldney considered that it was necessary to start treatment immediately29.

12. Conclusions 12.1. In my view, Natassja’s treatment at Flinders University was very good. I think that Mr Wood acted very appropriately and that significant efforts were made by Dr Douglas and Ms Bretag to attend to her needs. Mr Wood acted very appropriately in response to Natassja’s two page document by elevating the matter to the urgency of the Mental Health Triage Service and a need for psychiatric assessment. I believe it was perfectly appropriate for Dr Douglas to prescribe the Lexapro as she did.

12.2. As regards Natassja’s treatment at the hands of ACIS, I am of the view that the individuals within ACIS performed as best they could in the circumstances. A number of efforts were made to contact Natassja and the initial response was very prompt. The difficulty is that which was identified by Professor Goldney, namely that ACIS is simply not set up to handle a situation such as that confronted by them in the present case.

12.3. Professor Goldney made the point, and it accords with my own experience in my present role, that it is a very rare thing for a person to present with a clear a statement of their mental state and intentions as Natassja did when she produced the two page document which has been closely discussed in this matter. On Professor Goldney’s expert view, the document necessitated a rapid response. That was apparently not Dr Toh’s opinion. In that respect I suspect that Dr Toh’s response is conditioned by his 27 Transcript, page 315 28 Transcript, pages 315-316 29 Transcript, pages 322-323

experiences within the ACIS environment. On any view it seems to me that the two page document was extraordinary. It was certainly regarded by Professor Goldney as a very rare case. That conclusion is consistent with the experience of this Court. In my view, Natassja’s case was one which necessitated a more urgent response than ACIS was able to afford her.

13. Recommendations

1. I recommend that the Chief Psychiatrist of South Australia consider this finding and the views of Professor Goldney;

2. I recommend that the Assessment and Crisis Intervention Service develop a risk management framework which would enable outlying cases such as Natassja’s to be identified with a view to fast tracking a psychiatric assessment in such cases.

Key Words: Psychiatric/Mental Illness; Asphyxiation; Helium In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 18th day of June, 2012.

State Coroner Inquest Number 15/2011 (0941/2009)