Coroner's Finding: Davis, Ross James

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (without inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Stephen Raymond Carey, Coroner, having investigated the death of Ross James Davis Find That: a) The identity of the deceased is Ross James Davis (“Mr Davis”); b) Mr Davis died in circumstances described in this finding; c) Mr Davis died on 6 or 7 November 2013 at Lennox Avenue, Lutana; d) Mr Davis died as a result of complications of intravenous drug use; e) Mr Davis was born in Hobart on 16 March 1957 and was aged 56 years at the time of his death; f) Mr Davis was divorced and the father of three adult children; he was unemployed at the date of his death; and g) No other person contributed to Mr Davis’ death.

Circumstances Surrounding the Death: Mr Davis was previously married to Elizabeth Davis and they had three children, Brett Davis, Casey Davis and Jessica Davis. Mr Davis was long term unemployed, received Commonwealth benefits and had a long term history of illicit drug abuse. In particular Mr Davis had become addicted to opiate medication which had initially been prescribed to him in respect of a chronic pain condition. Mr Davis became a patient of Dr Peter Sexton, from 22 October 2012. He reports that he was treated for severe chronic obstructive pulmonary disease and chronic pain. Mr Davis was a heavy smoker and this exacerbated the poor condition of his lungs. Attempts were made by Dr Sexton to have Mr Davis engage in programs conducted by the Persistent Pain Clinic at the Royal Hobart Hospital, however he refused to do so, and it was reported that all he wanted via that program was approval to use opiate analgesia. It was known that Mr Davis had a history of also using prescribed, or illicit opiate medication intravenously which would have contributed to the poor medical condition of his lungs and the difficulty he suffered with respiration. Dr Sexton advised Mr Davis was addicted to opiates, that he intermittently used illicit drugs obtained from the streets and he was known to inject opiates. He was admitted to the Royal Hobart Hospital on at least two occasions following the IV use of opiates. The last of these occasions was 18 October 2013

when he was required to be ventilated and remained in the High Dependency Unit for three days. The comment of the medical officer at the time noted: “Given that this is Mr Davis’ second presentation with either a cardio or respiratory arrest secondary to opiate overdose, we have encouraged him to refrain from injecting opiates. Mr Davis states that he does not inject opiates with suicidal intent, rather for his chronic pain issues. He seemed somewhat more receptive to the fact that he could easily die if he continues to abuse opiates given his extremely poor underlying respiratory disease. Mr Davis states that his son is going to move in with him to help care for him, he has also refused the offer of services during this admission”.

His family report that Mr Davis was in very poor health in the period leading up to his death, particularly in relation to his respiratory functions.

At some time between 5 and 6pm on 6 November 2014 Mr Davis has spent time with his daughter Casey Davis and her partner Nathan Clark together with their two young children.

At one stage they went to the Kmart, and whilst seated in the car Mr Clark noted that Mr Davis had in his possession a 100mg morphine tablet. That evening Mr Clark and Mr Davis stayed in a rumpus room area downstairs at Mr Clark and Ms Davis’ residence. Both Mr Clark and Ms Davis noted during the evening that Mr Davis appeared “stoned” and tired as he displayed a vague demeanour, his eyes were half shut and at times he slumped forward with his head between his knees. At an approximate time between 11pm to 11.30pm Mr Clark asked Mr Davis if he wanted to go upstairs to sleep. Mr Davis replied that he would be fine and he’d sleep on the couch in the rumpus room. The following morning at approximately 10.30am Mr Clark went down to the rumpus room and found Mr Davis on the couch, he was unresponsive. The alarm was raised, ambulance services contacted and Mr Clark carried Mr Davis upstairs and thereupon commenced CPR under instruction from the 000 operator. Upon arrival of ambulance personnel resuscitation endeavours continued for a short period before it was determined that Mr Davis had died. Police then attended the scene and an investigation conducted during which an amount of drug taking paraphernalia was located, however there were no suspicious circumstances indicated in relation to the death of Mr Davis.

The post mortem examination identified recent needle marks and track marks in the left arm and the toxicology examination of post mortem blood identified morphine being present within the reported toxic/fatal range. The forensic pathologist concluded that: “Autopsy reveals an empyema in the plural cavities with emphysema and some recent needle marks. This man has severe pulmonary hypertension due to IV drug user’s lung (accumulation of injected foreign material from crushed pills) a hypersensitivity myocarditis probably as a response to injected material and a relatively high morphine level. This man’s tolerance to morphine is not clear, but given the heart and lung damage and the pulmonary infarction it is likely to be impaired.” Comments and Recommendations: I have decided not to hold a public inquest hearing into this death because my investigations have sufficiently disclosed the identity of Mr Davis, the date, place, cause of death, relevant circumstances concerning how his death occurred and the particulars needed to register his death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest hearing would elicit any significant information further to that disclosed by the investigations conducted by me.

I wish to convey my sincere condolences to Mr Davis’ family.

Dated: 20 March 2015 at Hobart in the state of Tasmania.

Stephen Raymond Carey

CORONER