Coroner's Finding: USHER Peter Michael

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 25th day of June and the 12th day of October 2020, by the Coroner’s Court of the said State, constituted of Simon James Smart, Deputy State Coroner, into the death of Peter Michael Usher.

The said Court finds that Peter Michael Usher aged 56 years, late of 11 Harvey Terrace, Glenelg North, South Australia, died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 14th day of November 2018 as a result of hypoxic ischaemic encephalopathy following insulin and benzodiazepine overdose. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Peter Michael Usher was born on 29 April 1962 and died on 14 November 2018 at the Royal Adelaide Hospital. He was 56 years old.

1.2. Mr Usher’s medical records were reviewed by Dr Iain McIntyre from Forensic Science South Australia in discussion with Dr Karen Heath, forensic pathologist. In his report of that review Dr McIntyre found Mr Usher’s cause of death to be hypoxic ischaemic encephalopathy following insulin and benzodiazepine overdose1, and I so find.

2. Reason for inquest 2.1. This is a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mr Usher had been detained under an Inpatient Treatment Order (ITO) prior to his 1 Exhibit C1a

death. As it is possible that Mr Usher’s cause of death may have arisen whilst he was under the ITO, his death is to be treated as a death in custody.

2.2. The Level 1 ITO detaining Mr Usher had been made pursuant to section 21 of the Mental Health Act 2009. The order was made by Dr Alicia Paterson on 11 November 2018 and was due to expire on 16 November 2018. That order was revoked at 9:50am on 14 November 2018 by Dr Davis. There are no concerns in relation to the lawfulness of custody.

3. Background and medical history 3.1. Peter Usher was the adopted son of Maureen and Alfred Usher. He was adopted at 10 days old. Maureen Usher2 stated that she never knew her son had any mental health issues. In addition, she had only become aware that he had not been working as a result of his passing.

3.2. Mr Usher had been in a relationship with Kristen Davis for approximately 12 months.

In her statement Ms Davis noted that: 'It was common knowledge among Peter’s close friends that he suffered from depression.' 3 She described him as an ‘extremely intelligent man’.

3.3. Mr Usher visited a general practitioner, Dr Abegunawardene4, on three occasions and did not mention any mental health issues. Mr Usher’s normal general practitioner, Dr Cecilley Jennings5, had been seeing Mr Usher since 1973. The last appointment she had with Mr Usher was on 4 October 2017 for back and shoulder pain. He was prescribed 20 tablets of temazepam. Mr Usher advised Dr Jennings that the pharmacy had given him two tablets, but refused to give him more without a prescription.

3.4. Dr Jennings stated that at an early age Mr Usher was referred to a psychiatrist. Nothing eventuated from that referral and at no other time during his life did Mr Usher seek any further assistance with his mental health. He was not prescribed any other medications by Dr Jennings at the time of his death. Mr Usher was known to be a user of cocaine and was described as ‘very OCD’.

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4. Events surrounding Mr Usher’s death 4.1. Ms Davis stated that on Saturday 10 November 2018 Mr Usher came to her house during the evening and ‘said goodbye’. She stated that she ‘knew what he meant as he had always told me that he would control his destiny’. She stated that she begged him not to go and to stay with her and that she could help. He left her house later that night.

4.2. When Ms Davis attended Mr Usher’s address at 8:30am the following morning, 11 November 2018, she found a note that said: 'Please don’t come in. Call Ambulance or Police thanks. I am in very deep sleep forever thankyou Peter.' Ms Davis called an ambulance and the police.

4.3. Constable Aaron Frazer of SAPOL6 attended at the rear room of the house Mr Usher was renting in Glenelg North. Constable Frazer could see that Mr Usher was breathing but unconscious. Constable Frazer located a note and an empty syringe on a coffee table next to Mr Usher. The note stated: 'I took sleeping pills that I saved over the years and took insulin that I stole from mother regards Peter Usher. I am just worn out.'

4.4. Constable Frazer noticed that the house was devoid of all personal belongings except for some rings, the keys to the house and two cards addressed to the landlords and their son.

4.5. Paramedic Jessica Rocco attended Mr Usher’s house. She determined that Mr Usher was in cardiac arrest and breathing one breath per minute. He did not have a palpable pulse, but had a small amount electrical activity in the heart. Compressions were commenced and intravenous access was obtained. A supraglottic airway device was inserted in Mr Usher’s throat to assist with breathing.

4.6. Ms Rocco stated that a blood sugar test was conducted which came back as too low for the glucometer to read. She stated that this is consistent with Mr Usher having taken insulin and sedatives. A 250ml bag of glucose and some saline were given. Mr Usher was taken to the Royal Adelaide Hospital where he remained until his death on 14 November 2018.

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Mr Usher was in cardiac arrest with a low blood sugar reading. Paramedics were able to restore Mr Usher’s spontaneous circulation and take him to the Royal Adelaide Hospital where he had a second arrest in pulseless electrical activity. Mr Usher was again resuscitated but remained unconscious.

4.7. Imaging revealed that Mr Usher sustained global cerebral hypoxia and chest X-rays indicated that he had a right basal pneumonia.

5. Toxicological analysis 5.1. A toxicological analysis was performed at Forensic Science South Australia on a sample of ante-mortem blood taken at 9:46am on 11 November 2018. Alcohol was not detected. The analysis detected approximately 4mg temazepam per L, approximately 0.21mg oxazepam per L and 0.34mg benzoylecgonine per L.

5.2. 4mg temazepam per L is considered a toxic concentration. The presence of oxazepam is consistent with the ingestion of temazepam. Temazepam is partially metabolised to oxazepam. The presence of benzoylecgonine is consistent with the use of cocaine.

5.3. A note was found indicating that Mr Usher had deliberately taken an overdose of benzodiazepine sleeping tablets and insulin which he had taken from his mother.

5.4. Maureen Usher stated that she is insulin dependent and keeps her insulin in the door of her fridge. She had not noticed any of her insulin missing and did not suspect that her son was taking it from her.

6. Mr Usher’s admittance to the Royal Adelaide Hospital and decline 6.1. Dr Alicia Paterson, Anaesthetic Registrar at the Royal Adelaide Hospital, provided a statement to the Court7. On arrival at the hospital Mr Usher arrested and received CPR and defibrillation shock. His heartbeat and circulation returned. Mr Usher was intubated and remained unconscious.

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6.2. A CT scan was performed and the results were consistent with hypoxic brain injury as a result of the brain being deprived of oxygen for a significant duration.

6.3. Dr Paterson states that an ITO was placed on Mr Usher on 11 November 2018 in case Mr Usher recovered and refused treatment.

6.4. On 12 and 13 November 2018 Mr Usher’s prognosis became poor. On 13 November 2018 Mr Usher’s family were advised that there had been no signs of recovery and that Mr Usher had sustained an unrecoverable brain injury.

6.5. Palliative sedation was commenced on 14 November 2018 and the endotracheal breathing tube was removed at midday. Mr Usher ceased breathing at 10:34pm and was pronounced deceased at that time.

7. Conclusion 7.1. Consistent with the conclusions of the SAPOL Investigating Officer in this matter, Detective Brevet Sergeant Jordan Koch8, Mr Usher was in lawful detention whilst under an Inpatient Treatment Order. The circumstances surrounding his death are not suspicious and do not indicate the involvement of any third party. There are no concerns relating to Mr Usher’s care.

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

Key Words: Death in Custody; Natural Causes; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 12th day of October, 2020.

Deputy State Coroner Inquest Number 68/2020 (2212/2018) 8 Exhibit C10