Coroner's Finding: ROBERTS Brian Matthew

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 11th day of March 2016 and the 8th day of February 2018, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Brian Matthew Roberts.

The said Court finds that Brian Matthew Roberts aged 36 years, late of 13 Nitschke Street, Berri, South Australia died at 13 Nitschke Street, Berri, South Australia on the 22nd day of March 2014 as a result of hanging. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Brian Matthew Roberts was 36 years of age when he died on 22 March 2014. He had hanged himself at accommodation that he occupied alone in Berri. At the time of his death he was subject to home detention bail. The place of home detention was his accommodation in Berri. Thus, this was a death in custody in respect of which an Inquest was mandatory. These are the findings of that Inquest.

2. The events leading to Mr Roberts’ death 2.1. On Friday 23 November 2012 Mr Roberts had been arrested and charged with two counts of rape. On 6 December 2012 in the Berri Magistrates Court he was granted home detention bail to reside at his home address at 13 Nitschke Street, Berri. One of the conditions of bail was that Mr Roberts had to wear an electronic monitoring device on his ankle. Other conditions included that he place himself under the supervision of a Community Corrections Officer (CCO), not consume alcohol or any other drug not medically prescribed or otherwise legally available and to submit to drug analysis as

directed by the CCO. Mr Roberts would be assigned a CCO who was Ms Maryanne McClelland, a CCO employed by the Department for Correctional Services (DCS).

2.2. Mr Roberts was last seen alive by a neighbour at about 12pm on 22 March 2014, the day of his death. He was working on a motor vehicle in the driveway of his home. He and the neighbour had a conversation lasting a few minutes. Mr Roberts is described as having appeared happy and smiling during that time.

2.3. At about 5:37pm on the same day the DCS monitoring centre detected that Mr Roberts’ ankle monitoring device had been tampered with. DCS attempted to contact him by telephone without success and so requested SAPOL to attend at the property. At about 6:18pm police attended the Berri address and located Mr Roberts hanging in his home.

He was already dead at the scene. No other person was on the premises.

2.4. Mr Roberts had left a note which described the emptiness in his life, a lack of family and friends and his prolonged confinement within his home, no doubt a reference to the rigours of the detention imposed by his bail. He mentioned the love that he had for his nine-year-old son who at that time was in foster care. It is clear that the note was written by Mr Roberts in contemplation of his death.

2.5. Mr Roberts died alone and by his own hand. No other person was involved in his death.

It is evident that he hanged himself with the intention of ending his life. I so find.

3. Cause of death 3.1. A post-mortem examination was conducted in relation to Mr Roberts by Professor Roger Byard, a forensic pathologist at Forensic Science South Australia. In his report Professor Byard expresses the cause of death as hanging. I find that to have been the cause of Mr Roberts’ death.

3.2. Mr Roberts’ post-mortem toxicology demonstrated that he had alcohol (0.073%), methadone, diazepam, temazepam and the active component of cannabis in his system.

His consumption of alcohol and cannabis was contrary to the conditions of his bail.

Alcohol and bongs were found by police in his home. There is no evidence as to their source or manner of acquisition. It is conceivable that the level of alcohol in Mr Robert’s system at the time of his death had loosened his inhibitions. The effect of any of the other substances alone or in combination with alcohol is unclear. The levels

of the prescription drugs were all therapeutic. Mr Roberts had a history of amphetamine, heroin, morphine and cannabis abuse. The most recent instance of breath or urine analysis as revealed in the papers tendered to the Court had occurred on 17 February 2014 when he complied with a breath analysis which was negative. A mandatory urinalysis of the same day was unsuccessful despite him being given several glasses of water to consume over time. He failed to produce a sample which he put down to his having experienced trouble passing urine for the last three weeks, a claim that would naturally have attracted scepticism.

4. Mr Roberts’ home detention and mental health 4.1. Between December 2012 and his death in March 2014 Mr Roberts was supervised by the CCO of the DCS. A weekly program was instituted for him to attend activities including courses with MADEC Employment Agency and a weekly supervised visit with his son which at one point he told his CCO was the only positive thing in his life.

The CCO also assisted Mr Roberts in engaging with medical practitioners and with Centrelink.

4.2. During 2014 suicidal ideation was expressed by Mr Roberts. As a result Mr Roberts was referred to a social worker at Centrelink who provided him with counselling.

4.3. In October 2103 Mr Roberts had been referred by a Berri general practitioner to a psychiatrist, Dr Neeraj Gupta. The reason for the referral was that Mr Roberts was said to be displaying signs of paranoia. It was also said that he was self-medicating with cannabis.

4.4. Dr Gupta’s statement was tendered to the Inquest. On 23 October 2013 Dr Gupta and Mr Roberts had a lengthy consultation at the Riverland Community Health Centre. On that occasion Dr Gupta concluded that Mr Roberts had chronic issues with anger control and impulsivity complicated by cannabis use. He noted a significant forensic history, a past history of polysubstance abuse including alcohol, speed, heroin, morphine and cannabis, and features suggestive of antisocial personality traits. Mr Roberts mentioned some recent stressors including a conflict with a neighbour and a relationship breakdown but he denied any active suicidal ideation or intent. He also referred to the restrictions of home detention. It was considered that there was not enough evidence to confirm a diagnosis of schizoaffective disorder or schizophrenia, but a suspicion that Mr Roberts had experienced past episodes of drug induced psychosis was entertained.

At the time of presentation Mr Roberts was not on any psychotropic medications, was seeing a drug and alcohol counsellor, was doing a parenting course and was on the waiting list for an anger management course.

4.5. Dr Gupta states that there was no reason to believe that Mr Roberts was at risk of selfharm at the time of this examination and that no psychotic symptoms were present. The recommendations from the consultation were that Mr Roberts cease using cannabis, a matter that I observe he was in any event mandated to do by virtue of his bail conditions, that he continue with his drug and alcohol counselling, that he attend the anger management course when it became available and that he commence on a mood stabiliser. The doctor recommended carbamazepine following baseline investigations.

The objective of this prescription was to assist in curbing impulsivity and anger outbursts. Mr Roberts expressed satisfaction at this plan and with the idea of enlisting the assistance of his general practitioner to help him. He agreed to request a further psychiatric appointment if he felt he needed it in the future.

4.6. Mr Roberts attended his general practitioner regularly. On 4 March 2014 he presented to a general practitioner, Dr John Dunn, with his CCO, Ms McClelland. According to Mr Roberts this presentation resulted from his having broken down and becoming highly agitated at the Berri Centrelink office where he had attended to see his social worker. Centrelink had then contacted DCS and as a result the CCO had intervened.

At the consultation Mr Roberts and Dr Dunn discussed depression and the suicidal thoughts that centred around his son having been in care since he was 2 years of age and that due to Mr Roberts’ past and the matters that he was currently facing, the likelihood was that the boy would have to remain in care until he turned 18. Mr Roberts was concerned that he was only seeing his son fortnightly and that the lack of frequency was upsetting him. He stated to the doctor that he had multiple previous undocumented suicide attempts and he wondered whether he was schizophrenic. Dr Dunn prescribed Mr Roberts Largactil which was designed to settle his agitation and to address the voices that he complained of hearing. Mr Roberts was accepting of that plan and agreed to follow up with Dr Dunn in a few days.

4.7. On 7 March 2014 Mr Roberts presented to Dr Dunn as planned. He reported that he was sleeping better and that he felt more relaxed but that he was feeling a bit ‘dopey’ from the tablets. He agreed that the tablets were doing him more good than harm and so he agreed to continue with them and attend for a review again in a few days.

4.8. On 12 March 2014 Mr Roberts again presented. He reported that due to the tablets his energy levels were low and that he had stopped taking them two days prior to the appointment. He also reported that he was not sleeping well. He was recommended to continue working with his social worker at Centrelink. He was prescribed Tegretol (carbamazepine). He was prescribed Valium to be taken at night in the event that he needed to have any assistance in getting to sleep while he was waiting for the Tegretol to take effect. The prescription of Tegretol represented another attempt to stabilise Mr Roberts’ mood.

4.9. On 21 March 2014, which was the day before his death, Mr Roberts presented to the same clinic but saw a different doctor, this time Dr Stanton. On this occasion Mr Roberts indicated that he had developed some side effects due to the Tegretol including nausea and vomiting. He asked to try something else. It was decided that they would try a lower dose of the Largactil for his mood and anxiety and that they could slowly increase the dose over time if required. Mr Roberts seemed to be happy with that plan. Dr Stanton described Mr Roberts as not psychotic, that his mood seemed normal, that he did not appear depressed, had no signs of thought disorder and was not hallucinating. He did not express thoughts of suicide or self-harm.

4.10. Ms Maryanne McClelland, who was Mr Roberts' CCO, had many contacts with him throughout 2014. On the last of these occasions, which occurred on 20 March 2014, she had a telephone conversation with him. He was in good spirits. He said that he had had a good counselling session with the Centrelink social worker. He discussed his hopes of being able to obtain sufficient leave from his home detention conditions to take up part-time voluntary work that a friend had offered in a car wrecking yard. They discussed making an application for him to receive the disability support pension. They discussed the need for him to have more structure in his days and they agreed that the voluntary work that he had mentioned would assist him in achieving that.

5. Conclusions 5.1. Mr Roberts seems to have received no shortage of support during his period of home detention. He was seen by his CCO. He received social work input and medical and psychiatric assistance. Despite his bail conditions, Mr Roberts elected to continue consuming alcohol and cannabis. He had received medical and psychiatric advice in relation to the same. I do not believe that his death was preventable.

6. Recommendations 6.1. I make no recommendations in this matter.

Key Words: Death in Custody; Home detention; Hanging In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 8th day of February, 2018.

Deputy State Coroner Inquest Number 8/2016 (0482/2014)