Coroner's Finding: Mordha, Debra Christine

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Duncan Fairley, Coroner, having investigated the death of Debra Christine Mordha Find that: a) The identity of the deceased is Debra Christine Mordha; b) Ms Mordha died in the circumstances set out further in this finding; c) Ms Mordha died as a result of mixed drug toxicity; d) Ms Mordha died on 23 August 2015 at Unit 1/1 Pleasant Street Burnie; e) Ms Mordha was born in Smithton, Tasmania on 20 May 1957 and was aged 58 years; f) Ms Mordha was divorced and was a retired nurse at the date of her death.

Background: Debra Christine Mordha was one of 10 children born to Geoffrey David Moore and Shiela May Moore. Ms Mordha was raised in Smithton and completed year 10 before moving to Burnie in order to study nursing. She qualified as a Registered Nurse and worked at the Burnie Hospital before marrying in 1978 and leaving employment prior to the birth of her only child, Kalon Dru Salter.

Shortly after the birth of her child Ms Mordha relocated with her family to Papua New Guinea, where her husband was engaged as a pilot. It is apparent that the marriage struck difficulty at an early juncture with Kalon and Ms Mordha returning to Tasmania in the early 1980s. Ms Mordha divorced soon after. She never remarried, however, decided to change her surname by deed poll to Mordha in or about 1982.

During the late 1990s Ms Mordha was diagnosed as suffering from a chronic endocrine condition known as Addison’s disease. Subsequently, her physical health deteriorated and as at 2015 Ms Mordha’s general practitioner, Dr Marinovic-Stiller, recorded that she also suffered from Addison’s associated adrenal issues, chronic pain subsequent to laparoscopic gallbladder surgery in 2004, high blood pressure, asthma, chronic headaches, transient ischaemic attacks, a thyroid disorder and regular episodes of depression. A MRI scan conducted in November 2014 revealed

evidence of a previous minor stroke. She was under the care of a number of specialist practitioners and required multiple medications to manage her conditions.

Due to her multiple illnesses and chronic pain condition Ms Mordha was unable to continue with her employment as a nurse. As a result she was not able to meet her mortgage payments and shortly prior to her death moved to Unit 1/1 Pleasant Street, having previously lived at 2 Harrison Street Burnie.

Circumstances Surrounding the Death: On Friday 21 August 2015 one of Ms Mordha’s borthers, Terence Moore, attended Unit 1/1 Pleasant Street, as he did regulary of a Friday. He dropped off a number of personal items and spoke briefly with his sister. According to Mr Moore she appeared quite ill and remained in bed throughout the visit. Ms Mordha asked her brother to obtain a number of grocery items on her behalf. He left her address and did not speak to Ms Mordha again.

On Sunday 23 August 2015 Mr Moore received a telephone call from the Red Cross advising that they had been unable to contact Ms Mordha. The Red Cross provided a service whereby they would contact Ms Mordha on a daily basis.

As a result of the telephone call Mr Moore attended at Unit 1/1 Pleasant Street but was initially unable to gain entry to the house. He subsequently gained entry via an open window at the front of the property. Upon entering the lounge room Mr Moore found Ms Mordha laying face down.

Mr Moore immediately contacted the Tasmanian Ambulance Service who provided advice via telephone until paramedics arrived on scene. Richard Chapman (Intensive Care Paramedic) attended and after an initial examination declared Ms Mordha was deceased. Due to a lack of any signs of life there was no attempt at resuscitation.

Police attended and took possession of, amongst other items, Ms Mordha’s prescription medication. Investigating officers noted that there did not appear to be any suspicious circumstances surrounding Ms Mordha’s death.

The circumstances of Ms Mordha’s death meant that an investigation pursuant to the Coroners Act 1995 was required. As part of that enquiry Dr Terence Brain (Pathologist) conducted a post mortem examination. Dr Brain expressed the opinion that the cause of Ms Mordha’s death was the combined effect of mixed drug toxicity.

I accept that opinion. The drugs identified as a consequence of the analysis of samples taken during the post mortem examination included tramadol, amitriptyline and venlafaxine, all of which were found in concentrations above the theraputic range. Each of these medications are serotonegic drugs and may, when used in combination, cause the development of serotonin syndrome. Diazepam was found in

the samples analysed at theraputic levels, however, I note that in combination with other central nervous system depressants the sedative effects of diazepam may be enhanced.

I am satisfied that Ms Mordha died in the circumstance set out in this finding.

Comments and Recommendations: In the circumstances there is no need for me to make any further comment or recommendations.

In concluding, I convey my sincere condolences to the family of Ms Mordha.

Dated: 23 January 2017 at Launceston Coroners Court in the State of Tasmania.

Duncan Fairley Coroner