Coroner's Finding: Abbott, John

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 14th day of July and the 22nd day of December 2022, by the Coroner’s Court of the said State, constituted of Naomi Mary Kereru, Coroner, into the death of John Abbott.

The said Court finds that John Abbott aged 69 years, late of 7 Young Street, Dudley Park, South Australia died at Dudley Park, South Australia on the 26th day of August 2020 as a result of plastic bag asphyxia and mixed drug toxicity (oxycodone and pentobarbitone). The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. John Abbott was born on 25 January 1951 and died on 26 August 2020 at his residence of 7 Young Street, Dudley Park. He was 69 years of age.

1.2. A post-mortem examination of Mr Abbott’s remains was conducted on 31 August 2020 by Dr Cheryl Charlwood who is a forensic pathologist at Forensic Science South Australia (FSSA). Dr Charlwood reported that the death was ‘due to the combination of plastic bag asphyxia and mixed drug toxicity’.1

1.3. Post-mortem toxicology of Mr Abbott’s blood detected the presence of 0.4mg per litre of oxycodone2 and 23mg per litre of pentobarbitone.3 In addition to these drugs, duloxetine, codeine, morphine, paracetamol and prochlorperazine were detected.4 1 Exhibit C2a, page 2 2 A semi-synthetic narcotic analgesic used for moderate to severe pain (Exhibit C3a) 3 A short-acting barbiturate used as a sedative-hypnotic agent. In Australia it is only prescribed for veterinary use (Exhibit C3a) 4 Exhibit C3a

1.4. I find that the cause of Mr Abbott’s death was plastic bag asphyxia and mixed drug toxicity (oxycodone and pentobarbitone).

2. Reason for inquest 2.1. In September 2019, Mr Abbott was arrested and charged with offences alleged to have occurred between 2009 and 2018. Mr Abbott was refused police bail and remanded in custody at Yatala Labour Prison (YLP).

2.2. On 30 October 2019, Mr Abbott was released from custody and into the care of a Community Corrections team on home detention bail with electronic monitoring.

2.3. As Mr Abbott was the subject of a home detention bail agreement with electronic monitoring at the time of his death, his death was a death in custody of which an inquest was mandatory.

2.4. In law this meant that Mr Abbott’s death was a death in custody within the meaning of that expression of the Coroners Act 2003 and the inquest was held as required by section 21(1)(a) of the Act.

3. Background 3.1. Mr Abbott was born in Engadine which is a suburb in southern Sydney. His father married three times and Mr Abbott had six siblings. He spent some of his childhood in Tenant Creek before moving to Adelaide. After school he joined the Army but was discharged. It was reported that he was deemed to be unsuitable.

3.2. Mr Abbott worked for a number of years as a site project manager for the South Australian Government and he travelled extensively throughout the State.

3.3. In 1990 Mr Abbott married Joelle Casse. They had two daughters. That marriage ended in 1996. In 2000 Mr Abbott met Grant Sullivan and they became friends. That friendship lasted for the rest of Mr Abbott's life. Mr Abbott also developed a friendship with Grant Sullivan's son, Loughlin.

3.4. As set out above, Mr Abbott was arrested on 10 September 2019. He was refused police bail and was remanded in custody. He was released on home detention bail on 30 October 2019 to reside at an address in Kensington, South Australia. This address

was varied by the Court for Mr Abbott to reside at 7 Young Street, Dudley Park with his carer Loughlin Sullivan. This was the address at which he died.

4. Medical history 4.1. Mr Abbott was a life-long smoker who suffered from chronic obstructive airways disease, malignant hypertension, arthritis, and chronic pain. He was also said to suffer from chronic depression.

4.2. In the 1980s, Mr Abbott was diagnosed with chronic fatigue syndrome which brought about the end of full-time employment. Mr Abbott undertook part-time work for two politicians in their offices, but never worked full-time again.

4.3. Mr Abbott had an extensive and complicated medical history. This became more so in the last few years of his life. Mr Abbott was in receipt of a level 4 aged-care package for home help.

5. Mr Abbott’s decline in health 5.1. In 2019 Dr Khalil Ghuman took over as Mr Abbott's treating general practitioner. In a statement tendered to the Court, he described Mr Abbott's mental health as beginning to significantly decline around this time.5 During that year Dr Ghuman referred Mr Abbott to a number of specialists including a general physician, a number of cardiologists, a respiratory physician, geriatric specialist services, and the Older Persons Mental Health Service. Mr Abbott attended his appointments, as directed, with the assistance of Loughlin Sullivan.

5.2. In the two years prior to Mr Abbott's death he had a number of emergency admissions to public hospitals following falls. Those falls were thought to be related to non-compliance with the direction and frequency of medications to which he had been lawfully prescribed.

5.3. In March 2020, Mr Abbott was seen by Dr Patrick Flynn, a psychiatrist consulting at the Older Persons Mental Health Service. Dr Flynn opined that while Mr Abbott's precise diagnosis was unclear, he was displaying a paranoid psychosis and neurocognitive decline.6 He commenced Mr Abbott on an antipsychotic, risperidone.

5 Exhibit C7 6 Exhibit C16 – Dr Flynn letter to Dr Ghuman dated 2 March 2020

5.4. In April 2020, Mr Abbott was seen by Dr Fiona Hawker, a psychiatrist of the same service. She agreed with Dr Flynn's diagnosis and increased Mr Abbott's risperidone.

At a further appointment, four weeks later, Dr Hawker again increased the risperidone and prescribed an antidepressant.

5.5. Dr Hawker saw Mr Abbott again in mid-May 2020 and stated in a letter to Dr Ghuman that ‘[i]n summary John continues to present with a complex clinical picture of deterioration in his cardiac pulmonary, cognitive and mental functioning’.7 Dr Hawker was of the opinion that Mr Abbott was receiving benefit from the antipsychotic and the antidepressant medication.

5.6. In July 2020, Mr Abbott was admitted to the Queen Elizabeth Hospital (QEH) following a fall with reported head strike. On presentation he was found to be sedated and was administered naloxone to which he responded. Mr Abbott was admitted to the hospital for an inpatient psychiatric assessment. The discharge summary recorded that although Mr Abbott’s presentation was not entirely convincing for psychosis, he was continued on a low dose of risperidone. Mr Abbott underwent a SPECT scan of his brain.8 This demonstrated asymmetrical left frontoparietal hypoperfusion, but no particular dementia pattern.

5.7. A neuropsychological assessment was not able to be performed while Mr Abbott was an inpatient because he was reportedly not cooperative. It was determined that evidence of a pervasive psychosis was lacking. The risperidone was ceased and Mr Abbott become a voluntary patient. He was advised that the assessment was not consistent with a primary psychiatric illness or cognitive impairment.

5.8. Concerns were raised with Mr Abbott and his general practitioner about his numerous admissions relating to falls in the presence of being prescribed opioids and benzodiazepines. Those medications were ceased.

5.9. Mr Abbott was discharged on 3 August 2020 and had only one further medical attendance before his death. This appointment was with Dr Ghuman who refused Mr Abbott’s request for opioid and benzodiazepine prescriptions.

7 Exhibit C16 – Dr Hawker letter to Dr Ghuman dated 15 May 2020 8 Single-photon emission computerised tomography scan

6. Events leading to Mr Abbott’s death 6.1. In the days prior to his death, Mr Abbott spoke to Grant Sullivan about his concerns relating to his pending criminal matters, particularly around his bail being revoked and being returned to YLP. The day before his death, Mr Abbott had also asked Grant Sullivan to be the executor of his estate.

6.2. The evening prior to his death, Mr Abbott gave Loughlin Sullivan three full bags of canned food, he hugged him several times and drank a glass of Drambuie. All behaviours were noted by Loughlin Sullivan to be unusual for Mr Abbott.

6.3. The following morning, 27 August 2020, at 8:55am, Loughlin Sullivan went to Mr Abbott's room when he had not arisen to attend court. On entering Mr Abbott's room Loughlin Sullivan found Mr Abbott with a plastic bag over his head. He noticed he was not breathing and he was cold to the touch. Loughlin Sullivan did not perform any resuscitative measures but called his father who subsequently called police.

6.4. Police received the tasking at 10am and arrived shortly thereafter. An ambulance attended and Mr Abbott was declared life extinct.

7. Evidence collected from Mr Abbott’s bedroom 7.1. A large number of medications were located in Mr Abbott's bedroom. Various electronic exhibits were also seized and a number of them were examined by the police.

It was discovered that one such device was used to access multiple websites concerning voluntary euthanasia. Several of those websites had links to sites from which the purchase of voluntary euthanasia drugs (including pentobarbitone) was possible.

7.2. On examination of websites accessed by the device found in Mr Abbott's bedroom, only one date was recorded, being 22 June 2019, some 14 months before his death. On that same date, Mr Abbott's Commonwealth Bank visa card recorded a debit payment to Exit International for a two-year subscription to ‘The Peaceful Pill eHandbook’. No pentobarbitone or packaging of the same was located in Mr Abbott's bedroom.

7.3. Whilst there is no evidence as to where or how Mr Abbott obtained the pentobarbitone that was detected in his blood, the inference is open that he acquired it from, or through, information obtained from Exit International or their publications.

8. Conclusion 8.1. The circumstances of Mr Abbott’s death were investigated thoroughly by Detective Brevet Sergeant Edward Boyes of the Western District Criminal Investigation Branch. In his comprehensive report, Detective Boyes expressed the view that Mr Abbott had formulated a plan to take his own life some time before his death, with the purchase of the pentobarbitone in June 2019. The prospect of a prison sentence ahead provided the ultimate motivation for Mr Abbott taking his own life.

8.2. In my view those conclusions are correct and I so find.

8.3. I find that Mr Abbott was cared for in a professional and appropriate manner by Dr Ghuman in the last two years of his life. Dr Ghuman made appropriate referrals to specialists and agencies to assist Mr Abbott.

8.4. Mr Abbott was compliant with his home detention bail and there was no reason for those supervising him to suspect he would take his own life. `

8.5. The investigating officer concluded there were no suspicious circumstances that indicated the involvement of any third party, and I so find.

9. Recommendations 9.1. I make no recommendations.

Key Words: Death in Custody; Home Detention; Suicide; Pentobarbitone In witness whereof the said Coroner has hereunto set and subscribed her hand and Seal the 22nd day of December, 2022.

Coroner Inquest Number 15/2022 (1717/2020)