Coroner's Finding: Bruns, Corbus Kenneth

ORONERS 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 27th day of April and the 15th day of August 2022, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Corbus Kenneth Bruns.

The said Court finds that Corbus Kenneth Bruns aged 64 years, late of 6 Hoylake Arcade, Stirling, South Australia died at Stirling, South Australia on the 16th day of May 2019 as a result of sodium nitrite poisoning. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for inquest 1.1. Corbus Kenneth Bruns was born on 1 October 1954 and died on or about 16 May 2019.

He was 64 years of age and was known as ‘Ken’.

1.2. This inquest into Mr Bruns’ death was a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mr Bruns was on home detention bail at the time of his death. His death is deemed to be a death in custody as defined by section 3 of that Act.

1.3. By way of background, Mr Bruns was remanded in custody on 19 October 2018 in relation to an allegation that he had attempted to murder his wife, Mrs Kim Bruns. He was released on home detention bail with electronic monitoring on 13 November 2018.

1.4. His bail address was the home of his son, Daniel Bruns, who resided at 6 Hoylake Avenue, Stirling with his mother, Joanne Packham. Ms Packham and Mr Bruns had divorced in about 1980.

2. Circumstances surrounding Mr Bruns’ death 2.1. At the time of Mr Bruns’ release on home detention bail, Ms Packham resided in an annexe at the rear of the house. Mr Bruns slept in a bedroom at the front of the house but spent most of his time in a shed at the rear of the property, which had been converted into a room.

2.2. At about 7pm on 16 May 2019, Mr Bruns had a minor argument with Ms Packham about the dishes. Ms Packham had told Mr Bruns to place the dishes in the dishrack to dry. Mr Bruns said that that was not nice and went back to the shed.

2.3. The following morning, Ms Packham asked her son to check on Mr Bruns as she noticed that his bed did not appear to have been slept in, and he had not answered her knock on the door of the shed.

2.4. Daniel Bruns found his father lying on the lounge. He did not appear to be breathing.

He was cold to the touch and his face was grey in colour. Daniel Bruns went outside to tell his mother that his father had passed away.

2.5. Daniel Bruns and Ms Packham returned together to the shed. They located an envelope on the printer addressed to ‘The Authorities’. In the centre drawer of the desk there were two more letters, one addressed to his wife, Kim Bruns, and the other to his son.1 Daniel Bruns read the letter to ‘The Authorities’ and recognised the handwriting to be that of his father.

2.6. An ambulance and the police were called. Senior Constables Barney2 and Bartle arrived at the scene at 12:15pm. By that stage the ambulance officers had already attended and declared life extinct at 12:05pm.

2.7. In the shed police located a number of items relevant to the death of Mr Bruns.3 An Australia Post express post label and a packaging slip relating to the purchase of sodium nitrite were found in the bin next to the desk.4 Both the invoice and the express post label were addressed to Ken Bruns. The sender was listed as ‘Back to Basics Artisan Supplies, Leanne, Forrestfield WA’. There was no date on either item.

1 Exhibit C10, MC10 2 Exhibit C8 3 Exhibit C10 4 Photographs of express post label and packaging slip - MD2

2.8. A glass containing a teaspoon, a small amount of clear liquid and the remnants of a powdered substance was on the desk. Chemical analysis was later undertaken of these three items. This confirmed that the substance was sodium nitrite.

2.9. A packet labelled ‘sodium nitrite technical grade 100g’ was located in the centre drawer of the desk. The packaging was marked with three different company names - Home Chemistry PO Box 263 Armdale 6992’, Homebrewing.com.au and Facebook/TheHomeChemistryShop.

2.10. Police also located two cylinders of food grade dry nitrogen, unused. One cylinder was in a box underneath the desk, and the other was in the boot of a car belonging to Mr Bruns.

2.11. Information provided to police by Kim Bruns indicates that Mr Bruns had spoken of gas assisted suicide several years ago and had attended meetings related to euthanasia hosted by Dr Philip Nitschke. I note that as of 2017, Dr Nitshcke’s book The Peaceful Pill included a chapter on lethal inorganic salts, including sodium nitrite.

3. Medical history 3.1. Mr Bruns had a documented past history of depression. He suffered from type 2 diabetes mellitus, obesity, hypogonadism5 and high blood cholesterol.

3.2. Mr Bruns was a patient at Greenwith Family Health from January 2013 until September

2018. The records from that practice reflect that Mr Bruns suffered from anxiety and stress, and was first prescribed Lexapro on 9 August 2018.

3.3. As of December 2018, Mr Bruns was a patient of Dr Winn, a general practitioner practising at the Bridgewater Medical Clinic. At his first appointment on 5 December 2018, Dr Winn ordered blood tests and prescribed various medications for diabetes, blood pressure and testosterone deficiency.

3.4. At his next appointment on 12 December 2018, Dr Winn prescribed the antidepressant Lexapro6, and Circadian, a natural sleep medication. Dr Winn also completed a mental health plan with Mr Bruns, and noted that while he was clearly unhappy, he denied any suicidal intent and did not have any acute indicators of suicidal intent.

5 Diminished functional activity of the gonads, resulting in reduced production of testosterone 6 The generic name of Lexapro is escitalopram oxalate - it is a selective serotonin reuptake inhibitor used to treat depression and anxiety

3.5. On 28 December 2018, Dr Winn referred Mr Bruns to psychologist Silvana Savvy.

Dr Winn prescribed Stilnox7 on this date.

3.6. Mr Bruns attended an appointment with Ms Savvy on 22 January 2019. He told Ms Savvy that he had been taking Lexapro for a couple of years but stopped that when he was in prison.

3.7. He reported suffering from depression since the death of his best friend and the loss of his job at 26 years of age. He also spoke of a traumatic incident that occurred when he accidentally killed a pedestrian at age 19. Mr Bruns appeared uneasy and agitated when he recounted the alleged attempted murder of his wife. He made a follow-up appointment for 14 February 2019. He did not attend or cancel this appointment.

3.8. Dr Winn next saw Mr Bruns on 5 February 2019. She made a note that Mr Bruns was ‘pretty much suicidal’. He reported to her that he did not find his consultation with Ms Savvy to be helpful but agreed that a different psychologist might be more helpful.

On this occasion, Mr Bruns denied any suicidal intent, so Dr Winn did not take steps to detain him under the Mental Health Act. She did however discuss hospitalisation and detention with Mr Bruns. Mr Bruns agreed to continue having regular appointments with Dr Winn.

3.9. Dr Winn last saw Mr Bruns on 19 February 2019. He reported that he wished that he could have a heart attack. On that occasion, Dr Winn completed a referral for Mr Bruns to see Mrs Cheryl Aherns, a forensic psychologist. The Offender Case Notes from the Department for Correctional Services (DCS) indicate that Mr Bruns was on the waiting list for a psychological appointment as of 1 April 2019.8 Dr Winn did not consider Mr Bruns to be detainable on this occasion as there was no indication that he was actively suicidal.

4. Cause of death 4.1. Dr Gilbert, a forensic pathologist at Forensic Science South Australia (FSSA), conducted a post-mortem examination on 21 May 2019 and provided a written report of his findings.9 He determined the cause of death to be sodium nitrite poisoning, and I so find.

7 Stilnox (zolpidem tartrate) is indicated for short term treatment of insomnia 8 Exhibit C5 9 Exhibit C3

4.2. Sodium nitrite is an inorganic salt used for a variety of legitimate purposes in Australia, including curing meat, baiting feral pigs, as an anti-corrosive agent, and medically to treat cases of cyanide poisoning. Sodium nitrite has been suggested as a means of suicide.10 It can be toxic to humans, resulting in methaemoglobinemia.11

4.3. FSSA does not have validated methods for the analysis of sodium nitrite in body fluid, or the quantification of methaemoglobin. However, the findings on autopsy were consistent with sodium nitrite poisoning, and no other significant natural disease was identified. Dr Gilbert noted that the body of the deceased was an unusual greyish colour. This correlated with the presence of dark brownish discoloration of the blood and internal organs. Nitrites were also detected by dipstick testing of the vitreous humour and gastric contents.

4.4. Toxicological analysis of post-mortem samples identified the presence of metoclopramide, paracetamol and zolpidem. Zolpidem is commonly known by the brand name Stilnox.

4.5. Metoclopramide is an antiemetic drug commonly used for the control of nausea and vomiting. Detection of metoclopramide is consistent with advice given by advocates of voluntary euthanasia, that people using sodium nitrite in suicide take an antiemetic first to reduce the risk of the salty solution being vomited after ingestion.

4.6. The post-mortem observations of Dr Gilbert, combined with the items found at the scene, indicate clearly that Mr Bruns died as a result of intentional sodium nitrite poisoning and I so find.

5. Sodium nitrite 5.1. A report prepared by the National Coronial Information System dated April 2022 indicates that the first reports of sodium nitrite or sodium nitrate contributing to death occurred in 2017.12 Since 2017 there have been a total of 106 such deaths nationwide.

The frequency of deaths related to sodium nitrate or nitrate increased from 4 in 2017, to 35 in 2020. This increase suggests a concerning trend in the use of sodium nitrite as a means of suicide. However, there were only 20 cases reported nationwide in 2021, and two cases reported this year. While this appears to be a comforting decrease in 10 The Peaceful Pill eHandbook from 2017 includes a chapter entitled Lethal Inorganic Salts 11 This condition is associated with significant impairment of oxygen transport mechanisms, leading to loss of consciousness 12 Exhibit C16

deaths involving sodium nitrite, the report writer urges caution in the interpretation of these figures. In the report she notes that it is possible that open cases of relevance were unable to be identified due to the manner in which cases are reported to the NCIS.

5.2. In response to the increase in deaths associated with sodium nitrite, amendments have been made to the legislative and regulatory restrictions on the sale of sodium nitrite.

The Therapeutic Goods Administration has made an interim decision to amend the Poisons Standard as it relates to sodium nitrite. Those amendments have an implementation date of 1 June 2022.

5.3. The Poisons Standard is a legislative instrument classifying medicines and poisons into Schedules for inclusion in relevant legislation of the States and Territories. The schedule of a substance determines how the product may be sold or supplied, the labelling and storage of the product and requirements for record keeping.

5.4. In South Australia, the schedules are adopted under the Controlled Substances (Poisons) Regulations 2011. Substances listed under Schedules 1 to 8 and Schedule 10 are declared poisons pursuant to Regulation 5. The changes to the Poisons Standard will have the effect of further restricting the availability of sodium nitrite.

5.5. Substances containing 15% sodium nitrite or less will be regulated by Schedule 6.

Schedule 6 restrictions currently only apply to preparations containing 40% or more of sodium nitrite.

5.6. Preparations containing more than 15% sodium nitrite will be regulated by Schedule 7.

The Controlled Substances Act imposes a number of restrictions on the sale, supply, and storage of Schedule 7 poisons.13

5.7. Section 15 of the Controlled Substances Act restricts the sale of Schedule 7 poisons to health practitioners, veterinary surgeons and retailers who have obtained a licence from the Minister14. Sale of a Schedule 7 poison in other circumstances is an offence punishable by a fine of up to $10,000.

5.8. Section 16 sets out further requirements for the sale of a schedule 7 poison. Pursuant to section 16, a retailer may only supply a Schedule 7 poison to a person who is over 13 See also Controlled Substances (Poisons) Regulations 2011, r 12, 15, 25, 27(1), 27(d), 30 and 49.

14 The responsible Minister is the Minister for Health and Wellbeing

18 years old, is known to the licensee or can provide evidence of identity, and provides a satisfactory answer when asked the purpose for which they are purchasing the poison.

The purchaser must also hold a current chemical user accreditation card or pesticides licence, or be the nominated agent for an accredited person.

5.9. The sodium nitrite obtained by Mr Bruns was labelled ‘technical grade’ and branded ‘The Home Chemistry Shop’.15 Forensic Science South Australia does not have the necessary equipment to analyse the purity of sodium nitrite as there are other salts which may not be detected. However, as set out in the addendum statement of Detective Brevet Sergeant McClean, the analyst opined that the substance was predominantly sodium nitrite, indicating that it was over 50%.16 Further, on the ‘Aussie Brewing’ website as at 22 May 2019, technical grade sodium nitrite was advertised as being ‘filler free’, suggesting it was close to pure. It is probable that the substance obtained by Mr Bruns was a Schedule 7 poison. Accordingly, Detective McClean made a number of enquiries in relation to the Home Chemistry Shop.

5.10. In his report, Detective McClean states that the substance was purchased via the internet from a website with the address of www.aussiebrewing.com.au.17 His enquiries revealed that the company is based in Western Australia and is promoted variously as ‘Aussie Brewing and Chemical Supplies’, ‘Back to Basics Artisan Supplies’, and ‘The Home Chemistry Shop’. The express post label indicated that the sender was ‘DeGralla, PO BOX 367’, and also ‘Back to Basics Artisan Supplies, Leanne.’

5.11. Material obtained as a result of a coronial direction to the WA Department of Health established that the company did not hold the necessary licence to sell Schedule 7 poisons.18 Of note, the owners of Aussie Brewing, Leanne and David DeGraff, were investigated by WA Health in May 2019, and directed to cease all sales and advertising of Schedule 7 poisons, including sodium nitrite. The documents also included photographs of sodium nitrite sold by the company as technical grade, the labelling indicating that the substance was at least 99% pure.

5.12. I find that Mr Bruns was able to obtain a Schedule 7 poison without difficulty from a company which was not licensed to sell it. While that clearly should not have occurred, 15 Exhibit C9a, page 11 16 Exhibit C10c, paragraph 5 17 Exhibit C10, page 15 18 Exhibit C10c

the WA Department of Health has taken action in relation to this company, and there has been legislative reform restricting access of this chemical. For these reasons, I do not consider it necessary to make recommendations in relation to the availability of sodium nitrite.

6. Mr Bruns’ involvement with the Department for Correctional Services 6.1. Mr Bruns was supervised by DCS Community Corrections Officer Paul Crocker from 15 November 2018 until his death.19 During that time Mr Crocker saw Mr Bruns at his office on 17 occasions and spoke to him regularly on the telephone. Mr Crocker encouraged Mr Bruns to see a psychologist. He has stated that Mr Bruns did not present in any way as suicidal in his dealings with him. Mr Crocker last spoke with Mr Bruns by telephone on 8 May 2019.

6.2. The Offender Case Notes indicate that DCS officers attended the residence of Mr Bruns on 12 and 15 May 2019 in relation to issues with the electronic monitoring. On 15 May 2019 they found him working in the back yard of the premises.

6.3. Mr Crocker was proactive in assisting Mr Bruns to seek psychological help. I make no criticism of the manner in which he supervised Mr Bruns. Further, I do not have any criticism of the psychologists who attempted to assist Mr Bruns. Dr Winn considered detaining Mr Bruns pursuant to the Mental Health Act but did not do so as he did not meet the criteria.

6.4. I note however that Mrs Kim Bruns (now deceased) expressed some concerns regarding the supervision of Mr Bruns. She advised Detective McClean that she had told both the police and DCS that Mr Bruns had threatened suicide. There are no records establishing that either organisation received this information.20 This information does not appear in the notes of Mr Crocker.

6.5. There is a record of an email sent from Mrs Bruns to Detective Brevet Sergeant Alan Graham on 15 April 2019 in which she advised that a lady by the name of Ms Leanne Sammut had telephoned and told her that Ken was in a ‘very bad way’.21 The effect of the email is to express concern about the nature of the contact from Ms Sammut and, in particular, whether it amounted to a breach of Mr Bruns’ home detention bail 19 Exhibit C5 20 Exhibit C10b, paragraph 5 21 Exhibit C10b, Annexure RM1

conditions. I do not suggest that the information provided in that email should have prompted police to take urgent action to check on the welfare of Mr Bruns.

6.6. Detective McClean opines that the supervision of the deceased by DCS during the period of home detention bail was adequate and appropriate. I agree with Detective McClean on this issue and I so find.

6.7. Detective McClean received information that a third party may have offered to assist Mr Bruns to commit suicide if he were prepared to sign over his estate. That information was not able to be verified in any way. Further, it is clear on the evidence that Ms Bruns did not require any assistance to obtain the sodium nitrite. Further, the letters he wrote to his son, his ex-wife, and his wife all express concern that they may be angry with him for taking his life.

7. Conclusions 7.1. I find that the Mr Bruns’ ended his own life by ingestion of a lethal dose of sodium nitrite. I further find that no other party was involved in the death of Mr Bruns.

7.2. I make no recommendations in this matter.

Key Words: Death in Custody; Home Detention; Poisoning; Suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 15th day of August, 2022.

State Coroner Inquest Number 08/2021 (0989/2019)