Coroner's Finding: KEITH George

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 9th day of April, the 21st day of May and the 19th day of June 2013 and the 17th day of April 2014, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of George Keith.

The said Court finds that George Keith aged 80 years, late of 76 McIntyre Road, Dawesley, South Australia died at Dawseley, South Australia on the 1st day of March 2011 as a result of gunshot wound to the head. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mr Keith was 80 years of age when he died on 1 March 2011. He died at home in the late morning having shot himself in the head with his .22 calibre rifle. An autopsy was conducted by Dr John Gilbert, forensic pathologist from Forensic Science SA, on 7 March 2011 and he gave the cause of death as gunshot wound to the head1, and I so find. An analysis of a specimen of blood obtained at autopsy showed therapeutic levels of oxycodone, paracetamol, diazepam, nordiazepam (metabolite of diazepam) and warfarin. No other common drugs were detected2.

2. Background 2.1. Mr Keith held a firearms licence for the weapon which was effective at the time of his death3. Mr Keith had owned the rifle for 35 years4.

1 Exhibit C2a 2 Exhibit C2a 3 Exhibits C8b and C8d 4 Exhibit C1b

2.2. A suicide note was located in the study of Mr Keith’s house. It was addressed to his wife and said that he ‘couldn’t bear the pain anymore’5.

2.3. Mr Keith had suffered with extensive and chronic back pain for some 20 years. He had been treated for a prolapsed disc in his back and had undergone a laminectomy, which was performed by Dr Fraser. He also experienced multi-levelled degenerative disease in his back with thoroacolumbar scoliosis with moderate stenosis remaining at the L2-3 and L3-4 levels. He also had osteoarthritis, atrial fibrillation, hypertension and heart failure. He had told his wife on a number of occasions that he could not put up with the pain from his back any longer.

2.4. On 24 February 2011, approximately five days before his death, Mr Keith visited his general practitioner, Dr Daniels. Dr Daniels explained in his evidence that his note of this consultation was handwritten because the computer was not working that day. Dr Daniels said that the note was as follows: 'Repeat progout and diazepam. Talking about suicide soon using a rifle – not discussed with Olga. Increasing pain cervical and lumbar spine – seen by Dr Fraser INR ' Mr Keith first presented as a patient of the Hahndorf Family Medical Centre at which Dr Stephen Daniels practised in 1986. He remained a patient of that clinic until his death6. Dr Daniels reported that his medical history included glaucoma, carpal tunnel syndrome, osteoarthritis of the hips, knees, ankles and chronic back pain. Mr Keith had a total hip replacement in 2000. Other conditions included heart failure and cardiomyopathy, diverticular disease with rectal bleeding, mitral valve disease, alcohol abuse, prostatic nephrolithotomy and varicose veins7. Between 1996 and 2011 Mr Keith had been referred to various specialists for the management of these conditions. In particular he was referred to Dr Fraser, orthopaedic surgeon, in February 2000. Dr Fraser performed a laminectomy on 28 March 2000. Mr Keith saw Dr Fraser again in December 2000 and again in September 2004. Mr Keith next saw Dr Fraser in February 2006 and as a result of that consultation, Dr Fraser performed a foraminal steroid injection in April 20068. In June 2006 Dr Fraser treated Mr Keith with facet injections to the lumbar spine. He was reviewed again by Dr Fraser in October 2007 and saw Dr Fraser for the last time in January 2011.

5 Exhibit C1b 6 Exhibit C10a 7 Exhibit C10a 8 Transcript, pages 24-27, Exhibit C11

2.5. Dr Fraser gave evidence at the Inquest about his treatment of Mr Keith. He said that the decompression laminectomy performed in 2000 had a good result9. Dr Fraser had no further contact with Mr Keith until September 2004 when Mr Keith was referred by his general practice. It was Dr Fraser’s opinion that no surgical intervention was necessary at that time. Dr Fraser said that as a result of his assessment of Mr Keith in February 2006, he decided to provide treatment in the form of steroid injections but these were of no benefit10. Dr Fraser said that he next saw Mr Keith in November 2007 but surgery was not indicated. Dr Fraser said that he encouraged Mr Keith to improve his fitness by hydrotherapy and performing stabilising exercises. Dr Fraser said that he advised Mr Keith to adjust his lifestyle around the problem11. Dr Fraser did not see Mr Keith between 2007 and January 2011 when he again informed Mr Keith that surgery would not be helpful12.

2.6. Dr Fraser said that he did not recall during any of these consultations Mr Keith ever expressing a desire to end his life. However, Dr Fraser did state that this is not an uncommon sentiment for people to express in the context of chronic back pain13.

Dr Fraser did not note any indication of depression when he saw Mr Keith in January

201114. He said that Mr Keith’s presentation was ‘more one of frustration’15.

2.7. Dr Daniels also gave evidence at the Inquest. He has a specific interest in mental health and his practice deals with a significant number of people who present with mental illness, including depression16. As a result Dr Daniels is experienced in recognising the signs of depression and is registered on the Beyond Blue website. He keeps abreast of trends and developments in the area of mental health17.

2.8. Dr Daniels treated Mr Keith as his patient between 1986 and 2011. Over this significant period Dr Daniels came to know Mr Keith as a pragmatic and intelligent man who was widely read and single-minded18.

2.9. Significantly, Dr Daniels said that throughout the years of treating Mr Keith he did not ever regard Mr Keith as suffering from depression. This was also true of the 9 Transcript, pages 14-18 10 Transcript, pages 24-27 11 Transcript, page 28 12 Transcript, pages 29-31 13 Transcript, page 33 14 Transcript, page 33 15 Transcript, page 36 16 Transcript, pages 47-48 17 Transcript, page 48 18 Transcript, page 49

presentation on 24 February 2011. On that occasion Dr Daniels said Mr Keith presented as flat and expressionless, but it was not Dr Daniels’ opinion that this was indicative of depression19.

2.10. Dr Daniels was well aware of Mr Keith’s problem with chronic back pain. He adopted a graded approach in relation to the use of analgesics and narcotic medication in that treatment20. Dr Peter Joyner, who provided an overview of this case for the benefit of the Court, agreed that Dr Daniels had a protocol and a graded approach in relation to the use of narcotics21.

2.11. Dr Daniels adopted a conservative method of managing Mr Keith’s complex medical conditions22 and the management of his pain.

2.12. Dr Daniels gave evidence about his knowledge of his mandatory reporting obligations under section 27a of the Firearms Act 197723. At the time of his assessment of Mr Keith on 24 February 2011 Dr Daniels said he had no reasonable cause to suspect that Mr Keith was suffering from a mental illness, or that there were circumstances that posed a threat to his safety. Accordingly, Dr Daniels did not make any notification under that Act on that day.

2.13. Dr Daniels frankly admitted that with the benefit of hindsight he should have asked more questions of Mr Keith about the rifle that he referred to. He agreed that he should have asked questions relating to how Mr Keith might access a rifle. He gave evidence that he regretted not having done so24.

2.14. Dr Daniels said that over the 25 years of his doctor/patient relationship with Mr Keith he had developed what he regarded as a close rapport with Mr Keith. He said that Mr Keith was a man with a dead pan sense of humour who would joke about various things. At times Dr Daniels recalled that when he was writing prescriptions for Mr Keith that Mr Keith might jokingly suggest that the doctor might ‘help him when it gets to the end’, or words to that effect. Dr Daniels did not take these comments seriously, nor did he note them. Dr Daniels regarded comments of that kind as being 19 Throughout all of the years of his treatment of Mr Keith, Dr Daniels never prescribed any treatment for the management of depression, Transcript, page 49 20 Transcript, pages 50-53 21 Transcript, page 147 22 Transcript, pages 55-57 23 Transcript, page 77 24 Transcript, pages 77-78

in keeping with Mr Keith’s personality. Dr Daniels thought that these were throw away lines25.

2.15. Dr Daniels emphasised that he never assessed Mr Keith as having a mental health issue26.

2.16. Dr Daniels said that when Mr Keith said that he would commit suicide using a rifle he also mentioned that he would not do so until the kitchen renovations he was involved with at his home had been completed. Dr Daniels took this reference to kitchen renovations to be indicative of a lack of seriousness on Mr Keith’s part about the subject of suicide27. Dr Daniels said that with the benefit of hindsight he should have assessed the level of intent or severity, and asked whether Mr Keith had access to a rifle, either of his own or through someone he knew28.

3. Conclusion 3.1. On the face of it, Dr Daniels’ brief note of his consultation with Mr Keith on 24 February 2011, referring as it does to Mr Keith ‘talking about suicide soon using a rifle – not discussed with Olga’, is alarming when one considers that some five days later Mr Keith carried out that very act. On the other hand, after hearing extensive evidence from Dr Daniels about his rapport with Mr Keith and his knowledge of Mr Keith over a 25 year period, and Mr Keith’s propensity for making dead pan remarks, this otherwise alarming note takes on a much more benign character. Dr Daniels’ explanation about his interpretation of Mr Keith’s reference to waiting for kitchen renovations to be completed, and Dr Daniels’ assessment of Mr Keith over a very lengthy period with chronic back pain but no sign of depression, places this matter in context. I accept that Dr Daniels was not in all the circumstances under any obligation to make a report to the Firearms Branch of South Australia Police under section 27a of the Firearms Act 1977. Dr Daniels was clearly saddened and distressed by the circumstances of Mr Keith’s death. I accept his evidence about Mr Keith’s character and personality. In that context I can see why Dr Daniels did not regard Mr Keith’s remark about suicide as a serious remark.

25 Transcript, pages 79, 83 26 Transcript, page 82 27 Transcript, page 75 28 Transcript, pages 77-78

4. Recommendations 4.1. I have no recommendations to make in this matter.

Key Words: Medical Treatment – Medical Practitioner; Suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 17th day of April, 2014.

State Coroner Inquest Number 10/2013 (0324/2011)