Coroner's Finding: Johnstone, Aaron George

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INQUEST INTO THE DEATH OF AARON GEORGE JOHNSTONE [2025] SACC 12 Inquest Findings of her Honour Coroner Giles 20 May 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of a 43-year-old man who died while subject to home detention bail.

Held:

1. Aaron George Johnstone, aged 43 years of Paralowie, died at Paralowie on or about 3 September 2022 as a result of methylamphetamine and heroin toxicity.

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MR D EVANS Hearing Date/s: 11/04/2025 Inquest No: 09/2025 File No/s: 2186/2022

Counsel Assisting: MR D EVANS Hearing Date/s: 11/04/2025 Inquest No: 09/2025 File No/s: 2186/2022

11 12 13 14 15 16 This judgment contains discussion of suicide and may be distressing to some people There is always help available If you need support, contact Lifeline Australia Call 13 11 14 or Text 0477 13 11 14 or chat online at www.lifeline.org.au/crisis-chat Aboriginal & Torres Strait Islander Support Call 13YARN (13 92 76) Kids Helpline Call 1800 55 1800 MensLine Australia Call 1300 78 99 78

INQUEST INTO THE DEATH OF AARON GEORGE JOHNSTONE [2025] SACC 12 Introduction and cause of death Aaron Johnstone was born on 11 April 1979 and died on 3 September 2022 at the age of 43 years.

An external post-mortem examination was conducted by forensic pathologist, Dr John Gilbert, at Forensic Science South Australia. Toxicological analysis of Mr Johnstone’s blood revealed a high, potentially lethal or toxic, level of methylamphetamine (approximately 1.6 mg/L), and the metabolite amphetamine. Also detected were morphine, monoacetylmorphine and codeine in keeping with recent heroin use.

Dr Gilbert concluded that Mr Johnstone died as a result of methylamphetamine and heroin toxicity,1 and I so find.

Reason for inquest Mr Johnstone was on home detention bail at the time of his death. His death therefore amounted to a death in custody, and an inquest into his death was mandatory in accordance with Section 21 of the Coroners Act 2003.

Background and medical history Mr Johnstone was the only child born to Wilma Waters and Kevin Johnstone. They separated when he was approximately 8 years of age and Mr Johnstone then resided with his father. From time to time, he would stay with his mother for periods of up to two weeks.2 Ms Waters later re-partnered and had another child, the half-brother of Mr Johnstone. He also had a stepbrother.

As a young child Mr Johnstone suffered severe asthma and used a ventilator regularly.

This condition subsided by his teenage years.3 At about the age of four he was diagnosed with irritable hips which was corrected mechanically.4 He had no other chronic conditions during his childhood.

Mr Johnstone had been in a relationship with Tyna Brunt for more than 20 years when they separated in 2019.5 They had two children together.

Mr Johnstone had a history of illicit drug use.6 In 2000 he engaged with Drug and Alcohol Services South Australia (DASSA) saying that he wanted to get off heroin and get his life back.7 At that point, he said he was using heroin daily. He commenced buprenorphine detox. In 2004, he again attended wanting assistance to cease drug use and was commenced on the methadone program.8 1 Exhibit C9a at 1 2 Exhibit C15 at 12 3 Exhibit C2 at [3] 4 Exhibit C2 at [4] 5 Exhibit C2 at [8]; Exhibit C15, pages 12-13 6 Exhibit C2 at [9] 7 Exhibit C15, page 5 8 Exhibit C15, page 5

[2025] SACC 12 Coroner Giles In 2010 Mr Johnstone was taken to The Queen Elizabeth Hospital (TQEH) by SAPOL after reporting that he was hearing voices telling him to kill himself.9 He told medical staff that he attempted suicide at age 15, although there are no records of this earlier attempt.10 In 2012 Mr Johnstone was referred to TQEH by DASSA after reporting suicidal thoughts following a break-up with his partner, losing his job and being homeless.11 He was taken into Cramond Clinic after he said he had not hanged himself because he felt guilty about his mother finding him. At this time, he said he had a $700-800 per week addiction. The following day he discharged himself against medical advice.

In July 2015 Mr Johnstone consulted with Dr Rohan Dhillon, a psychiatrist at TQEH, who diagnosed him with partially treated major depressive disorder, polysubstance use and dependence disorder, mixed personality disorder, and complex post-traumatic stress disorder.12 He was prescribed an SSRI;13 venlafaxine.14 In 2017, Mr Johnstone presented to TQEH. He had reported to his general practitioner that he was having suicidal thoughts without firm plans, but with worsening anxiety and auditory hallucinations. At this time he said he had been clean for three years, excluding cannabis.15 He was discharged and reviewed again a month later where he said he was still having paranoid and possibly delusional thoughts, as well as hearing voices. On this occasion Dr Dhillon reached a differential diagnosis of emerging schizophrenic illness related to years of substance abuse.16 Mr Johnstone was commenced on antipsychotic medication.

In October 2020 Mr Johnstone re-engaged with DASSA. He was initially commenced on Suboxone before commencing on a buprenorphine depot in late October 2020.

In November 2020 Mr Johnstone consulted with psychologist Michelle Wharton through Forensic Mental Health. Ms Wharton consulted with him on approximately six occasions, the last being on 11 March 2021. The following month, April 2021, psychologist Kane Drewe took over treatment of Mr Johnstone through Forensic Mental Health. Mr Drewe spoke to Mr Johnstone on the telephone on a number of occasions, however only assessed him in person on one occasion, being 17 May 2021.17 Mr Johnstone reported that his mental health was good and had been for a long time. He reported that he was compliant with his medications. Mr Drewe described that on this occasion Mr Johnstone presented as stable and did not disclose any suicidal ideation, intent or plans.18 Following this initial assessment, Mr Drewe found Mr Johnstone difficult to engage and was only able to speak to him over the phone. They had no further face to face consultations. Mr Johnstone explained that he did not feel comfortable attending at the 9 Exhibit C15, page 5 10 Exhibit C15, page 15 11 Exhibit C15, page 6 12 Exhibit C8, page 2; Exhibit C7 at [7]; Exhibit C15, page 15 13 Selective Serotonin Reuptake Inhibitors – an antidepressant commonly prescribed to treat depression and anxiety 14 Exhibit C15, page 6 15 Exhibit C15, page 6 16 Exhibit C15, page 7; Exhibit C8, page 2 17 Exhibit C7 18 Exhibit C7 at [10]

[2025] SACC 12 Coroner Giles location where Mr Drewe worked, and that his preference was to see a female clinician.19 A referral was made for Mr Johnstone to be seen by a female psychologist at another location, however Mr Johnstone did not consult with that psychologist prior to his death.

In March 2022 Mr Johnstone attended DASSA for his monthly depot injection of buprenorphine. At this appointment he admitted to the fortnightly use of methylamphetamine. That was the last time he attended DASSA for his monthly depot.

Early in 2022 Mr Johnstone commenced a new relationship with Annaika Pondi.20 On 26 April 2022 Mr Johnstone was arrested by police in respect of serious criminal trespass, interfering with a motor vehicle and theft.21 He was released on bail.

On 16 June 2022 Mr Johnstone was arrested for breaching his curfew which was a condition of his bail.22 On this occasion, he was remanded in custody.

On 2 August 2022 Mr Johnstone was released on home detention to live with his grandparents at Paralowie following review proceedings in the Supreme Court.23 He resided in a granny flat at the back of the premises.

Ms Pondi reportedly resided with Mr Johnstone in the granny flat until approximately four days prior to his death, when they reportedly had an argument and Ms Pondi left the premises and did not return.

Events leading to death Mr Johnstone tested positive for amphetamine and methylamphetamine on 19 August 2022 which was in breach of his bail conditions. On 27 August 2022 he was reported for breach of bail.24 On 30 August 2022 he reported to the Department for Correctional Services (DCS) that he had tested positive to COVID-19 and commenced isolation.25 DCS cancelled his regular passouts and tasked themselves to check in on him on 5 September 2022.

At about 6pm on 3 September 2022 Mr Johnstone spoke to his grandmother. He told her that he was thinking about cutting off his home detention anklet.26 She talked him out of it, and he was excited for his children to visit for a Father’s Day barbeque the following day. He locked the front gate as he usually did and retired to his accommodation. A person visited him for a short time at about 6:35pm.27 Mr Johnstone was observed locking the front gates of the property after this person departed.

19 Exhibit C7 at [11] 20 Exhibit C15, page 14 21 Exhibit C15, page 7 22 Exhibit C15, page 7 23 Exhibit C6 at [3]; Bail Agreement dated 2 August 2022 24 Exhibit C6 at [6]; Exhibit C14 at [6] 25 Exhibit C6 at [9] 26 Exhibit C3 at [7]; Exhibit C15, page 8 27 Exhibit C14 at [15]; Exhibit C3 at [11]

[2025] SACC 12 Coroner Giles Shortly after, Mr Johnstone sent a series of messages to Ms Pondi which she forwarded to his cousin, Jamie Johnstone, at 6:47pm. The text messages read as follows: ‘I’m Gona send U a recording soon I’m sorry I have to get rid of this pain I’m sorry I lovr U no joke – it’s m I no I nevr ment to hurt U I hope U can find forgiveness ---’ He sent an image depicting scales with 0.5 grams of a white substance, a syringe, a lighter and an ice pipe with a text as follows: ‘It’s only hg I will b right I thought it might b bit to much to send U recording Im not that cruel it’s the same stuff as last time U can tell its deadley by the colour --- no Mattr wat I always love U just no that my love was eternal --- go C yr son if this doesn’t stop you nothing will xxxxxxx’28 On the morning of 4 September 2022, DCS Intensive Compliance Unit Monitoring Centre received various alerts in relation to a critically low battery in Mr Johnstone’s tracking device. Following no response to calls, DCS officer Scott Jones was tasked to conduct a welfare check on Mr Johnstone.29 When Mr Jones arrived at approximately 9:33am, he found that Mr Johnstone had locked himself inside his accommodation.30 He was able to look through a side window and see that Mr Johnstone was lying face down on the floor not responding.31 An ambulance was called, arriving within 10 minutes.32 A paramedic saw blood pooling in Mr Johnstone’s body. MFS were called to assist with forcing entry.

Paramedics entered and advised police that Mr Johnstone was obviously deceased, and that CPR was not appropriate.33 Mr Johnstone was pronounced life extinct at 10:10am.34 Mr Johnstone was located clenching a used syringe in his right hand with the plunger fully depressed.35 Located on the dining table next to him was drug paraphernalia including a set of scales, a used ice pipe, a tablespoon, a lighter, the cap of a syringe and an empty small plastic ‘deal’ bag.36 The small plastic bag on the table was later analysed at FSSA and found to contain residue of heroin.37 Conclusion and recommendations I find that Mr Johnstone administered methylamphetamine and heroin to himself on 3 September 2022 causing his death. I am unable to conclude whether this was an accidental or deliberate overdose. Though the text messages sent to Ms Pondi could be construed as an expression of intent to end his life, they also contain words that could be construed to the contrary, and the evidence from his grandmother who spoke to him not long before these text messages were sent does not suggest he was suicidal at that time.

28 Exhibit C5 at [3]; Exhibit C5, Annexure A 29 Exhibit C4 at [3]-[4] 30 Exhibit C3 at [13] 31 Exhibit C4 at [7] 32 Exhibit C15c 33 Exhibit C11 at [6]-[7] 34 Exhibit C15c 35 Exhibit C13 36 Exhibit C 11 37 Exhibit C15b

[2025] SACC 12 Coroner Giles I am satisfied that no third party was present at the time Mr Johnstone administered these drugs to himself.

I further find that Mr Johnstone was lawfully detained at the time his cause of death arose.

In all of the circumstances, I make no recommendations.

Keywords: Death in Custody; Home Detention; Drug Overdose