Coroner's Finding: Lyons, Matthew Clayton

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the death of Matthew Clayton Lyons, Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is Matthew Clayton Lyons; b) Mr Lyons died in the circumstances set out further in this finding; c) The cause of Mr Lyons’ death was mixed prescription drug toxicity (quetiapine, olanzapine, lorazepam and diazepam); and d) Mr Lyons died between 15 and 23 October 2018 outside the Royal Hobart Hospital, Liverpool Street, Hobart, Tasmania.

Introduction In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Lyons’ death. The evidence includes:

• Police Report of Death for the Coroner;

• An opinion of Dr Donald Ritchey, the Forensic Pathologist who carried out the autopsy;

• The results of toxicological analysis of samples taken at autopsy;

• Letter from Dr Roger Cox – Mr Lyons’ general practitioner;

• Affidavit of Ms Susan Austin – Mr Lyons’ caseworker;

• Affidavit of Mr Craig Doolan – registered nurse;

• Letter from Dr Ben Harwood – locum psychiatrist;

• Affidavit of Dr Paul Francis Lam Cham Kee – confirming Mr Lyons’ life extinct;

• Affidavit of Ms Emily Rist – registered nurse;

• Affidavit of Dr Daya Sadiq – Mr Lyons’ treating psychiatrist;

• Affidavit of Ms Laura Woods – Ambulance Tasmania Paramedic;

• Medical records – Royal Hobart Hospital;

• Medical records – Dr Roger Cox, general practitioner;

• Records – Baptcare – Case file;

• Affidavit of Ms Cassandra Bouteris – Mr Lyons’ sister;

• Affidavit of Ms Sonia Caccavo – Mr Lyons’ girlfriend;

• Affidavit of Ms Hannah Cook – care coordinator – Baptcare;

• Affidavit of Mr Adam Crawford – friend of Mr Lyons;

• Affidavit of Mr Ewan Higgs – senior tenant support officer – Common Ground Tasmania;

• Affidavit of Ms Kay Lyons – Mr Lyons’ mother;

• Affidavit of Mr Jade Munnings – Tenancy and Finance Manager, Common Ground;

• Affidavit of Mr Peter Schnetler – Support Coordinator, Common Ground;

• Affidavit, photographs, interview – Mr Bradley Barr (who found Mr Lyons’ body);

• Affidavits of investigating police officers;

• Mr Lyons’ history of prior convictions;

• Report – Department of Foreign Affairs and Trade – Australian Embassy, Bangkok, Thailand;

• CCTV footage – Common Ground; and

• Forensic and photographic evidence.

Background Mr Lyons was born on 31 January 1971 in New South Wales. Less than a month old, Russell and Kay Lyons adopted him. He was raised in New South Wales and had two younger sisters.

Mrs Lyons is still alive; Mr Lyons died several years ago.

He commenced smoking cannabis as a teenager. Mrs Lyons reports that her son was diagnosed with mental health issues as a teenager and was hospitalised on a number of occasions.

Mr Lyons’ mother and sister, and his medical records, indicate that he moved to the use of heavier drugs including methadone, methylamphetamine and benzodiazepines as an older teenager and younger adult.

It is evident from the affidavits of those that knew Mr Lyons and from his medical records that he battled mental illness for much of life.

Mr Lyons’ formal diagnosis, in the lead up to his death was:

• Schizophrenia;

• Severe anxiety disorder;

• Substance abuse (cannabis); and

• Anxious dependent personality traits.

In the lead up to his death, he was under the treatment of, and receiving support from, a GP (Dr Cox), a psychiatrist (Dr Sadiq) and a mental health caseworker (Ms Austin). Mr Lyons was living in semi-supported accommodation at Common Ground, Campbell Street Tasmania and receiving support from Baptcare as well as treatment from time to time at the Royal Hobart Hospital and treatment and support from the Hobart and Southern Districts Adult Community Mental Health Service.

An interrogation of his medical records indicates several admissions to the Royal Hobart Hospital Department of Psychiatric Medicine.

Recorded in the same records are a number of references to suicidal ideation (but not planning).

On 8 May 2018 during an appointment with his mental health caseworker, Mr Lyons outlined suicidal ideation.

On 31 July 2018 at an appointment with his psychiatrist, he expressed suicidal thoughts.

During an admission to the Department of Psychiatric Medicine at the Royal Hobart Hospital between 25 August and 3 September 2018, Mr Lyons articulated suicidal thoughts. On the day after his discharge from the Royal Hobart Hospital, in a meeting with Ms Austin, Mr Lyons spoke freely about killing himself. He asked Ms Austin “how many tablets he would need to do it properly”. In addition, Ms Austin reported after Mr Lyons’ death that he told her that prior to this admission he had taken between 130 and 140 x 5 mg diazepam tablets.

On the same day – 4 September 2018 – he had an appointment with a locum psychiatrist, Dr Benjamin Harwood. Dr Harwood noted Mr Lyons expressing suicidal ideation (as well as psychosis and paranoia). Dr Harwood’s notes of that consultation expressly record the possibility of self-harm or suicide and Mr Lyons expressed desire to take an overdose.

Mr Lyons’ last admission to the Department of Psychiatric Medicine at the Royal Hobart Hospital was on 4 October 2018. The notes of that admission recorded history of poly substance abuse (amphetamine and cannabis) as well as recent use of methadone and benzodiazepines. Mr Lyons reported feeling paranoid.

Whilst an inpatient during this admission he underwent electroconvulsive therapy.

It was planned that Mr Lyons be discharged on 6 October 2018 but he left the hospital late in the evening of 5 October 2018, prior to his official discharge.

The next morning he flew to Thailand via Melbourne and Singapore. It seems that he had never been out of Australia prior to this trip.

Within 24 hours, Mr Lyons found it necessary to approach the Australian Embassy in Bangkok for assistance. He reported having been robbed and had no money or nowhere to stay.

In the meantime, family and friends, concerned for him, had reported Mr Lyons as a missing person.

By 9 October 2018, Mr Lyons was back in Hobart where he self-presented to the Royal Hobart Hospital Department of Emergency Medicine seeking admission. He told staff that he wished to “jump off the bridge” and complained of anxiety and paranoia.

He spent time in the Royal Hobart Hospital before being discharged the following day, 10 October 2018, without being admitted to the Department of Psychiatric Medicine.

Two days later, on 12 October 2018, he re-presented at the Department of Emergency Medicine, where he again spent the night, before being discharged at 1.40pm on 13 October 2018, again without being admitted to the Department of Psychiatric Medicine.

In the morning of 15 October 2018, Mr Lyons went to the Southern District Adult Community Mental Health Service to see his case manager, Ms Austin. Ms Austin was unavailable, so he met with Ms Emily Rist, one of Ms Austin’s colleagues. Mr Lyons told Ms Rist he was feeling suicidal and wanted admission for respite. She later told investigators that Mr Lyons said he had felt suicidal for a significant period but had no plan for killing himself. Ms Rist attempted to obtain a placement for respite for Mr Lyons. She was unable to secure a bed for him. She described him as being dressed in dirty clothing, appearing unkempt and malodorous. Ms Rist advised Mr Lyons to either go to the Royal Hobart Hospital Department of Emergency Medicine or call an ambulance. Ms Rist also later told investigators that Mr Lyons was upset about the inability to secure a respite bed for him.

It is clear that Mr Lyons’ mental health was extremely problematic in the last months of his life.

At the time of his disappearance and death Mr Lyons was prescribed quetiapine, olanzapine and being trialled with clozapine.

Lead up to Disappearance After the meeting with Ms Rist, Mr Lyons returned to his accommodation at Common Ground in Campbell Street Hobart.

He spoke to Ms Rist later that morning by mobile telephone.

His room was accessed at 1.42pm. Access to rooms at Common Ground is by a personal swipe card. I am satisfied that the access at 1.42pm was by Mr Lyons. I note that swipe cards are not necessary to exit rooms or the building.

CCTV footage from Common Ground shows Mr Lyons in the foyer area of the building at 7.04pm, apparently shortly before leaving the building.

There is no evidence of Mr Lyons being seen alive by anyone after this time.

On 19 October 2018, staff from Common Ground, Mr Schnetler and Mr Munnings checked on Mr Lyons’ bedroom and unlocked the door using a master key but no one was inside the room.

They checked the garage of the building and confirmed that Mr Lyons’ red Holden Barina was parked in the garage, the keys inside it.

Discovery of Body At about 1.45am on 23 October 2018, Mr Bradley Barr was walking along the southern side of Liverpool Street near the intersection with Campbell Street. Mr Barr was then living in a tent on the Queens Domain. It is apparent that he also has mental health issues. Those mental health issues explain his otherwise unusual behaviour but do not, in my view, affect his reliability as a witness.

He later told police he was in the habit of looking for “stuff” that could have been “stashed”.

He noticed disturbed bushes against the wall of the Royal Hobart Hospital near the top of the ambulance ramp to the Department of Emergency Medicine. Thinking that perhaps he would find some “stuff stashed” that might be of some use to him, he looked into the bushes and found Mr Lyons’ body.

The spot where Mr Lyons’ body was found was a matter of a few hundred metres from Common Ground, and a very short distance from the entrance to the Royal Hobart Hospital’s Department of Emergency Medicine.

Mr Barr went straight down the ramp to the Department of Emergency Medicine where he found two paramedics who accompanied him back and confirmed that the body, of a male, was obviously dead.

Police were contacted and arrived a short time later. Officers from Hobart uniform, Forensic Services and the Hobart Criminal Investigation Branch all attended to deal with the discovery of Mr Lyons’ body.

The area was secured, forensically examined and photographed. Mr Lyons’ body was photographed where it had been found, lying on its back with his head on two backpacks.

Articles which helped identify Mr Lyons were located, including Medicare, bank, Link Tasmania and Woolworth’s reward cards, all in his name.

No signs of violence or a struggle were identified by investigating police. No obvious signs of injury to Mr Lyons were located about his body.

Police did not find medication or any empty medication boxes on Mr Lyons’ body or near where it was found.

His mobile phone was also found and seized.

Because of the articles found at the scene, police were reasonably satisfied that the body located was that of Mr Lyons. Accordingly, his room at Common Ground was searched. A number of empty boxes of medication, as well as a significant amount of medication, was found in his room.

Empty boxes of medication found in Mr Lyons’ room included:

• Quetiapine (Seroquel) – 3 empty boxes of 60 tablets – 200 mg;

• Diazepam (Valium) – 1 empty box of 50 tablets – 5 mg;

• Sildenafil (Viagra) – 1 empty box of 12 tablets – 100 mg;

• Olanzapine – 2 empty boxes of 28 tablets – 10 and 20 mg; and

• Rosuvastatin – 1 empty box of 30 tablets – 10 mg.

Actual medication located by police included:

• Olanzapine;

• Quetiapine;

• Prazoson;

• Venlafaxine; and

• Amisulpride.

Forensic Pathology An autopsy was carried out on Mr Lyons’ body by Dr Donald Ritchey, an experienced forensic pathologist, on 23 October 2018. He noted that Mr Lyons’ stomach contained dissolved pill fragments.

Dr Ritchey located no injuries or signs of violence or assault at autopsy.

Samples taken at autopsy were subsequently analysed at the laboratory of Forensic Science Service Tasmania. That analysis showed that the drugs quetiapine, lorazepam, diazepam and olanzapine were all present in Mr Lyons’ body and the levels of quetiapine were found to be within the “reported fatal range”.

I am satisfied to the requisite legal standard that the cause of Mr Lyons’ death was mixed prescription drug toxicity.

Mr Lyons’ body was formally identified by fingerprint comparison performed by a Tasmania Police fingerprint expert. The evidence from that expert, along with the material located with his body, satisfy me to the requisite legal standard that the body located by Mr Barr was that of Matthew Clayton Lyons.

Other Investigations Police carried out a number of investigations to attempt to cast light on the circumstances in which Mr Lyons died. His mobile telephone was forensically examined. Nothing, which provided any assistance in relation to determining the circumstances of Mr Lyons’ death, was found as a result of that examination.

CCTV from the Royal Hobart Hospital was obtained and interrogated. The CCTV from the Royal Hobart Hospital does not show the area where Mr Lyons was located in enough detail to assist in clarifying how it was that he came to be there. CCTV does show Mr Barr on the ramp and then approaching the two paramedics before taking them back to where Mr Lyons’ body was located.

An interrogation of Mr Lyons’ bank records did not provide any evidence which assists in determining the circumstances of his death.

Nothing was located in his room, other than a significant amount of empty medication containers, which assists in relation to determining the circumstances of his death.

Conclusion Mr Lyons had a lifelong well-documented history of mental illness.

In the months leading to his death, his difficulties with mental illness appear to have worsened.

He expressed suicidal ideation to a number of health care professionals and support persons.

He unsuccessfully sought respite care immediately before his disappearance.

There is evidence from which it can be concluded that he may have been stockpiling prescription medication. There is evidence from which it can be concluded that he may have made a previous suicide attempt using prescription medication. Even if he had not, it is apparent that the idea of utilising prescription medication to commit suicide was something that Mr Lyons had seriously contemplated.

However, whilst I suspect Mr Lyons’ death may have been the result of suicide, I am not satisfied on the evidence to the requisite legal standard that the actions which caused Mr Lyons’ death, namely the ingestion by him of prescription medication, was u.ndertaken by him voluntarily and with the express intention of ending his own life.

There is nothing in the nature of a suicide note that was located in the extensive police investigation. More importantly though, Mr Lyons was found not far from the entrance to the Department of Emergency Medicine at the Royal Hobart Hospital, a place where he regularly sought treatment. Accordingly, I cannot exclude, on the evidence, that his death was the result of an accidental overdose of prescription medication.

Comments and Recommendations I acknowledge in particular the work of the principal investigating officer, Detective Constable Jamie Hart in relation to his investigation of Mr Lyons’ unfortunate death.

The circumstances of Mr Lyons’ death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

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

Dated: 17 July 2020 at Hobart in the State of Tasmania.

Simon Cooper Coroner