Coroner's Finding: HADLEY Duke Zenon

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 15th, 16th, 17th and 18th days of July 2013, the 27th, 28th and 29th days of November 2013 and the 31st day of January 2014, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Duke Zenon Hadley.

The said Court finds that Duke Zenon Hadley aged 2 years, late of 29 Johnson Street, Royal Park died at Royal Park, South Australia on the 5th day of November

2009. His cause of death was attributed to asphyxiation due to neck and/or chest compression. The said Court finds that the circumstances of his death were as follows:

2010. Introduction and cause of death 1.1. Duke Zenon Hadley was 2 years of age when he died on 5 November 2009. An autopsy was performed by Dr Carl Winskog on 7 November 2009 and Dr Winskog prepared a post mortem report dated 15 April 20101 which gave the cause of death as attributed to asphyxiation due to neck and/or chest compression, and I so find.

2011. Background 2.1. Duke had been alone with his mother, Ms Rachael Hadley, during the day of 5 November 2009. He was last seen alive by his father, Mr Jason Hura, when he left to take Duke’s 9 year old sister, Chloe, to school at approximately 8:30 that morning. Mr Hura had various work related commitments during the day. On his return to the family home later that day Mr Hura found Ms Hadley locked inside the house. She was not permitting access.

1 Exhibit C1a

2.2. Eventually police were called and they gained entry to the premises. They located Duke in his cot. He was dead. Dr Winskog was unable to give an exact time of death. Insect activity suggested that Duke had been deceased for some time.

2.3. Ms Hadley was charged with Duke’s murder. She was 26 years of age at that time.

In due course Ms Hadley conceded the objective elements of the offence, being that she caused the death of her son by asphyxiation due to chest and/or neck compression by placing her feet on his mouth and chest and standing on him.

2.4. On 5 November 2010 Duggan J found that the objective elements of the offence were established beyond reasonable doubt. However, at the time of the alleged offence Ms Hadley was in a state of acute manic psychosis. His Honour found that she was, at the time of the alleged offence, mentally incompetent to commit the offence and was therefore not guilty by virtue of mental incompetence. The outcome was that Ms Hadley was declared liable to supervision under Part 8A of the Criminal Law Consolidation Act 1935.

2.5. Duggan J had the benefit of the opinions of two psychiatrists, Drs Raeside and Tomasic, who both prepared reports about Ms Hadley’s competence to commit the alleged offence.

2.6. Dr Raeside interviewed Ms Hadley at James Nash House on 29 July 2010. He noted that Ms Hadley had been admitted on two prior occasions to the psychiatric unit of The Queen Elizabeth Hospital. The first was at the age of 22 when she displayed signs of paranoia and was admitted to the hospital under a detention order for approximately three weeks. An antipsychotic drug was prescribed for her.

2.7. In the ensuing years the psychotic symptoms continued. Dr Raeside noted that Ms Hadley started to hear voices, a phenomenon which she first experienced at around the age of 19 years. During this time she continued to exhibit signs of paranoia. In due course she expressed delusional ideas. In the opinion of Dr Raeside, Ms Hadley was acutely psychotic at the time she killed her son. This was as the result of either a manic relapse of a bipolar disorder or a drug induced psychosis. In either event, the result was a mental impairment.

2.8. In Dr Raeside’s view a drug induced psychosis is much less likely. He pointed to Ms Hadley’s long history of deteriorating mental health, described by her friends and

partner, as well as a protracted psychosis that continued after her admission to hospital.

2.9. Dr Raeside said that the police description of Ms Hadley’s behaviour when they arrived at the house on the occasion of her son’s death demonstrated acute psychotic disturbance on her part. She was voicing bizarre delusional ideas. Her speech was rapid and pressured and marked by thought disorder. Dr Raeside said that he had seen few examples of manic psychosis as stark as Ms Hadley’s reported presentation.

2.10. Dr Raeside concluded that Ms Hadley had a bipolar disorder and that there was an acute manic psychotic episode at the time of the killing of Duke. In Dr Raeside’s view she was clearly psychotic at the time of the incident. He said she would have been unable to know the nature and quality of her actions, namely that she was killing her son. Rather, she believed that she was expelling an evil spirit from him and that she expected him to recover. Dr Raeside was of the opinion that she was unable to reason with a moderate degree of sense and composure about the wrongfulness of her actions as a result of her delusional beliefs and psychotic confusion.

2.11. Ms Hadley was also examined by Dr Maria Tomasic, a forensic psychiatrist. This occurred on 25 August 2010 at James Nash House. Dr Tomasic said that Ms Hadley had been transferred to James Nash House on 31 March 2010. Dr Tomasic noted Ms Hadley’s disorganised and erratic behaviour after being taken into police custody and expressed the opinion that Ms Hadley was suffering a bipolar affective disorder with underlying borderline personality traits. Dr Tomasic was of the opinion that at the time of Duke’s death Ms Hadley was acutely manic, elevated in mood and acting with psychotic symptoms of paranoid religious and grandiose delusions and hallucinations.

She said that Ms Hadley was clearly suffering from a mental impairment at the relevant time. In Dr Tomasic’s view Ms Hadley did not know the nature and quality of her actions at the time. Furthermore, she was of the opinion that Ms Hadley was not able to reason with a moderate degree of sense and composure about the wrongfulness of her actions. She did not appear to understand that her actions were harming her son but instead believed that she was saving him as she believed that he had been taken over by an evil spirit.

3. December 2008 - Ms Hadley is admitted to Cramond Clinic 3.1. In December 2008, some eleven months before Duke’s death, Ms Hadley was admitted to Cramond Clinic at the Queen Elizabeth Hospital. Ms Hadley’s admission to Cramond Clinic is best described through the evidence of Dr Mohan, consultant psychiatrist, who was a Registrar at the time he treated Ms Hadley in December 2008.

He said that he was involved in her treatment as part of a multi-disciplinary team. Dr Mohan said that Ms Hadley was an inpatient between 5 December 2008 and 17 December 2008 at Cramond Clinic. She was 22 years of age and living in a rental property with her two children. Her partner was away. She had presented to the Queen Elizabeth Hospital Emergency Department after calling South Australia Police.

She was afraid to stay in her house because she felt there were intruders and claimed to hear specific noises from different parts of the house which made her wonder whether people were breaking in. She also mentioned some notes on her refrigerator which she misinterpreted as being very threatening messages. She explained that the people who had lived in the house in the past may still have keys to the property and may be gaining access and stealing her things. This was the reason why she had come into the hospital. She also said that she had been using cannabis fairly recently.

3.2. Dr Mohan’s clinical impression at the time was that she was displaying symptoms of a psychosis characterised by hearing voices which were non-existent, and having persecutory beliefs that people were targeting her. Given the proximity of the drug use, the first diagnosis that was considered was a drug induced psychosis. She was reviewed by the clinical team on a regular basis over her admission to observe how her mental state shifted over time. She was given anti-psychotic medication namely, Risperidone at 4mg. This medication alleviated her symptoms to a large extent2.

3.3. Dr Mohan said that she was discharged on 17 December 2008 and follow up was arranged with a community team known as the Port Adelaide Community Treatment Team3. Dr Mohan said that the plan for discharge was that there would be an interim follow up as a transition of care from Cramond Clinic’s care to the Port Adelaide Community Treatment Team’s care. This was dealt with in what was referred to as a Transition of Care Clinic at the Port Adelaide premises. The Transition of Care 2 Transcript, page 58 3 Transcript, page 59

Clinic consisted of Dr Mohan and Sue Morrison, a Social Worker with the Port Adelaide Community Treatment Team.

3.4. The first transition of care consultation with Ms Hadley took place on 24 December 2008, only a week or so after her discharge from Cramond Clinic. Dr Mohan recorded notes of that consultation. In his evidence he recalled that Ms Hadley appeared quite reactive and was able to engage in a conversation. Her condition had not worsened since discharge and she reported that she had secured the house against intruders. She was still troubled by the noise of what she thought was a watch ticking which she could not find. She also admitted to an episode of cannabis use after discharge, which Dr Mohan thought might have explained why some of her symptoms had not dissipated. Ms Hadley reported that she had plans as to how she was spending Christmas. She reported a side effect of Risperidone, namely the secretion of breast milk, and Dr Mohan’s plan was to review her in a couple of weeks to monitor that side effect and consider a different medication.

3.5. Dr Mohan saw Ms Hadley again on 7 January 2009, again with Ms Morrison as part of the Transition of Care Clinic. He said there was a difference in Ms Hadley’s presentations. She appeared flat and was not reactive and appeared to be sad. She said that she was extremely tired and had tremors which might have been a side effect of the Risperidone, and the milk secretion was continuing. She reported that she could still hear the watch ticking but she was no longer concerned or worried about that. She was looking after the household and her two children quite well and was cooking, cleaning and doing the shopping. She said that she had stopped taking cannabis and requested that the Risperidone be tapered or reduced because of the side effects. Dr Mohan’s view at the time was that the episode in December was likely to be a drug induced episode, from which she was showing improvement after abstaining from drugs. He considered that she had made a functional recovery and so he reduced the dose of Risperidone by 1mg. His plan was to gradually taper the Risperidone further over the next few months4.

3.6. Dr Mohan next saw Ms Hadley on 21 January 2009. He noted that her presentation was appropriate and that she was euthymic and reactive so that her mood had returned to base line and she was more reactive. He said that compared to her previous visit when she had appeared flat she had certainly improved although was still complaining 4 Transcript, page 63

of a lack of energy. She said that her partner perceived her as lazy and she attributed this to the effect of the medication. She requested a reduction in medication. She denied any psychotic phenomenon. Dr Mohan’s clinical impression was still that there had been a brief psychotic episode which was drug related. However, the change in her mood from sad two weeks previously might have been a reflection of a primary psychiatric disorder such as bipolar disorder and Dr Mohan was considering that as a possibility as part of a differential diagnosis. He said that it was hard to say at that point what the true position was because there had been a recent history of drug use and that it would be necessary to review her over a longitudinal period when being followed up by the community team. He resolved to keep the differential diagnosis under review and to taper and stop her Risperidone over the next few months. He made a dose reduction at that point from 3mg of Risperidone to 2mg. He was aware that she was due to have an appointment shortly with Dr Nalaye who was a doctor at the Port Adelaide Community Treatment Team. He assumed that she would be followed up regularly by the Port Adelaide Community Treatment Team and at that point his involvement with Ms Hadley ceased5. Dr Mohan’s expectation at that time was that Ms Hadley’s needs would be met appropriately by the Port Adelaide Community Treatment Team with medication or case management6.

4. Ms Hadley’s appointment with Dr Nalaye 4.1. The documentary evidence7 showed that she was seen by Dr Nalaye on 26 February

5. At this time she was formally under the care of the Port Adelaide Community Treatment Team. Dr Nalaye’s progress note was the only evidence of what occurred on this occasion because unfortunately Dr Nalaye developed an illness shortly after this and died in 2009. Thus, the only information for the Court to rely on is his documentation. Fortunately, the notes are quite comprehensive.

4.2. Dr Nalaye recorded that Ms Hadley had been referred from the Transition of Care Clinic after an admission to Cramond Clinic. He recorded that Ms Hadley said that she was stable but that she had been living with an abusive partner for the last six years. She said that she had been abused verbally and emotionally for the whole of the relationship and that she was petrified to stay with him. She was afraid that he 5 Transcript, page 66 6 Transcript, page 66 7 Exhibit C70

would take the children from her. She reported, according to Dr Nalaye, that she had put up with the abuse but could no longer live under the same roof as her partner.

4.3. I interpose to note that this was the first occasion on which a clinician had recorded complaints of domestic violence. Certainly Dr Mohan made no mention of domestic violence in his dealings with Ms Hadley, which were more extensive than Dr Nalaye’s.

4.4. Dr Nalaye recorded that at the time that he saw her, Ms Hadley was not experiencing any psychotic phenomena and no neuro-vegetative features or delusions. He recorded her past psychiatric history and that she had reportedly ceased smoking cannabis. He recorded her developmental history quite comprehensively. He noted that her premorbid personality was that of a friendly and artistic person. He remarked that her mental state was tearful, agitated and it was hard to control her emotions. When she settled down she was friendly, cooperative and able to explain the turmoil she was in.

Her speech was of normal flow and there were no delusions or formal thought disorder. Her sleep, appetite and mood were fine. In short, there were no psychotic symptoms and she had insight into her condition. Dr Nalaye made the provisional diagnosis of adjustment disorder with mild depressive symptoms. He noted that there was domestic violence. He made a differential diagnosis of mood disorder and bipolar effective disorder and then recorded the following plan: 'She was informed to contact DV Crisis Intervention and will be placed in a hotel for the time being and will eventually placed (sic) in a home with her two children. The crisis worker will send a cab for her when she goes home and pack few things. Continue with her medication Risperdal 2mg nocte.' 8

4.5. That was the last time Ms Hadley was seen by the Port Adelaide Community Treatment Team. No follow-up appointment was made and she did not make further contact herself.

4.6. It is impossible to tell from the available material whether Dr Nalaye had planned to arrange a further appointment. It is possible that he had planned to do so and that through inadvertence that did not happen. Whatever Dr Nalaye’s intentions, the fact is that no further appointment was arranged for Ms Hadley. It is quite clear that she needed to continue her treatment with the Port Adelaide Community Treatment Team.

Clearly there was a need for the Risperidone to be monitored, and for the dosage to be 8 I have omitted certain obvious typographical errors

further adjusted and eventually ceased. Without attributing responsibility for this breakdown in care to any particular individual, it can certainly be seen as a system failure.

5. Ms Hadley’s file is closed by the Port Adelaide Community Treatment Team 5.1. The next event in the chronology is when the Port Adelaide Community Treatment Team decided to close Ms Hadley’s file. This occurred on 15 September 2009 and the only record of it is a handwritten note on the file as follows: 'Discussed closure of this file with team leader and TOCC worker, Sue Morrison. Close file today. No contact since Feb 09.'

5.2. That file note was written by Mr Michael Wooden who was a Social Worker with the Port Adelaide Community Treatment Team in 2009. He gave evidence at the Inquest that in 2009 the Port Adelaide Community Treatment Team did not have a formal policy for closing dormant case files. An informal process had developed. Mr Wooden said that: 'We would close files after there was six months of no contact and what we would do is we would look into whether there was – how much history there was, how much contact there was.' 9 He said that if there was no contact and the issues seemed to be resolving, they would either write to the person or make a phone call and then close the file. They would usually send a letter saying ‘if we don’t hear from you within a fortnight we will assume you do not require our service and close the file’10. In this instance, no such letter was written. Mr Wooden said that ‘it wasn’t deemed as needing to be followed up’11, by which he meant that there was some indication on the file that Ms Hadley had left the property where she was living and: 'There was no place to write to.'12 This conclusion was inferred from the file note that had been written by Dr Nalaye suggesting that Ms Hadley would collect her possessions and take her children to a domestic violence shelter. Mr Wooden acknowledged that there was nothing on the file to confirm that that had ever happened. The fact of the matter was that Ms 9 Transcript, page 333 10 Transcript, page 333 11 Transcript, page 335 12 Transcript, page 351

Hadley had continued to live at the address in Royal Park known to the Port Adelaide Community Treatment Team right up until Duke’s death.

5.3. Mr Wooden did not know Ms Hadley. He had never met her and had not been involved in her care. His review involved reading the Port Adelaide Community Treatment Team file and the Community Based Information System (CBIS) record.

Mr Wooden’s Counsel conveniently summarised the factors that were considered by Mr Wooden in his decision to close the file as follows: a) Ms Hadley’s admission to Cramond Clinic in December 2008 was a short one; b) Her principal psychiatric diagnosis was ‘drug induced psychosis’; c) Her diagnosis upon referral to the Port Adelaide Community Treatment Team was ‘?drug induced psychosis’; d) There had been no contact between Ms Hadley and the service since 26 February 2009; e) No follow up appointment with Dr Nalaye had been made; f) No other service or health professional had contacted the Port Adelaide Community Treatment Team about Ms Hadley since February 2009; g) Ms Hadley had not had contact with any other mental health service since February 2009; h) Ms Hadley’s referral was for medical review only and she did not have a case manager; i) The score recorded on Ms Hadley’s file for her ‘health of the national outcome’ was low; j) Her score under the proforma ‘Service Needs Scale’ was low; k) A need for ongoing community care had not been identified; l) Dr Mohan’s noted plan in January 2009 was ‘to treat, to taper and cease Risperidone in the next two to three months’;13 m) Ms Hadley’s Risperidone dose had been tapered; n) Ms Hadley was reported in January 2009 to have made ‘a functional recovery’ from her drug induced psychosis14.

13 Exhibit C72

5.4. Mr Wooden gave evidence that he spoke to Mr Renigers who was then the team manager at the Port Adelaide Community Treatment Team and Mr Wooden’s immediate superior. Mr Renigers also gave evidence at the Inquest. Although there were some differences in their evidence, it is not necessary to reach a conclusion about those. Both Mr Renigers and Mr Wooden agreed that when Mr Wooden suggested closure of Ms Hadley’s file to Mr Renigers, they sought the views of Ms Morrison about that matter before a final decision was made. They both considered that her views were important given that she had participated in the appointments between Ms Hadley and Dr Mohan as part of the transition of care process following the discharge from Cramond Clinic and pending the transfer of Ms Hadley’s care to the Port Adelaide Community Treatment Team. In fact, Ms Morrison was present at each of the transition of care appointments and had some familiarity with Ms Hadley’s case. The only other person in the Port Adelaide Community Treatment Team with any direct knowledge of Ms Hadley was Dr Nalaye who it will be recalled was then on sick leave from which he did not return. It was Mr Wooden’s evidence that he, Mr Renigers and Ms Morrison concurred in the decision to close Ms Hadley’s file. For his part, Mr Renigers’ evidence was that Ms Morrison showed some reluctance about closing the file. I did not hear from Ms Morrison and I do not find it necessary to reach a conclusion about the matter. I express no criticism of Ms Morrison in this finding.

5.5. Mr Renigers’ evidence was broadly consistent with that of Mr Wooden except in relation to the issue to which I have already referred. Mr Renigers acknowledged that the responsibility for the decision to close the file was his and his alone15. He agreed that in retrospect it would have been preferable to have made contact with Ms Hadley before making a decision16. He said that the process has now changed. A decision to discharge a client will not be made unless it has been approved by the psychiatrist as the lead clinician17.

5.6. Mr Renigers gave the following evidence about the nature of the service provided by the Port Adelaide Community Treatment Team: '… we operated on a service model which is premised on flow through, so that case loads don't become too large and over-burdened. So, that we have the capacity to respond to 14 Exhibit C72 15 Transcript, page 363 16 Transcript, page 364 17 Transcript, page 365

new referrals in a timely fashion. And so the expectation is to - I suppose, facilitate recovery and then at some point refer the person on or to discharge them so that - yes, we maintain that flow through and have the capacity to respond to new clients.' 18

5.7. I was left with the impression that the workload of the Port Adelaide Community Treatment Team was such that there was a greater emphasis on closing the file in this case than might have been the case had the workload been more manageable.

5.8. It was regrettable and inappropriate that the file was closed and that there was no follow-up with Ms Hadley. There should have been. In my view it was attributable not so much to any wrongful act on the part of an individual, but the systemic factors affecting the Port Adelaide Community Treatment Team, including pressure of work which is indicative of under-resourcing and poor procedures19.

6. Mr Hura’s call to the Mental Health Triage Service 6.1. On the evening of 4 November 2009 Mr Hura attempted to obtain assistance for Ms Hadley whose mental condition had been deteriorating for some time. He contacted Cramond Clinic at first and then was told to contact the Mental Health Triage Service.

He followed that advice and made a call to the Mental Health Triage Service and spoke to Mr Daniel Bienewitz who was on duty that evening. He is a mental health nurse and gave evidence at the Inquest. The call was recorded and a transcription was made from the recording20. It speaks for itself. I have reproduced it in the appendix to this finding. Mr Bienewitz acknowledged in hindsight that he could have handled the call better21. He acknowledged that his approach conveyed a rather discouraging overtone to Mr Hura who was seeking assistance22.

6.2. While the transcript is an accurate reproduction of the audio recording of the call, it does not convey the many long pauses and the very lengthy duration of the call. The call occupied some 45 minutes in real time. An expert opinion was obtained in this matter from Professor Goldney who is a distinguished psychiatrist. He has provided many medico legal opinions in the field of psychiatry and is currently Emeritus Professor in the Discipline of Psychiatry at the University of Adelaide. Professor 18 Transcript, page 386 19 For example, no automatic process for attempting contact with a patient before a formal file closure occurs 20 Exhibit C67g 21 Transcript, page 183 22 Transcript, pages 176-177

Goldney provided a written report23 and also gave oral evidence at the Inquest.

Professor Goldney commented that he did not think the call was handled well. He said: '… it was somewhat excruciating listening to it because there were extraordinarily long silences.' 24 Professor Goldney did not think that there was any sort of empathy conveyed by Mr Bienewitz. Professor Goldney was critical of the use of leading questions and the failure to pursue things which should have been followed up25. Professor Goldney said: 'And really, the whole conversation seemed to go round in circles and it was as if it was being stone-walled, that there was some - I mean it almost sounded as if the person taking the call was, you know, trying to find reasons not to help.' 26 Professor Goldney summed up the position as follows: 'I mean it's just not very professional and it - as I said, I mean, it was excruciating and painful to listen to.' 27

6.3. A major factor in the conversation was Mr Hura’s reluctance to be nominated by the Mental Health Triage Service if they did make contact with Ms Hadley, as the person who had alerted them to her situation. Mr Hura referred to it as a need for there to be a ‘referrer’. Mr Hura was reluctant and explained his reasons quite clearly. He was concerned that Ms Hadley would be angry with him and react aggressively as she had in the past in a similar situation. Professor Goldney remarked that he hoped that this is not an example of what is being done all of the time in the Mental Health Triage Service28.

7. The events of 5 November 2009 7.1. In the result Ms Bowling, who was the shift coordinator at Western ACIS, noted the contact between Mr Hura and the Mental Health Triage Service the previous night on her arrival at work that morning29. She raised the contact at a meeting at 8:30am at which the work for the day was being allocated. A decision was made to conduct a 23 Exhibit C86 24 Transcript, page 414 25 Transcript, page 414 26 Transcript, pages 414-415 27 Transcript, page 415 28 Transcript, pages 421-422 29 Transcript, pages 225-226

home visit that morning and the task was assigned to two social workers, Ms Radcliffe and Ms Evans. She said the decision was made because it appeared as though Ms Hadley was probably experiencing a drug induced psychosis and they were not certain whether there were children in the house. It was decided that Ms Hadley needed to be assessed and it was to be done that morning.

7.2. Ms Radcliffe and Ms Evans did in fact attend at the house at approximately 11am and they were unable to gain access or any response at all from Ms Hadley. After some 10 minutes or so they left the house with the intention of returning that afternoon. In the result other events overtook that plan.

8. Professor Goldney’s opinion 8.1. Professor Goldney was asked to review this case and provided his opinion in the form of a report dated 13 July 201330. Professor Goldney said that Ms Hadley had an evolving severe psychotic illness complicated by drug abuse. Professor Goldney was not critical of Ms Hadley’s treatment at Cramond Clinic, nor by her treatment at the hands of Dr Mohan. Professor Goldney was however very critical of the treatment afforded by the Port Adelaide Community Treatment Team and also of the interaction between Mr Hura and the Mental Health Triage Service, to which I have already referred.

8.2. Professor Goldney was of the view that it was completely unacceptable for the Port Adelaide Community Treatment Team not to have continued to afford ongoing care to Ms Hadley. It was his opinion that this was certainly necessary. At the time of her last contact with the service, through Dr Nalaye, she was still being medicated with Risperidone. The plan was to gradually titrate the dosage down at some point in the future as she responded to treatment. However, that stage had certainly not been reached at the point of her last interaction with Dr Nalaye. No further appointment had been made by Dr Nalaye or any other person at the Port Adelaide Community Treatment Team for her to be seen again.

8.3. As I have previously noted, Dr Nalaye was distracted by Ms Hadley’s complaints of domestic violence. While I do not in any way understate the need to treat complaints of domestic violence with the utmost seriousness, the difficulty here is that Ms Hadley 30 Exhibit C86

had a severe mental illness. While it might have been perfectly appropriate for an allegation of domestic violence to be explored by a domestic violence service at that point, it was no substitute for continuing psychiatric treatment. It may well have been that her complaints of domestic violence were a manifestation of her psychotic illness.

Nothing would be lost by referring her to a domestic violence service, but it was certainly inappropriate not to maintain her psychiatric treatment and her contact with the Port Adelaide Community Treatment Team. That needed to happen and it did not.

In fact, there was no further contact between Ms Hadley and the Port Adelaide Community Treatment Team. No further action was taken by the Port Adelaide Community Treatment Team until her file was closed in September 2009. Professor Goldney was critical of the systemic lack of continuity of care. He said that continuity of care is ‘so important’. He added, however, that continuity of care is: '…something that just doesn’t seem to be valued I think in the way the mental health services are structured. There is very little continuity of care in the longer term.' 31

8.4. Professor Goldney commented that Dr Nalaye’s caseload of 200 people is simply ‘unrealistic’ and that it was not possible for Dr Nalaye to ‘really do justice’ to that sort of caseload32. Professor Goldney’s opinion was that to leave it to Ms Hadley’s own initiative to return to the service or to make an appointment, was an ‘abdication of responsibility’33. Professor Goldney was unable to discern from Dr Nalaye’s note whether it was his intention that the Port Adelaide Community Treatment Team’s involvement with Ms Hadley was to cease or not. He simply could not interpret Dr Nalaye’s note one way or the other. As I have already said, Dr Nalaye was not heard at this Inquest because of his death following these unfortunate events. He was therefore unable to provide any explanation. But on the face of it, there has most certainly been a failure in the provision of care to Ms Hadley in this case. Whether it was Dr Nalaye’s responsibility or that of someone else is really not to the point. It simply should not have happened. Professor Goldney commented that: '… I don't think that that system is good enough and if people expect to get a specialist treatment service, they are certainly not getting a specialist treatment service at that unit.' 34 31 Transcript, page 394 32 Transcript, page 396 33 Transcript, page 398 34 Transcript, page 404

I wholeheartedly agree. Professor Goldney commented that this inadequacy was probably a result of lack of resources35. Professor Goldney was very critical of the decision to close the file on the basis that Ms Hadley had not made contact with the service for some considerable time. He said that it was a result of the excessive number of patients being looked after by the Port Adelaide Community Treatment Team, which is another way of referring to the inadequacies of the Port Adelaide Community Treatment Team’s resources to deal with that caseload. He remarked: 'But the dilemma is that in such a service with, you know, 500 people on the books as I understand there was, I can well understand that there is this pressure to, you know, close the file off and reduce the numbers and it's not really a very - very good service.' 36

8.5. Professor Goldney commented that the closure of Ms Hadley’s file showed a lack of curiosity and a lack of responsibility. Alarmingly, he said that he thinks that those shortcomings are pervasive at the moment in the mental health system37.

8.6. Professor Goldney remarked that: '…this case amply demonstrates the paucity of people in that service who have got the qualifications to deal with psychiatric illness.' 38

9. Conclusions 9.1. The circumstances leading up to Duke Hadley’s death are extremely disturbing. His mother was admitted to Cramond Clinic with an episode of psychosis and a differential diagnosis of possible bipolar disorder. She was prescribed antipsychotic medication that required medical supervision. She was appropriately discharged via a transition of care arrangement to the Port Adelaide Community Treatment Team, which is part of the South Australian Mental Health System. It is intended to deal with people with a psychiatric illness. It is intended to deal with people such as Rachael Hadley. The evidence shows that the Port Adelaide Community Treatment Team failed in its duties and responsibilities towards Ms Hadley. Whether that failure was causative of Duke Hadley’s death is a matter on which it is not possible to reach a conclusion, given the amount of time that passed between Ms Hadley’s contact with the team and Duke’s death. It is not unreasonable however to speculate that had Ms Hadley been afforded proper and appropriate psychiatric care, she may not have 35 Transcript, page 405 36 Transcript, page 409 37 Transcript, page 410 38 Transcript, page 411

relapsed and deteriorated to the point of the acute psychotic condition she suffered at the time of Duke’s death.

9.2. On any view it is extremely disturbing that the mother of a 2 year old child would be the subject of such a serious breakdown in the mental health system in February, and would be arrested for the violent murder of that child the following November, and yet that is what happened in this case.

9.3. The breakdown that led to the cessation of contact between the Port Adelaide Community Treatment Team and Ms Hadley was unacceptable and should not have happened. In my opinion it is a result of the unrealistically high workload that the Port Adelaide Community Treatment Team had at that time. That workload was, in Professor Goldney’s words, unrealistic.

9.4. The decision to close Ms Hadley’s file in September 2009 was an occasion on which an opportunity to rescue the system breakdown of February presented itself. The opportunity was not taken and the file was closed. I can only conclude that the pressures of work and the insufficient resources available to perform that work were such as to create an environment in which file closure occurred so readily. In such an environment the appropriate course, once again adopting Professor Goldney’s formulation, of asking questions and demonstrating ‘curiosity’ did not exist. Instead, there was an environment in which ‘flow through’ to use Mr Renigers’ expression, was the order of the day. Again, this is indicative of an under resourced service.

9.5. The explanation proffered by Mr Wooden for not writing to Ms Hadley’s last known address – namely that the referral to the domestic violence service suggested that she would not be at that address by September, is facile and specious. It could only be offered in an environment in which the pressure to deflect work because of a lack of resources makes the preposterous appear to be reasonable.

9.6. The next opportunity to prevent Duke’s death came with Mr Hura’s contact with the Mental Health Triage Service. Once again, the system failed to provide an intervention that might have saved this young boy. Again, I am left with the feeling that Mr Bienewitz was working in an environment in which he felt more obliged to ration a precious resource, than to be encouraging of Mr Hura’s efforts to obtain care for Ms Hadley. In saying this, I do not mean to be unduly critical of Mr Bienewitz.

As I have previously said, he acknowledged that he could have done things

differently. As a witness he presented as a sincere person. In my view it was the organisational environment in which he worked that is responsible for this very poor outcome. The conversation between Mr Bienewitz and Mr Hura makes harrowing listening. If anything, Professor Goldney understates the case when he said that it almost sounded as if the person taking the call was trying to find reasons not to help.

In fact, that was precisely how the call came across to me and in my opinion how it would be viewed by any reasonable listener.

9.7. I acknowledge that the situation was belatedly remedied the following morning when the ACIS team reviewed Mr Bienewitz’s contact of the previous night and determined to send two workers out for a home visit to Ms Hadley’s house. It is arguable that a different approach to the telephone contact of the previous night might have resulted in an arrangement where Mr Hura could have been encouraged to remain on the premises until the arrival of ACIS workers the following morning. Nevertheless, that is speculation and I do not suggest that the Mental Health Triage Service call, excruciating though it was, was causative of Duke’s death.

9.8. The ACIS response on the morning of the day of Duke’s death was appropriate and timely. Unfortunately it was too late to save him.

10. Recommendations 10.1. 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. I make the following recommendations.

10.2. The affidavit of Lisa Courtney39 refers to changes that have been made since this tragic event. It is to be hoped that they might improve the system. However, in my view there is no substitute for adequate resourcing. I recommend that the Minister for Mental Health and Substance Abuse carry out periodic reviews to ensure that all providers of mental health services are adhering to the changes referred to in Ms Courtney’s affidavit40. Secondly, that regular audits of each of the community mental health teams, such as the Port Adelaide Community Treatment Team, are regularly audited to ensure that they are adequately and appropriately staffed and have systems 39 Exhibit C83 40 Exhibit C83

to track patients and to track appointments. Thirdly, that there are regular random audits of recordings of calls made to the Mental Health Triage line to ensure, in Professor Goldney’s words, that the example contained in the Appendix to this finding is not representative of calls to that service. Fourthly, that the Minister for Mental Health and Substance Abuse note Professor Goldney’s comment that the mental health system as currently structured does not ensure continuity of care, and that this should be addressed as a matter of priority.

Key Words: Psychiatric/Mental Illness; Homicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 31st day of January, 2014.

State Coroner Inquest Number 20/2013 (0865/2011)

APPENDIX