Coroner's Finding: KW

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased, family, friends and others by direction of the Coroner) I, Olivia McTaggart, Coroner, having investigated a death of KW Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is KW; b) KW died in the circumstances described below; c) The cause of KW’s death was the combined effects of mixed drug (alcohol and promethazine) toxicity and environmental heat exposure; and d) KW died in December 2017 in southern Tasmania.

In making the above findings I have had regard to the evidence gained in the investigation into KW’s death. The evidence comprises the police report of death; an opinion of the forensic pathologist who conducted the autopsy; the results of toxicological testing; and police and witness affidavits.

KW was born in 1962 and was aged 55 years at the time of his death. He resided with his father and sister. He was separated and the recipient of a disability pension for a neck injury.

He suffered alcohol dependency, often drinking in excess of a cask of wine a day, and was a very heavy smoker. KW was under the care of a general practitioner and was prescribed medication for his pain. He regularly presented at his general practitioner in a state of intoxication. Although his doctors tried to provide advice and referrals regarding his alcoholism, he was not able to reduce his consumption.

KW suffered many falls due to intoxication. Ten days before his death, he suffered a significant fall. He was conveyed to the Royal Hobart Hospital by ambulance. He was assessed as having suffered no serious injury and counselled on a plan to withdraw from alcohol.

On the day of his death, KW was at home with his father and sister. At approximately 9.45am he went into the backyard in order to sunbake on the patio. His sister, SJ, stated that this

was his regular practice, often sunbaking for hours at a time. Temperatures during this particular day were high, exceeding 30 degrees.

At approximately 11.30am, SJ noticed KW lying on the cement outside the back door. She asked him why he was lying there to which he replied “it’s warm” and she left him to continue sunbaking. A few hours later she was at the clothes line and noticed that his hands were moving and that he was playing with a nearby ladder propped against the fence, and therefore she concluded that he was still sleeping.

At about 4.45pm KW’s son, MW, called the home telephone and spoke with SJ. He had been trying to contact his father to advise him that he was on his way to the house for his usual visit. Also with him was his mother, SS, (KW’s ex-partner). SJ advised MW that KW had been sunbaking for 4 to 5 hours in the backyard.

SS and MW arrived a few minutes later and MW immediately went into the backyard. He observed his father laying straight on his back on the concrete patio. His head was towards the fence and was underneath a ladder, which was leaning against the fence. He called out to him and tried shaking him but received no response.

SS checked for a pulse but could not locate one. She telephoned for an ambulance and performed CPR on KW for approximately 10 minutes. KW’s skin was so severely burnt that it was peeling from his body whilst CPR was being performed. Paramedics arrived and immediately determined that KW was deceased.

An autopsy was performed upon KW by State Forensic Pathologist, Dr Christopher Lawrence. At autopsy, Dr Lawrence noted no obvious anatomical cause of death. Toxicology testing of a sample of blood taken at autopsy revealed a blood alcohol level of 0.234mg/L (urine 0.323 g/100ml) as well as high levels of promethazine (an antihistamine). In Dr Lawrence’s opinion, based upon the circumstances of death and blood alcohol level, the cause of death was the combined effects of mixed drug toxicity (alcohol and promethazine) and environmental heat exposure. In support of Dr Lawrence’s opinion regarding the role played by heat exposure, I note that attending paramedics recorded KW’s temperature as being 45 degrees.

Although SJ stated that she did not see KW drink alcohol on the day of his death, in the days prior to his death he had consumed very large quantities of alcohol and had not eaten for two days.

I accept the opinion of Dr Lawrence as to cause of death and find that KW died as a result of alcohol and promethazine toxicity and heat exposure. Unfortunately, KW was in a sedated state by virtue of his alcohol and medication consumption and was not able to wake himself to move out of the heat. As SJ did not see him consuming alcohol on the day of his death,

and given his habit of prolonged sunbaking, it is understandable that she did not appreciate the danger of his situation.

Comments and Recommendations The circumstances of the unfortunate death of KW illustrate the extent of respiratory, cerebral and cardiac depression that is caused by excessive consumption of alcohol, preventing protective responses to dangerous environmental conditions.

I do not make any recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of KW.

Dated: 25 July 2018 at Hobart Coroners Court in the State of Tasmania.

Olivia McTaggart Coroner