Coroner's Finding: Boon Alison Kim

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 Alison Kim Boon, Find, pursuant to section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is Alison Kim Boon (also known as Fisher-Boon); b) Mrs Boon died in the circumstances set out further in this finding; c) The cause of Mrs Boon’s death was peritoneal sepsis with multiple organ failure; and d) Mrs Boon died on 8 July 2018 at St Luke’s Hospital, Launceston, Tasmania.

Introduction In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mrs Boon’s death. The evidence includes:  Tasmania Police Report of Death for the Coroner;  The opinion of Dr Donald Ritchey, the forensic pathologist who performed the autopsy;  Results of toxicological analysis of samples taken at autopsy;  Affidavit of Dr Karen Richardson, General Internal Medicine Specialist Doctor;  Report of Ms Nishanti Gurusinghe, General and Colorectal Surgeon, Launceston General Hospital;  Report of Miss Amanda Young, General Surgeon, Launceston General Hospital;  Ambulance Tasmania Records;  Affidavit of Mrs Boon’s mother, Ms Marjorie Fisher, sworn 9 July 2018;  Affidavit of Mrs Boon’s brother, Mr Michael Fisher, sworn 10 July 2018;  Affidavit of Mrs Lois Jarvis, a neighbour of Mrs Boon, sworn 31 July 2019;  Affidavit of Lisa Dale Marie Newton, sworn 24 November 2020;  Record of interview with Mrs Boon’s husband and carer, Graham Leslie Boon, conducted on 14 July 2018;  Affidavits of investigating police officers;

 Tasmania Police records;  Medical records and reports;  Report of Dr Anthony J Bell, medical advisor to the Coronial Division; and  Photographic and forensic evidence.

Background Alison Kim Boon was born Alison Kim Fisher in Launceston on 19 November 1966. She was aged 51 years and living with her husband, Graham,1 in the Launceston suburb of Ravenswood at the time of her death.

Mrs Boon was born to Marjorie and Graeme Fisher and she had two siblings. She grew up in and around the Launceston area and attended local schools, except for a three-year period in 1980 where the family lived in Melbourne.

Mrs Boon’s first marriage was many years ago. She had a child, Dharanna.

It is apparent that Mrs Boon suffered significant mental and physical illness. For this reason, she was a long-term recipient of the Disability Support Pension.

Identified as suffering an intellectual disability in childhood, Mrs Boon also suffered bi-polar schizoaffective disorder, which was diagnosed when she was 18 years old. That condition was managed with medication, but Mrs Boon was not always rigorous in her adherence to her medication regime.

In 2015, she underwent surgery and associated treatment for rectal cancer. That condition necessitated her using a colostomy bag. As a consequence, she had a stoma (or opening) in her stomach to enable the bag to be used.

Mrs Boon married Graham Boon approximately 15 years prior to her death. It is not unfair, I think, to describe the marriage as ‘rocky’. Tasmania Police has many records of reports of family violence within the marriage.

Circumstances of Death On 15 May 2018 a crew from Ambulance Tasmania went to Mrs Boon’s home. She was, at the time, complaining of ‘general unwellness and abdominal pain’.2 She was taken to the 1 Mr Boon died in the Launceston General Hospital on 21 November 2020. He had been ill for a long time before that.

2 Ambulance Tasmania Electronic Patient Care Report

Launceston General Hospital and admitted. A CT scan showed the presence of an intraabdominal foreign body sitting just above her bladder.3 Mrs Boon was operated on immediately. An abdominal laparotomy was carried out and the foreign object removed. Her abdomen was washed out and drains put in place. The foreign object was identified as a wooden stick, 11.5 cm in length and about 6 mm in diameter.

The stick had perforated her small bowel, but the perforation was unable to be seen when the first operation was carried out because of significant pelvic adhesions. Mrs Boon was transferred to the Hospital’s Intensive Care Unit (ICU) after surgery.

Because there was no improvement in Mrs Boon’s condition, a second operation was performed on her abdomen. It was during this surgery, after the pelvic adhesions were cleared, that the perforation in her bowel was identified.

Ms Gurusinghe, the surgeon, re-sected Mrs Boon’s bowel. Mrs Boon’s abdomen was left open for 48 hours with a negative pressure dressing. She was regularly returned to theatre for replacement dressings.

Unfortunately, Mrs Boon’s condition did not improve. At no stage was she able to provide a coherent history to her treatment team. She did not tell anyone at the hospital how the stick came to be in her body. She developed sepsis and a decision was made to palliate her. She transferred on 6 July 2018 from the LGH to St Luke’s Hospital for care. At St Luke’s, Mrs Boon was made as comfortable as the circumstances permitted. In the early hours of 8 July she died, without regaining consciousness.

Investigation The fact of Mrs Boon’s death was reported in accordance with the requirements of the Coroners Act 1995.

After her body was formally identified by staff at the Launceston General Hospital, it was taken to the mortuary at the Royal Hobart Hospital. At the Royal Hobart Hospital experienced forensic pathologist, Dr Donald Ritchey, performed an autopsy.

Dr Ritchey did not find any signs of violence or injury. He noted that she had a stoma on the left side of her abdomen that was not in use at the time of her death. Histologic sections of her liver, kidneys and lungs confirm sepsis and multi-organ failure.

3 Report Miss Amanda Young, 28 August 2019.

Following the autopsy, Dr Ritchey provided a report in which he expressed the opinion, which I accept, that the cause of Mrs Boon’s death was peritoneal sepsis with multiple organ failure, due to the perforation of her bowel by a foreign object. 4 Toxicological analysis of samples taken at autopsy was unremarkable. In other words, that analysis did not provide any clue as to why Mrs Boon died or how the stick came to perforate her bowel.

The medical evidence satisfies me, to the requisite legal standard, that the stick was not swallowed and is very unlikely to have been inserted into her abdomen via the stoma. As her anus was, in effect, “closed” when she underwent rectal surgery, the stick could not have entered her body by that route either.

I am satisfied that it entered her body via her vaginal canal.

Mrs Boon’s husband, Mr Graham Boon, was interviewed by detectives on 14 July 2018. That interview was video recorded. I have had the opportunity to watch that video interview. At the time of the interview police considered, with good reason, that the stick had made its way into Mrs Boon’s body by the stoma tube. Mr Boon was asked about that. He told investigators he had no knowledge of that occurring. He was questioned at some length about his wife’s death over a 60 minute period. He was unable to cast any light on her death.

When it became apparent that the stick had entered Mrs Boon’s body by her vaginal canal and not through her stoma, anus or mouth, arrangements were made to interview Mr Boon again.

Unfortunately, he died before that could occur.

Accordingly, even if he knew anything that could be of assistance (and there is no evidence that he did so) that knowledge is no longer available to assist the investigation.

Mrs Boon’s death was investigated as comprehensively as the circumstances allowed. While I am satisfied that the stick which pierced her bowel entered her body through her vaginal canal, I cannot determine whether the insertion of the stick was done by Mrs Boon voluntarily, or by someone else with her consent or by someone else without her consent.

Accordingly, while I am satisfied that her death was caused by the perforation of her bowel and the sepsis that was caused by that, I am unable to make any further findings. I do not consider that any further investigation will cast any light on the circumstances surrounding Mrs Boon’s death.

4 Rule 19 affidavit, Donald MacGillivray Ritchey, sworn 8 October 2018, page 9 of 12.

Comments and Recommendations The circumstances of Mrs Boon’s death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I wish to express my thanks to Detective Senior Constable Dean Logan, who carried out a detailed and thorough investigation into Mrs Boon’s death.

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

Dated 3 February 2021 at Hobart in the State of Tasmania.

Simon Cooper Coroner