Coroner's Finding: McKinley-Glen, Haydn James

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign King at Adelaide in the State of South Australia, on the 19th day of March and the 13th day of September 2024, by the Coroners Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Haydn James McKinley-Glenn.

The said Court finds that Haydn James McKinley-Glenn aged 22 years, late of Spry Support Services, 14 Wattle Crescent, Munno Para West, South Australia died at Munno Para West, South Australia on the 1st day of March 2022 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. Haydn James McKinley-Glenn was born on 5 November 1999 and died on 1 March 2022 at the age of 22 years.

1.2. Following a post-mortem examination comprising external examination, CT scan and toxicology, the suggested cause of death given by forensic pathologist, Dr Karen Heath of Forensic Science South Australia, was ‘neck compression due to hanging’,1 which I find to be the cause of Mr McKinley-Glenn's death.

2. Reason for inquest 2.1. As at the time of his death, Mr McKinley-Glenn was under a guardianship order with special powers of detention pursuant to Section 32(1)(b) of the Guardianship and Administration Act 1993, and his cause of death is not a natural cause, an inquest is mandatory pursuant to Section 21 of the Coroners Act 2003.

1 Exhibit C2a

3. Background and medical history 3.1. Mr McKinley-Glenn was born in South Australia to Alicia Eileen Ely and James Michael Glenn (aka McGrath), who separated shortly after Mr McKinley-Glenn was born.

3.2. As a child, Mr McKinley-Glenn was healthy with no known health or developmental problems. He lived with his mother and stepfather and was reportedly doing well in school until his mental health began to decline from the age of about 15 years, after which his mother sought the help of a psychologist.

3.3. As he approached 16 years of age, Mr McKinley-Glenn’s behaviour became more erratic and violent and, at 17 years, he was twice arrested for assaults on family members. Shortly afterwards he began living in assisted accommodation.2

3.4. Mr McKinley-Glenn was diagnosed with treatment resistant schizophrenia. As a result of his condition, he held some unusual beliefs regarding his health which made his treatment more difficult. He also suffered from delusions, impaired self-care and poor motivation.

3.5. Mr McKinley-Glenn was prescribed various medications over the years in an effort to treat his schizophrenia. In 2019 he was placed under a community treatment order and commenced on three-monthly paliperidone injections, which were still being administered at the time of his death. He was also prescribed quetiapine and perindopril.

3.6. Throughout his adult life, Mr McKinley-Glenn maintained regular contact and had regular appointments with his mental health team.3

4. SACAT order 4.1. On 20 June 2019 an application was heard by the South Australian Civil and Administrative Tribunal (SACAT) for an administration and guardianship order. The Tribunal found that Mr McKinley-Glenn had a mental incapacity and that an administration order should be made. It ordered that the Public Trustee be appointed as full administrator of the estate of Mr McKinley-Glenn. The Tribunal also ordered 2 Exhibit C6 3 Exhibit C8

the Public Advocate be appointed as limited guardian of Mr McKinley-Glenn, and the duties of the guardian were limited to matters concerning accommodation.

4.2. An application for a guardianship order with special powers under section 32(1) of the Guardianship and Administration Act 1993 was heard by SACAT on 5 January 2021 and special powers to order residence and detention were granted. These were reviewed and confirmed on 2 July 2021 and were valid as at the time of Mr McKinley-Glenn’s death.

5. Accommodation 5.1. Over the years Mr McKinley-Glenn lived in various assisted living facilities, but on 16 September 2021 he commenced care in the form of supported independent living with Spry Support Services at an address in Munno Para West. This was funded through the National Disability Insurance Scheme (NDIS).

5.2. Mr McKinley-Glenn lived with two housemates, with 24-hour support, including with passive night care.

5.3. Although there was a special powers order in place, Mr McKinley-Glenn was never detained on a permanent basis and was able to leave his place of residence with the knowledge and support of his carers.

5.4. Prior to residing with Spry Support Services, Mr McKinley-Glenn had been living in a rehabilitation centre where he reportedly felt that his care workers did not like him and bullied him. According to his long-term social worker Ms Sarah Erskine, this likely played on his feelings of isolation and rejection, which he had been experiencing since the onset of his schizophrenia symptoms. Mr McKinley-Glenn had moved out of that accommodation approximately six months prior to his death.

6. Circumstances leading to death 6.1. Mr McKinley-Glenn had few social networks and limited contact with family since his diagnosis. Also, in the weeks prior to his death, Mr McKinley-Glenn had been required to isolate for a number of weeks during which he and his housemates had COVID-19 or were close contacts. This likely caused feelings of isolation and loneliness.

6.2. On 4 February 2022, Mr McKinley-Glenn approached a carer and informed them he had attempted to drink bleach, as he no longer wanted to live. Carers contacted the poisons hotline, first aid was given and Mr McKinley-Glenn was conveyed to the Lyell McEwin Hospital where he was treated and assessed, but not detained. He was released back into the care of Spry Support Services the next day. This incident was referred to his ongoing mental health support workers.

6.3. Mr McKinley-Glenn was also involved in a traffic accident in the weeks preceding his death. Although he had only had occasional contact with his biological father, he visited him on 15 February 2022. At about 5:40pm that day, police attended a vehicle collision on Woodford Road at Elizabeth North. A vehicle driven by Mr McKinleyGlenn’s biological father had swerved into traffic and collided head-on with another vehicle. Mr McKinley-Glenn was a passenger in the vehicle. Mr McKinley-Glenn’s father was reported for driving related offences. Evidence suggests that Mr McKinleyGlenn was very concerned after this accident and seemingly had concerns that he may be going to gaol as a result of this incident.

7. Date of death 7.1. On Tuesday 1 March 2022 at approximately 8am, Mr McKinley-Glenn’s carer, Kishor Sunar, gave him his medication and he appeared to return to sleep. Mr Sunar said there was no indication of anything out of the ordinary with Mr McKinley-Glenn at this time.

7.2. At approximately 9am, Mr Sunar left the house with another resident, leaving Mr McKinley-Glenn in bed and another resident in his own bed. No other persons were at the house.

7.3. When the other resident woke up he saw through the back glass sliding door that Mr McKinley-Glenn was hanging from a rope tied to the pergola. He did not go outside but went to the office where there was no answer when he knocked on the door. He went out the front and saw Mr Sunar returning, then immediately reported what he had seen.

7.4. Mr Sunar stated that he returned to the house at about 10:50am and was met in the driveway by the other resident. Upon hearing what the other resident had seen,

Mr Sunar went to the back of the house, and saw Mr McKinley-Glenn through the rear glass door, hanging by his neck and clearly deceased. An ambulance was called.

7.5. At 11:06am police and paramedics attended the scene. At 11:18am Mr McKinleyGlenn was pronounced life extinct by paramedics.

7.6. Police later searched Mr McKinley-Glenn’s devices and his computer revealed a number of searches consistent with him having had suicidal ideation for some months prior to his death.

7.7. Police also located a cannabis ‘bong’ in Mr McKinley-Glenn's bedroom. He was known to smoke cannabis at times, but there was no cannabis located and no other evidence that he had recently smoked cannabis.

8. Conclusion and recommendation 8.1. I agree with the conclusion of the investigating officer that Mr McKinley-Glenn was under a lawful guardianship order with special powers at the time of his death and that the circumstances surrounding his death are not suspicious and do not indicate the involvement of any third party.

8.2. The investigating officer concluded that the care provided by the carers at the facility appears to be of a high quality and that Mr McKinley-Glenn’s medication and mental health condition were monitored closely until the time of his death. I agree and so find.

8.3. I make no recommendations.

Key Words: Death in Custody; Section 32 Powers; Suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 13th day of September, 2024.

State Coroner Inquest Number 20/2024 (0504/2022)