Coroner's Finding: Lindburg, Jason Richard

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Jason Richard Lindburg Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Jason Richard Lindburg.

b) Mr Lindburg was born on 14 December 1971 and was aged 49 years when he died.

He was divorced from his wife and has two adult children with whom he had no contact. Mr Lindburg was unemployed, in receipt of a disability support pension and lived alone in a Housing Tasmania unit in New Town.

Mr Lindburg had a long history of severe mental illness, having been diagnosed with schizopherenia in 1998. Unfortunately, this condition persisted until his death. Mr Lindburg had been subject to orders under the Mental Health Act on two occasions, the last of those orders expiring in 2015. Mr Lindburg was not subject to any other guardianship or administration orders. He did not have a general practitioner, as he refused to see doctors. Mr Lindburg was reclusive and had no contact with any family members and did not have friends. He owned very few personal items, rarely washed, and kept his unit in an unclean and unhygienic state. He had a a poor diet and was a regular smoker. He also regularly consumed alcohol in the form of beer, although the quantities cannot be ascertained. He would leave his unit to go for regular walks and to purchase items from the supermarket. He also recived an injection of paliperidone (an antipsychotic) every 12 weeks at the Carruthers Building in St Johns Park, arranged by the Hobart and Southern Districts Adult Community Mental Health Service. A personal care assistant with that organisation, Mr Jerome Jefferson, would collect Mr Lindburg from his home and transport him to and from St Johns Park to enable his treatment to occur.

On 12 November 2020 at approximatelty 11.00am, Mr Lindburg was collected as usual by Mr Jefferson for his scheduled appointment at St Johns Park. After his injection, Mr Lindburg was returned to his residence at 11.30am. Mr Jefferson said that Mr Lindburg was no different in his behaviour at that time than on any other occasion. This was the last time Mr Lindburg was seen alive. However, his bank records indicate a regular purchase amount from Woolworths on 20 November and it is likely that he was still alive on that date.

On 4 February 2021, when his injection was next due, Mr Lindburg could not be raised by Mr Jefferson who had come to collect him. Mr Jefferson, being concerned for his welfare, contacted police. At 12.30 pm the same day, police officers attended and forced entry to Mr Lindburg’s residence. Mr Lindburg was found deceased by the attending police officers. He was sitting on the floor of the kitchen area against the kitchen cupboard and in a state of advanced decomposition. Although the unit was dirty, there were no suspicious or unusual circumstances detected by the attending officers. Mr Lindburg was identified by fingerprint comparison.

c) I cannot determine the cause of Mr Lindburg’s death. Dr Andrew Reid, who conducted the autopsy, was of the opinion that Mr Lindburg’s cause of death could not be determined due to the extent of decomposition. Dr Reid could not determine any apparent natural cause of death, nor did he see evidence of violence or injury to Mr Lindburg. His antipsychotic medication was detected in his blood, as expected.

However, the prescription medications quetiapine, amitriptyline and citalopram were also detected. The investigation has not been able to uncover evidence about how Mr Lindburg obtained these prescription medications. A small quantity of alcohol was also detected which may have been caused by post-mortem processes, rather than Mr Lindburg having actually consumed alcohol before his death. It is difficult to determine whether the substances found in Mr Lindburg’s system played play any significant role in his death. Dr Reid commented that “Schizophrenic/psychotic patients are known to die suddenly in the context of their underlying mental illness with or without any adverse effects of medication”.

The most likely scenario is that death resulted from an undetermined natural medical condition but I cannot exclude that an excessive quantity of medication, taken

intentionally or unintentionally, may have caused or contributed to death. I am satisfied that he did not die as a result of homicide.

d) Mr Lindburg died between 20 November 2020 and 4 February 2021 at New Town, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Lindburg’s death. The evidence includes:  The police report of death;  An opinion of the forensic pathologist regarding cause of death;  Toxicology report regarding analysis of Mr Lindburg’s post-mortem blood sample;  Affidavit confirming identification and life extinct;  Affidavit of the Forensic Services officer attending the scene, together with photographs;  Affidavit of Felicity Evans, Mr Lindburg’s daughter;  Affidavit of Jemima Peck, Mr Lindburg’s ex-wife;  Affidavit of Jerome Jefferson, a personal care assistant for Southern Districts Adult Community Mental Health Service;  Affidavit of Leo Ringrose, Mr Lindburg’s neighbour;  Affidavit of attending and investigating police officers; Constable Miranda Walsh, Sergeant Bernadette Heyward, and First Class Constable Josie Crowden;  Body worn camera footage from attending officers; and  Mr Lindburg’s medical, housing and bank records; Comments and Recommendations I have not been able to determine the circumstances of Mr Lindburg’s death, despite a thorough investigation. Despite his illness, Mr Lindburg was able to make decisions and had capacity to manage his day-to-day living requirements. Numerous support and medical services had been offered to him but he refused all of them (except his injections), as he was entitled to do.

I extend my appreciation to investigating officer Constable Miranda Walsh for her very competent investigation and report.

The circumstances of Mr Lindburg’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 convey my sincere condolences to the family of Mr Lindburg.

Dated: 18 November 2021 at Hobart Coroners Court in the State of Tasmania.

Olivia McTaggart Coroner