Coroner's Finding: LATTUCA Christophe Thomas Bruno

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 24th day of July 2019 and the 29th day of October 2019, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Christophe Thomas Bruno Lattuca.

The said Court finds that Christophe Thomas Bruno Lattuca aged 34 years, late of 5 Quondong Avenue, Parafield Gardens, South Australia died at Parafield Gardens, South Australia on the 25th day of January 2016 as a result of neck compression due to hanging. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Cristophe Thomas Bruno Lattuca was 34 years of age when he died at 5 Quandong Avenue, Parafield Gardens on 25 January 2016. A post mortem examination was undertaken by Dr Karen Heath, forensic pathologist at Forensic Science South Australia. In her report Dr Heath provides the cause of death as neck compression due to hanging1, and I so find. A toxicological analysis of Mr Lattuca’s blood revealed that he had alcohol, methylamphetamine and cannabis in his system at the time of his death2.

2. Reason for inquest 2.1. Mr Lattuca was subject to a home detention bail order at the time of his death. On 1 July 2015 Mr Lattuca had been arrested and charged with attempted unlawful sexual intercourse with a person under the age of 14 and gross indecency. He was remanded in custody and on 15 October 2015 was released on home detention bail. At the time 1 Exhibit C2a 2 Exhibit C3a

of his death he remained subject to the home detention order and therefore, pursuant to the Coroners Act 2003 (the Act), his was a death in custody as defined in the Act, for which a mandatory inquest was required.

3. Background 3.1. Mr Lattuca's personal background has been established by way of statements tendered to the Court by his father, Mr Cristofero Lattuca3, his half-sister, Ms Brianna Lattuca4 and a friend, Mr Matthew Hartley5.

3.2. Mr Lattuca was born in Belgium and was the youngest of two boys. In 1985, at the age of nine, his parents separated and he moved to Australia with his father. He attended school at Parafield Gardens. He quickly learned to speak English and throughout school had many friends and part-time jobs.

3.3. His father stated that things changed in 1997, when Mr Lattuca left the family home.

Not long afterwards, Mr Lattuca senior had a heart attack and Mr Lattuca went to see him in hospital but did not explain why he had moved out of home. For some time thereafter, Mr Lattuca senior had occasional and quite limited contact with his son, and there were long periods without contact at all. He saw his son a couple of times in 2001, when Mr Lattuca’s baby boy Samuel had recently been born. A couple of years later he helped celebrate the birth of Mr Lattuca’s second son, to a different mother, before again not seeing him for a year or so. For the next seven years or so, when Mr Lattuca was living with a new girlfriend and his son Samuel, Mr Lattuca senior would see his son every week or so, during which time he seemed happy. Then there was a period of some three months in which he did not see Mr Lattuca, after which he learned that he had split up with his long-term girlfriend and had moved with Samuel to a Housing Trust house. Mr Lattuca senior visited his son at this address on a couple of occasions. After about three months, Mr Lattuca told his father that his son Samuel was back living with his mum, as he thought it would be better for him.

3.4. A couple of months later, in July 2015, Mr Lattuca's father discovered that his son was in custody. Mr Lattuca called his father not long afterwards and protested his 3 Exhibit C6 4 Exhibit C7 5 Exhibit C8

innocence, asserting he had been set up by drug dealers. His father did not perceive that he was suicidal, although he was plainly unhappy about being in custody.

3.5. His father remained in contact during Mr Lattuca’s incarceration and attended all his court appearances. When he was eventually granted home detention bail, on 15 October 2015, his father collected him and took him to the home detention bail address in Parafield Gardens. Mr Lattuca senior said his son was initially very happy but by December 2015 he was complaining to his father that he was always by himself and that Matthew Hartley, at whose address he was residing, was away for long periods of time.

3.6. He also states that his son would complain about his relationship with a new girlfriend, and that she was always asking him for drugs. At no time throughout the period of his bail did his father have the impression that Mr Lattuca was suicidal.

3.7. Mr Lattuca senior attended the inquest and addressed me at its conclusion. He was understandably and unsurprisingly distressed about the loss of his son. It was evident that he regarded his son’s use of drugs as the primary explanation for his tragic death.

3.8. Brianna Lattuca stated6 that after he moved out of the family home she barely saw her half-brother over the next ten years. She reconnected with him through Facebook when she was 18. She described Mr Lattuca as very needy and temperamental in the five years prior to his death. If she did not respond to one of his messages he would get extremely annoyed and send abusive and harassing messages, or he would delete her as a contact. She perceived a change in his mental health around August 2014. In an exchange of messages on Facebook he revealed two previous suicide attempts ‘since my life went to hell’, although Ms Lattuca thought he was ‘acting up’. He expressed anguish at his perceived loss of his family because of allegations apparently made against him at about that time. This appears to coincide with the end of the long-term relationship mentioned by his father. In a further Facebook exchange in November 2015, following his release on bail, he said he expected to be paid compensation for unlawful imprisonment and he would use it to start a new life in a different State.

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3.9. Brianna Lattuca messaged him for Christmas 2015 and he responded saying he had a rough Christmas and New Year but was doing a lot better. He told his sister he loved her.

3.10. On 23 January 2016 Mr Lattuca sent his sister a message which, in effect, asserted that he had learnt that his girlfriend, to whom he said he was to be engaged, was unfaithful.

He was clearly very upset and told his sister how much he was hurt, and that he was ‘losing it’. The next day Ms Lattuca messaged him, telling him not to let it bother him.

She thought not much of it, believing he was ‘acting up’ again. Ms Lattuca summarised her half-brother as a troubled man who meant well. She felt he had become involved with ‘the wrong crowd’ and his life had taken a downward spiral. She suspected he had an undiagnosed behavioural disorder of some kind.

3.11. Matthew Hartley’s statement noted that he had met Mr Lattuca at a party when Mr Lattuca was 16 and living on the streets. They got on well and spent time together at Mr Hartley’s house on a weekly basis. In 2012 Mr Lattuca came to live with Mr Hartley after he separated from his girlfriend, and soon afterwards his baby boy Samuel came to live with them as well. Mr Lattuca took up with a new girlfriend and they moved out of Mr Hartley’s house whilst she was pregnant. Mr Hartley did not see him for about three years, by which time Mr Lattuca had another young son, and his older son had apparently gone back to live with his mother. Soon afterwards, Mr Lattuca was single again and moved back into Mr Hartley’s house, where he was regularly seeing both his children but not, according to Mr Hartley, seeing his father.

In about 2008 Mr Lattuca started a new relationship and moved out of Mr Hartley’s house to live with a new partner. This relationship was to last about seven years, during which Mr Hartley saw the couple frequently. About three years prior to Mr Lattuca’s death, Mr Hartley started to see the couple using ice (methylamphetamine). He saw them smoking it on many occasions and told them they needed to stop, as it would ruin their lives. He observed that they always wanted more drugs, and they often asked Mr Hartley for money to buy food. It is clear, by reference to Mr Hartley’s account, that Mr Lattuca had, by then, developed a significant drug addiction. When his longterm relationship ended and his partner moved out, Mr Lattuca struggled to keep up with his rent and, after a time living with Mr Hartley again, he got a Housing Trust property at Burton. He appeared to successfully stop using methamphetamine for a time, but then he started using again and lost his licence. Mr Hartley frequently saw a new girlfriend at the Burton premises.

3.12. In August 2015, Mr Hartley received a call from Mr Lattuca saying that he had been arrested and remanded in custody. He wanted assistance in getting bail. Mr Hartley noted that Mr Lattuca did not get bail and was transferred to the Mount Gambier Prison.

Mr Hartley continued to speak with Mr Lattuca and eventually agreed to be his guarantor and allow him to live on home detention bail at his home address, 5 Quandong Avenue, Parafield Gardens. Mr Hartley signed a home detention residence agreement form on 13 October 2015. Mr Lattuca was granted and released on home detention bail on 15 October 2015.

3.13. Mr Hartley said that Mr Lattuca was happy, eating well and looked very healthy. On one occasion, he observed his new girlfriend smoking ice in the presence of Mr Lattuca and told her to get out, but Mr Lattuca stood up for her and assured Mr Hartley that he would not take any drugs. Mr Hartley stated that she would attend the house 'off her head on drugs'. Mr Hartley suspected that whilst Mr Lattuca was on home detention bail he had commenced using methylamphetamine again. He did not share this suspicion with the Department for Correctional Services.

3.14. Mr Hartley worked away from home in Melbourne and was often absent. The last time he saw Mr Lattuca was approximately one week before he died. Mr Lattuca told him he had received a payout from the government and he had passed a blood and urine test with the Department for Correctional Services and was to be permitted to work whilst on home detention bail.

4. Medical history 4.1. Dr Manpreet Ghataura,7 a general practitioner, saw Mr Lattuca in November 2013 when he presented with multiple mental health and anger issues. A mental health plan was completed and he was referred to Northern Medicare Local (NML). Dr Ghataura assessed Mr Lattuca as having no suicidal ideation. Mr Lattuca was offered appointments with the Northern Wellbeing Service, which he did not attend.

4.2. In February 2014 Mr Lattuca again presented to the surgery and complained that he had not received any communication from NML. Dr Ghataura contacted NML and made an appointment for him to attend on 17 February 2014. On 4 March 2014 Dr Ghataura received a request for a referral to a psychiatrist.

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4.3. Dr Ghataura saw Mr Lattuca in May and September 2014, at which time he stated he was feeling stressed and depressed. Again, he found no evidence of suicidal ideation.

On 5 September 2014 Dr Ghataura received correspondence from the Lyell McEwin Hospital, advising that Mr Lattuca had presented to the Emergency Department, where a situational crisis was diagnosed.

4.4. The last time Dr Ghataura saw him was on 18 February 2015 at which time Mr Lattuca said he had been assaulted. He also mentioned he was still feeling depressed and angry and Dr Ghataura provided him with a trial of antidepressants; Aropax 20mg with one repeat.

4.5. Kelly Stewart is a psychologist employed by the Northern Health Network8.

Ms Stewart provided Mr Lattuca with numerous opportunities to see her. He either failed to attend these appointments, or changed them and then did not attend. This led to his file being closed in August 2013.

4.6. A further referral was made in November 2013 but attempts to contact Mr Lattuca failed, as he did not respond. His file was closed. It was not until 3 March 2014 that Mr Lattuca attended an appointment, during which he denied any suicidal ideation and stated his son was his reason to live.

4.7. Ms Stewart requested Mr Lattuca be seen by a psychiatrist and secured a referral from Dr Ghataura. A number of appointments were offered with psychiatrist Dr Nagechesh but Mr Lattuca failed to attend any. Due to his non-attendance his file was closed.

4.8. In May 2014 Mr Lattuca contacted NML asking for further appointments, which were offered to him. Mr Lattuca failed to attend those appointments.

5. Mr Lattuca’s incarceration 5.1. After Mr Lattuca’s arrest on 1 July 2015 he was observed and assessed as having no medical or health concerns. On 2 July 2015, medical staff at Yatala Labour Prison spoke to him. Although he appeared depressed, to an extent which was unsurprising given his remand in custody, he denied any thoughts of self-harm.

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5.2. It was recommended that Mr Lattuca be monitored by the High Risk Assessment Team (HRAT). On 8 July 2015, he was seen by medical staff and stated he did not have any thoughts of self-harm, but as a matter of precaution he remained under HRAT and was continually monitored, despite his continual denial of self-harm and suicidal ideation.

5.3. On 16 July 2015 Mr Lattuca was transferred to Mount Gambier Prison. On 17 July 2015, he was seen by medical staff and again denied any suicidal ideation. As a matter of precaution, he was again kept on HRAT monitoring. The records state that Mr Lattuca did not show any signs of suicidal ideation or self-harm during the time he was remanded in custody. He was seen on numerous occasions by medical staff. On 4 August 2015, he was removed from HRAT monitoring as he was considered a low imminent risk of self-harm. He remained in custody without concern until 15 October 2015 when he was released on home detention bail.

6. Home detention bail 6.1. The Court received a statement of Peta Hagemann9, who worked in the Department for Correctional Services (DCS) and prepared a Bail Enquiry Report, after interviewing Mr Lattuca by telephone whilst he was still in custody. He told her, among other things, that he was the father of two children and the sole parent of the eldest. He said he was about to begin mediation with the mother of his youngest child. He expressed no suicidal ideation.

6.2. After an assessment by Mr Rodriguez, a DCS employee, Mr Hartley’s premises were deemed suitable as a home detention residence. Mr Lattuca was granted home detention bail and on 15 October 2015 was released from Mount Gambier Prison.

6.3. Ms Jayne Francis, a Case Manager with DCS was one of those responsible for ensuring Mr Lattuca’s compliance with the conditions of bail. Her statement10 discloses that he was visited at his home detention residence on five occasions and spoken to by telephone at least once per week. Mr Lattuca was detected breaching his bail agreement on 2 January 2016 by leaving the home detention address and going to another address.

Court proceedings alleging the breach of conditions were commenced, but had not progressed by the time of Mr Lattuca’s death. Following that breach, on 7 January 2016 Mr Lattuca was visited by DCS staff. On 20 January 2016, a random urine test 9 Exhibit C11 10 Exhibit C13

was positive for cannabis and on 22 January 2016 DCS staff again visited and spoke to Mr Lattuca at his home address. Despite the apparent breach of his conditions by consuming cannabis, Mr Lattuca appeared well and DCS staff were persuaded that he intended to comply with his conditions of bail. Ms Francis states that during his time on home detention bail, Mr Lattuca was polite and cooperative with those responsible for his management and gave no indication of suicidal ideation.

7. Mr Lattuca is found deceased 7.1. The last person to see Mr Lattuca alive was his girlfriend11, on 24 January 2016, at his home detention address. He became upset, as she left in a hurry without kissing him goodbye. Throughout that night he sent her many messages, approximately 200 in number.

7.2. When she awoke the following day, she saw there were more text messages from Mr Lattuca, requesting cigarettes and other items. She was annoyed at all the previous night’s messages and refused to bring them to him. During the day, they exchanged messages debating her perception that he expected her to drop everything and come and attend to him. He responded to her last message, saying, 'That's it. Chris Lattuca is gone'. She did not respond, as he had said such things before and not acted upon them.

She knew that a few months earlier he had sent a friend a picture of a noose. He had told her two or three times previously that he would hang or kill himself and he once sent her a picture of a knife in his hand. The tenor of her statement is that she did not take these seriously and thought he was being manipulative.

7.3. Later that afternoon, she sent Mr Lattuca a message to which he did not respond, and then sent several further messages because his failure to engage with her was unusual.

She tried to ring him but got the ‘uncontactable’ message. A little after 6pm she walked to the Salisbury interchange with her daughter and got on the bus, arriving at Mr Lattuca's address at about 9:30pm. She discovered Mr Lattuca sitting, deceased, on the rear veranda with a ligature around his neck. To protect her daughter, she immediately left the premises and went to her mother's house. She and her mother returned to the address and notified police and ambulance services.

11 Exhibit C1a

8. Coronial investigation 8.1. An investigation into Mr Lattuca’s death was undertaken by South Australia Police and a comprehensive and helpful report was provided by Brevet Sergeant Adam Crouch of the Elizabeth Criminal Investigation Branch12. As part of the investigation, Mr Lattuca’s mobile telephone was analysed and a photograph of him with a noose around his neck timed at 2:12pm on 25 January 2016 was found. Police found no suspicious circumstances surrounded the death of Mr Lattuca. No deficiencies were identified in monitoring or supervision by the Department for Correctional Services.

9. Conclusions 9.1. Cristophe Lattuca took his own life by hanging himself, without the assistance or involvement of any third party. A few days before his death, he had expressed to his half-sister a belief that his girlfriend had been unfaithful. He expressed a sense of hopelessness and it is evident that this had been building for some time. In the 24 hours before his death he had been arguing with his girlfriend by text message and was clearly having difficulty dealing with the restrictions imposed by home detention bail.

Contrary to the conditions of his home detention bail, he had consumed alcohol, methylamphetamine and cannabis prior to his death. It is evident that prior to his arrest and incarceration he had been abusing illegal drugs for some time. Clearly this affected various aspects of his life including, probably, the time he spent with his children. He was facing serious criminal charges. Beyond expressing these various factors as likely to have contributed to his decision to take his own life, it is not possible to determine with certainty what led him to do so.

9.2. Mr Lattuca had a history – albeit limited – of making statements of intention to selfharm or to take his life, including in the last three months of his life whilst he was on home detention. Knowledge of these statements was limited to a very few people close to him, who did not regard him as likely to act on those threats. They did not bring his threats to the attention of the Department for Correctional Services, which was responsible for Mr Lattuca during the period of his home detention bail.

9.3. Mr Lattuca did not express any thought of suicide or self-harm to any employee of DCS, during his three months on home detention bail. This mirrored his presentation 12 Exhibit C18

in custody, during the three months prior to his release. His breaches of home detention bail were few and Mr Lattuca persuaded DCS staff that further breaches were unlikely.

His usual presentation of being polite and cooperative undoubtedly served to reinforce this view. I consider it likely that he intended to conceal those thoughts from them.

Those employees could not, in all the circumstances, have been expected to conclude that he presented a risk of harming himself or taking his own life.

9.4. There is evidence that those involved in Mr Lattuca’s medical care over the years made sincere efforts to ensure that he received mental health treatment, which it appears he may well have needed, but that Mr Lattuca failed to avail himself of available treatment.

9.5. Although there is evidence that Mr Lattuca consumed alcohol, cannabis and methylamphetamine within a relatively short time before taking his life, he had exhibited no pattern of behaviour which should have led DCS to suspect that he was breaching, or was likely to breach his bail in that manner on that occasion.

9.6. Mr Lattuca was lawfully under detention, on home detention bail, by the Department for Correctional Services. I conclude that the Department for Correctional Services provided appropriate care for Mr Lattuca for the duration of that period of custody.

10. Recommendations 10.1. I make no recommendations in this matter.

Key Words: Death in Custody; Home Detention Bail; Suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 29th day of October, 2019.

State Coroner Inquest Number 12/2019 (0183/2016)