Coroner's Finding: ROBINSON Scott Alexander

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 30th and 31st days of August 2016, the 1st and 2nd days of September 2016 and the 11th day of May 2017, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Scott Alexander Robinson.

The said Court finds that Scott Alexander Robinson aged 44 years, late of 1/30 Mulberry Road, Glenside, South Australia died at Glenside Water Detention Basin, Corner of Fullarton Road and Greenhill Road, Glenside, South Australia on or around the 1st day of February 2014 as a result of neck compression consistent with hanging. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Scott Alexander Robinson was 44 years of age at the time of his death on or around 1 February 2014. An autopsy was carried out by Dr Stephen Wills of Forensic Science South Australia who provided a post-mortem report giving the cause of death as being consistent with hanging1, and I find the cause of death to be neck compression consistent with hanging.

2. Reason for Inquest 2.1. Mr Robinson’s body was not discovered until 18 February 2014, some two and a half weeks after the probable date of his death, and that is why the best estimate of his date of death can be no more precise than on or around 1 February 2014. Mr Robinson was last seen at the Royal Adelaide Hospital on 31 January 2014 where he was a patient 1 Exhibit C2a

who was under detention by virtue of an Inpatient Treatment Order under the Mental Health Act 2009. He had been permitted to leave the ward to smoke a cigarette but did not return. Because Mr Robinson was under detention at the time of his death, his was a death in custody within the meaning of that expression in the Coroners Act 2003 and this Inquest was held as required by section 21(1)(a) of that Act.

3. Background 3.1. Mr Robinson had an extensive psychiatric history which was very clearly explained by psychiatrist Dr Kimber who gave evidence at the Inquest. She said that he had treatment resistant schizophrenia and obsessive compulsive disorder from about the age of 15.

Dr Kimber said that Mr Robinson suffered greatly from his condition and was tried on many antipsychotic medications over the years. He also had electro-convulsive therapy and psychological input. He had occupational therapy input, he had care coordination and he had non-government organisation workers assisting him. She said that his longest period of admission as an inpatient was at Glenside Hospital for a period of 9 years. Dr Kimber said that Mr Robinson was very restricted in his communications and he lacked the normal ability to interact socially with others. He also lacked insight which meant that he did not agree with his diagnosis and did not understand that he had schizophrenia.

4. Mr Robinson’s admission to the Royal Adelaide Hospital 4.1. Dr Kimber treated Mr Robinson during his last admission at the Royal Adelaide Hospital and at that stage she thought that he had made good progress. She said that he was back to a healthy weight range, having in the past neglected his nutrition. She said that he was more talkative and appeared overall to be less tortured and less anxious2.

4.2. Dr Kimber said that Mr Robinson had been living in community housing on the Glenside Campus with 24-hourly support. However, he had been non-compliant with his medications for several weeks despite being on a Community Treatment Order and thus was detained and brought into the Emergency Department at the Royal Adelaide Hospital where he was placed on an Inpatient Treatment Order.

4.3. Dr Kimber said that Mr Robinson was transferred to Ward C3 at the Royal Adelaide Hospital on 24 January 2014, soon after his admission3. Dr Kimber first saw him that day. She said that she was delighted to see him looking well and having gained weight 2 Transcript, page 27 3 Transcript, page 30

and being in a healthy weight range. She said that at first she did not recognise him because his face had filled out. Dr Kimber said that at that time Mr Robinson was denying feeling suicidal and she added that being suicidal had never been a feature of his previous admissions4.

4.4. At that time the appropriate medications had already been initiated in the Emergency Department and it was Dr Kimber’s intention that Mr Robinson might remain as an inpatient for approximately one week before discharge back to his community housing.

At that time his detention would have been cancelled5.

4.5. Dr Kimber next saw Mr Robinson on 29 January 2014 when she noted that he continued to be insightless and refusing medication. She confirmed his Inpatient Treatment Order and her plan was to liaise with his community team regarding his likely length of stay in the Royal Adelaide Hospital. Her plan on 29 January 2014 was for Mr Robinson to remain in hospital under an Inpatient Treatment Order and to receive depot paliperidone, at a loading dose intramuscularly with a follow up dose a week later and then subsequent monthly injections under his Community Treatment Order.

4.6. Dr Kimber said that Mr Robinson was granted ground leave during that admission on five occasions and that similar ground leave had been granted to him on previous admissions. She said that walking was very important to Mr Robinson and helped him to feel good about himself. She said that ground leave was defined as leave to be on the hospital grounds themselves, including the cafeteria. She did not have any concerns about Mr Robinson having ground leave. She said that when she heard about his death she was shocked because she did not assess him as suicidal, and neither did two other psychiatrists who had assessed him during that admission6.

4.7. On 31 January 2014 Mr Robinson was being cared for by Ms Dowley, an enrolled nurse on Ward C3. Ms Dowley gave evidence that there was nothing particularly unusual about Mr Robinson’s presentation that day and in particular nothing that caused her to think that he would abscond. She said that she observed him at 1900 hours and that the next check was due at 2000 hours. It appears that Mr Robinson absconded from the ward sometime after that.

4.8. Mr Robinson signed himself out of the ward at approximately 7:10pm and at 8pm the staff were aware that he had taken ground leave and they were expecting him to return 4 Transcript, page 31 5 Transcript, page 32 6 Transcript, page 41

to the ward by the next ward round. In other words, at the time of the check at 2000 hours, there were no concerns. However, sometime after 2100 hours the staff had established that Mr Robinson had not returned from ground leave and they then took action to attempt to find him on the hospital grounds. By approximately 2200 hours the team leader on the ward, Mr Moyo, was notified that Mr Robinson was absent and the missing persons protocol was initiated at that time. All appropriate steps were taken to notify relevant services including SAPOL, but unfortunately none of the inquiries that were made by ward staff or SAPOL produced any evidence of Mr Robinson’s location.

4.9. Sadly, Mr Robinson’s body was not found until some two and a half weeks later on 18 February 2014 in a part of the Glenside grounds that were not often frequented. He was hanging from a leather belt attached to a branch of a tree trunk.

5. Conclusions 5.1. In my opinion Mr Robinson’s treatment was appropriate and it was reasonable for staff to permit him to have ground leave at the Royal Adelaide Hospital having regard to his assessed low risk of absconding and low risk of suicide. Indeed, such freedom of movement within the hospital grounds is therapeutically beneficial and confinement to the ward for a person such as Mr Robinson would do more harm than good.

5.2. I accept that there was no indication that he would abscond and take his own life in the manner he did.

6. Recommendations 6.1. I have no recommendations to make.

Key Words: Death in Custody; Psychiatric/Mental Illness; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 11th day of May, 2017.

State Coroner Inquest Number 48/2016 (0297/2014)