Coroner's Finding: PIKE Lucas Adam

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 12th, 13th, 14th and 15th days of February 2019 and the 9th day of May 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Lucas Adam Pike.

The said Court finds that Lucas Adam Pike aged 43 years, late of 26 Lipsett Terrace, Brooklyn Park, South Australia died at 129 Hindley Street, Adelaide, South Australia on the 4th day of March 2016 as a result of morphine (heroin) toxicity. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Lucas Adam Pike died on 4 March 2016 at 129 Hindley Street, Adelaide, the premises from which a general medical practice was conducted and still is conducted by Dr Jack Kerry, general practitioner. Mr Pike was 43 years of age when he died. It was obvious from the circumstances surrounding his death that he and others had taken heroin on the premises of the surgery. A post-mortem examination was conducted upon Mr Pike’s body and in a report1 the forensic pathologist gave the cause of death as morphine (heroin) toxicity, and I so find. That post-mortem report made reference to toxicological analysis of blood taken at autopsy which revealed morphine levels of 0.12mg per litre and alcohol at 0.08%. The report containing that analysis2 stated that blood morphine concentrations above 0.1mg per litre resulting from heroin use are generally considered potentially lethal.

1 Exhibit C1a 2 Exhibit C2a

2. The events leading to Mr Pike’s death 2.1. As I have said, Mr Pike died in what can only be described as most unusual circumstances: heroin overdose following consumption of that drug in the rooms of a general practitioner.

2.2. Mr Pike was a patient of Dr Kerry. Two other persons were involved in the drug taking: Dr Kerry’s daughter, Ms Athena Kyriacou, and an acquaintance of Mr Pike and Ms Kyriacou, Mr Mark Campbell. Mr Campbell was also a patient of Dr Kerry.

2.3. Ms Kyriacou, apart from being Dr Kerry’s daughter, also worked within his practice.

She worked there in two capacities, one as a general receptionist and secondly as a phlebotomist employed by Australian Clinical Laboratories. She worked in that capacity within a room dedicated for the purposes of the business of Australian Clinical Laboratories. It is plain on the evidence that Ms Kyriacou met Mr Pike and Mr Campbell through her work as a receptionist at Dr Kerry’s practice.

2.4. Ms Kyriacou and Mr Pike had been living together for 5 to 6 months, although their relationship was not sexual3. Clearly they spent a considerable amount of time together and they had spent the afternoon of 4 March 2016 together at the Woolshed Hotel in Hindley Street where they met Mark Campbell. Mr Pike and Mr Campbell did not know each other well, but they were acquainted to use Ms Kyriacou’s expression ‘through the surgery’4. She explained this in the following words: '… because in that surgery you get a lot of people that drop in at the same time.' 5 However, Ms Kyriacou said that the three had not spent time together as a group prior to that day6. She said that it was her intention that evening to work at the Adelaide Fringe and she was rostered to start at 7pm7.

2.5. CCTV footage was obtained from the Woolshed Hotel8. The footage shows a view of the footpath outside the Woolshed including outside tables. A summary of the footage9 shows at 4:25pm two people, a male and female, sitting at an outside table. At some 3 Transcript, pages 94-95 4 Transcript, page 98 5 Transcript, page 98 6 Transcript, page 99 7 Transcript, page 99 8 Exhibit C7a 9 Exhibit C7

point they are joined by a second male person. The second male person left the table at 6:06pm and the same male person returned to the table at 6:37pm. All three of those persons left the table at 6:40pm in a westerly direction along the northern footpath of Hindley Street10. The three persons were Ms Kyriacou, Mr Pike and Mr Campbell. The person who was absent for the period between 6:06pm and 6:37pm was Mr Campbell.

2.6. It happens that Dr Kerry’s medical practice is a short walk west of the Woolshed Hotel, and it was to that destination that the three were going when they left the hotel.

Mr White, counsel for Dr Kerry, has helpfully provided a timeline based on time stamps of the Woolshed Hotel recording as the beginning point and the timing of a triple zero call, to which reference will be made in due course, as the end point together with assumed timings for events between. While it cannot be regarded as definitive as far as the assumed timing of events between are concerned, it provides a useful guideline and I set it out hereunder.

6:40pm Mr Pike, Mr Campbell and Ms Kyriacou leave the Woolshed 6:42pm The three enter the surgery (This assumes 2 minutes to walk to and enter 129 Hindley Street) 6:47pm The three persons enter the Treatment Room (This assumes 5 minutes for conversations between Dr Kerry, Ms Kyriacou, and subsequently Mr Campbell) 6:52pm Heroin syringes prepared (This assumes 5 minutes to find the necessary equipment, prepare the heroin and the syringes) 6:53pm Ms Kyriacou is injected (This assumes administration of heroin to Ms Kyriacou first, which of course was her evidence) 6:54pm Mr Pike injected (This assumes the earliest possible time for administration of heroin to Mr Pike) ??pm At an unknown time after 6:54pm Mr Campbell attempted may have attempted to inject himself with heroin 7:06pm Dr Kerry enters the room (This assumes 4 minutes between Dr Kerry entering the Treatment Room and the commencement of the 000 call) 7:10pm Commencement of 000 call.

10 Exhibit C7

2.7. Ms Kyriacou gave evidence. She said that Mr Campbell left the Woolshed Hotel for the purpose of obtaining heroin. Her evidence on this topic is corroborated by the CCTV footage. Unfortunately, following the tragic death of Mr Pike, Mr Campbell himself died in unrelated circumstances. As a result of this he did not give evidence.

However, he gave three different accounts of the events of that afternoon to Sergeant Gibson who was a police officer who arrived in the aftermath of the triple zero call.

Thus he changed his story three times. The objective evidence is that he procured the heroin, something which in his statements he did not admit, but attempted to attribute to Mr Pike. No reliance can be placed on the statements provided by Mr Campbell except where they are not in conflict with other evidence.

2.8. The principal direct evidence of what transpired in the surgery is that of Ms Kyriacou, although as will be seen, Dr Kerry also came upon the scene after the heroin had been administered and therefore he can provide no assistance about the circumstances surrounding the administration of the heroin.

2.9. Ms Iles, counsel for Ms Kyriacou, very properly made certain concessions. She acknowledged on behalf of Ms Kyriacou that on the evening of 4 March 2016 she made an inexcusable error of judgment in both a professional and personal sense. She accepted that she was the ‘conduit’ for access to the clinic and the pathology room and that by providing Mr Campbell and Mr Pike with access to that room she also provided them with access to paraphernalia that could be used to administer drugs. She acknowledged that equipment from that room was indeed used by Mr Campbell to prepare the heroin for administration, whether or not he also used any material that happened to be in his possession as well. Ms Iles acknowledged that in facilitating access to the room and the equipment Ms Kyriacou demonstrated a complete lack of professional judgment as a phlebotomist as well as a complete lack of respect for the medical and health services environment in which she worked.

2.10. Clearly these concessions were made on Ms Kyriacou’s instructions and it is to her credit that she has made them.

2.11. In the witness box Ms Kyriacou did present as credible and I am prepared to rely upon her account of what transpired in the pathology room when the heroin was administered. I also accept her evidence about the circumstances in which Mr Campbell procured the heroin. She said that it was Mr Campbell who brought up the topic of heroin while they were at the Woolshed Hotel. She said that Mr Campbell

was insistent that the three of them consume heroin that evening and was ‘pushing it’.

Nevertheless, Ms Kyriacou acknowledged that there was a collective decision to consume heroin. Mr Campbell made a telephone call and then left the Woolshed Hotel for what Ms Kyriacou estimated as a period of 20 to 30 minutes. Ms Kyriacou said that she could not explain why she and Mr Pike decided to consume heroin that evening. It would appear that the decision was, as Ms Iles submitted, a spontaneous one made in response to the topic being raised by Mr Campbell. As frankly suggested by Ms Iles, it was no doubt influenced to a considerable degree by the fact that both Ms Kyriacou and Mr Pike had been drinking. I accept that neither Ms Kyriacou nor Mr Pike had contemplated consuming heroin when they set out for the night and that is corroborated by the fact that it was clearly Ms Kyriacou’s intention to work at the Fringe that evening, something that she could not have contemplated if she had intended to consume the heroin.

2.12. There was no evidence to suggest that Mr Pike was forced to consume the heroin that afternoon. Ms Kyriacou’s evidence supports the proposition that he voluntarily participated in the collective decision that the three would consume heroin.

Ms Kyriacou gave evidence about the layout of the pathology room and the respective positions of herself, Mr Pike and Mr Campbell within the room. She described in detail how she was sitting in a chair within the room and that Mr Pike was standing.

Ms Kyriacou said that the mixing of the heroin was undertaken using material obtained from within the room including a silver mixing bowl, three 5cc syringes and some cotton wool. The three syringes were loaded and the heroin was mixed by Mr Campbell. It was Mr Campbell who then administered the heroin to Ms Kyriacou and her last recollection before passing out was that Mr Campbell was turning towards Mr Pike, apparently to administer Mr Pike’s share of the heroin. As I have said, Mr Campbell gave a different account seeking to blame Mr Pike for preparing the heroin and injecting Ms Kyriacou and himself. I accept however Ms Kyriacou’s version of events. As I have said, Mr Campbell’s three statements were inconsistent and, furthermore, he clearly had a motive to shift responsibility onto someone else.

Furthermore, Mr Campbell in one of his statements admitted to having been on the methadone program at some point. This is indicative of past heroin addiction, if not a current addiction. Ms Kyriacou also said that Mr Campbell had used a lot of heroin and had a long drug history11.

11 Transcript, pages 122-123

2.13. Ms Kyriacou gave an account of seeing how Mr Campbell had lined the three syringes up on a desk and he then approached her with one of the syringes and injected heroin into her right arm. Her last recollection before passing out was that Mr Campbell turned away from her back towards the table where the two remaining syringes were, and then turned towards Mr Pike who was standing, holding out his right arm, bracing his bicep in a position that Ms Kyriacou thought consistent with preparing to receive an injection.

It was at this point that Ms Kyriacou passed out.

2.14. I have no doubt that Mr Campbell then proceeded to administer the heroin to Mr Pike.

2.15. The evidence as to whether Mr Campbell injected or tried to inject himself comes only from his various statements. The only objective evidence was that his arm showed puncture marks and his sleeve showed blood12. In one account Mr Campbell said that he went to the outside toilet and tried to inject himself in there. As it happened, the one piece of drug paraphernalia that was seized by police at the surgery was a syringe that was found on the floor of that outside toilet. The syringe was never forensically analysed by the police and it is not known whether that was a syringe used by Mr Campbell or whether it was one of the other syringes. The evidence showed that Dr Kerry was in a back room eating a sandwich and would have seen Mr Campbell pass the room in order to get to the outside toilet and that Dr Kerry did not see Mr Campbell pass the room. I agree with the submission of counsel for Dr Kerry that it is possible that Mr Campbell injected himself, or attempted to inject himself, in the treatment room after he had injected Mr Pike and before Dr Kerry entered the room. Mr Campbell did say in one of his accounts that he attempted to flush his own syringe down the toilet.

2.16. No person, including the police witnesses and Dr Kerry who entered the room in which the heroin was administered saw any drug paraphernalia. I agree with the submission of counsel for Dr Kerry that it is likely that Mr Campbell ‘swept’ the room before Dr Kerry entered. Mr Campbell was later found by the police to be in possession of Mr Pike’s telephone and this suggests that he had taken the time to search Mr Pike’s body. Counsel for Dr Kerry cogently submitted that the position in which Mr Pike’s body was seen when Dr Kerry entered the room is not consistent with a sudden collapse.

Mr Pike was laid out on the floor on his back when Dr Kerry first saw him. This seems consistent with some intervention by the only other person who was in a position to do 12 Exhibit C32 SG2, 10 and 11

so, namely Mr Campbell. Clearly Mr Campbell must have interfered with Mr Pike’s body in order to remove the telephone.

2.17. Dr Kerry gave evidence that his attention was drawn to the pathology room by Mr Campbell’s cries of ‘heroin, heroin’. On entering the room Dr Kerry found his daughter and Mr Pike in a state of collapse. Before he entered the room Dr Kerry saw Mr Campbell leaving the room. Dr Kerry said that he chose to treat his daughter first, a decision that he described as ‘paternal instinct’. He also said that his daughter was, on an objective assessment, the person with the better prospect of recovery. Dr Kerry said that Mr Pike’s face and lips were cyanosed. He was not moving at all. Dr Kerry said that: 'I had one look at him; I thought he'd had a cardiac arrest; I thought he was dead.' 13 On the other hand, his daughter had a pulse. I make no criticism of Dr Kerry for attending to his daughter first. It would appear that Mr Pike was likely in a state of total collapse when Dr Kerry walked into the room. I think it is likely that some time had passed between his collapse and Mr Campbell’s cries that alerted Dr Kerry to the fact that something had gone wrong. Certainly in that time it would appear that Mr Campbell had removed Mr Pike’s telephone and ‘swept’ the room of drug paraphernalia.

2.18. There was also evidence from Ms Kyriacou that she elected to have only half of her one third share of the heroin. I have no reason not to accept her evidence on that point.

It would therefore follow that she would have consumed approximately half the dose consumed by Mr Pike. If that is correct, and given that Ms Kyriacou’s own dose was enough to cause her to overdose, it can be inferred that Mr Pike’s dose would have had a much more dramatic effect upon him. It is indeed possible that he would have entered cardiac arrest very shortly after the drug was administered to him by Mr Campbell. It is possible that he had been collapsed in a state of cardiac arrest for some minutes before Dr Kerry even entered the room.

2.19. As I have said, Dr Kerry immediately commenced CPR upon his daughter.

Approximately a minute after Dr Kerry entered the room Mr Campbell returned to the room. Dr Kerry immediately enlisted him to perform CPR on Mr Pike. Mr Campbell 13 Transcript, page 188

then left the room again after about half a minute14. Dr Kerry then left his daughter and commenced CPR on Mr Pike15. Mr Campbell returned for the second time about a minute later16. Dr Kerry directed him to perform CPR on Mr Pike before leaving the room to initiate a triple zero call. He did that by approaching a pharmacist in the adjoining pharmacy and requesting that she make the call. On Dr Kerry’s return Mr Campbell was still in the room and performing compressions on Mr Pike. From that point CPR was continuously given to Mr Pike until the arrival of the paramedics at 7:16pm.

2.20. From about 7:12pm Ms Cacas, the pharmacist, brought a mobile phone into the room.

From that time there is a recording of the tripe zero operator talking and instructing upon CPR. Dr Kerry can be heard in the background as can Ms Cacas.

2.21. I heard evidence from a paramedic, Mr Bemmer, who arrived on the scene in response to the triple zero call. He noticed that Mr Pike was in a more advanced state of deterioration than Ms Kyriacou17. He gave a very similar description of Mr Pike’s condition to that provided by Dr Kerry. Mr Bemmer and two of his colleagues worked on Mr Pike for half an hour but to no avail. He had no shockable rhythm at any time and did not respond to fluids or adrenaline. He was pronounced deceased at 8pm.

Ms Kyriacou was taken to the hospital, admitted overnight and released the following day.

2.22. Dr Kerry gave evidence that on one of the occasions he saw Mr Campbell leaving the treatment room during the resuscitation efforts he noticed Mr Campbell had what appeared to be a 5cc syringe in his hand. This is consistent with the conclusions that I have reached that Mr Campbell was keen to avoid any link between the heroin and himself and had a good motive for hiding the drug taking paraphernalia, including the syringe. Dr Kerry saw no other evidence of drug paraphernalia.

2.23. In my opinion it is plain that Mr Campbell did dispose of all of the drug paraphernalia, including the bowl. The only exception was the used syringe that he somehow overlooked and which was found in the outside toilet.

14 Transcript, page 189 15 Transcript, page 190 16 Transcript, page 190 17 Transcript, page 26

3. The coronial investigation 3.1. The coronial investigation into Mr Pike’s death left a lot to be desired. No proper search was conducted of the surgery, and this is all the more concerning when one considers the unique nature of the circumstances. A death by heroin overdose in a doctor’s surgery is certainly no common occurrence. I would have expected that very thorough searches would have been conducted by the police with a view to finding any evidence of drug paraphernalia. That simply did not happen. There was no coordination amongst the various officers who attended that night and although statements were taken, physical evidence was not diligently pursued.

3.2. It does not appear that Mr Campbell was pressed about the absence of these items. The one item that was seized, namely the syringe from the outside toilet, was never analysed by police. The investigating officer gave evidence that there would have been no point in doing so.

3.3. The circumstances surrounding the discovery of Mr Pike’s telephone in the possession of Mr Campbell are most instructive. Sometime after 9pm, almost two hours after the triple zero, a police officer returned from the Royal Adelaide Hospital to attempt to find Ms Kyriacou’s telephone because she had complained that it appeared to be missing.

That officer then thought it might be useful to call the deceased’s phone and it was only then that it was realised that Mr Campbell was in possession of Mr Pike’s telephone. It beggars belief that Mr Campbell was allowed to maintain possession of the telephone for almost two hours after the arrival of police at the scene. There was ample basis for a search of Mr Campbell’s person to have been conducted as soon as the police arrived on the scene or very shortly thereafter. Indeed, there were probably grounds for his arrest and separation from the scene. The fact that he was permitted to wander around the scene for some two hours after the police arrived is something for which no explanation was provided.

3.4. The evidence showed that there were a number of Sulo rubbish bins in the street outside the premises which apparently belonged to the surgery. No effort was made by any police officer to search those bins. It appears that no effort was made to search the premises generally.

3.5. In summary, one would hope that police officers would take a serious approach to the investigation of a sudden unexplained death. There appears to have been an assumption

that the death was an overdose and that no more serious criminality was involved than the provision of a controlled substance. No thought was given to whether a murder may have been committed for example. Even if one dismisses the possibility that Mr Campbell might have had any motive to murder Mr Pike, nevertheless there remains the fact that police are investigators for the purposes of the Coroners Act 2003 and have a duty to carry out a proper coronial investigation.

3.6. It goes without saying that unless police carry out that task diligently and thoroughly, the quality of the coronial investigation is inevitably compromised. This is fundamental and axiomatic and was recognised in the Royal Commission into Aboriginal Deaths in Custody.

3.7. The fact that in 2016 it is possible for a coronial investigation to be conducted in such a slapdash and incompetent manner leaves me with little confidence in the overall quality of coronial investigations by police.

3.8. I find that Mr Pike died as a result of morphine (heroin) toxicity from an overdose of heroin administered on the premises of Dr Kerry’s general practice. He engaged in consumption of the heroin as part of an agreement that also included Ms Kyriacou and Mr Campbell. It is likely that more information about the cause and circumstances of his death would have been ascertainable had a proper coronial investigation been carried out.

3.9. I have no recommendations to make in this matter.

Key Words: Drug Overdose; SAPOL Investigation In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 9th day of May, 2019.

State Coroner Inquest Number 28/2018 (0418/2016)