Coroner's Finding: Parsons, Anna Maree

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 Anna Maree Parsons.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Anna Maree Parsons; b) Mrs Parsons died in the circumstances set out further in this finding; c) The cause of death was unintentional mixed prescription drug toxicity together with advanced lung disease (respiratory bronchiolitis); and d) Mrs Parsons died on 31 May 2018 at Newnham, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mrs Parsons’ death. The evidence includes:  Tasmania Police Report of Death;  Affidavits confirming identification and life extinct;  Opinion of the forensic pathologist regarding cause of death;  Toxicological analysis of Mrs Parsons’ post-mortem blood sample;  Ambulance Tasmania records of attendance upon Mrs Parsons;  Police video interview with William John Parsons, Mrs Parsons’ former husband;  Police video interview with Ian Baldwin, friend of Mrs Parsons;  Court sentencing documentation for Ian Baldwin;  Affidavit of Eric Mark Gul, Mrs Parsons’ half-brother;  Affidavit of Campbell Scott Barnes, acquaintance of Mr Parsons;  Affidavits of 7 attending and investigating police officers;  Civic Square Surgery general practitioner records for Mrs Parsons;  Pharmaceutical Services Branch records relating to Mrs Parsons, Mr Parsons and Mr Baldwin;

 Forensic and photographic evidence, including analysis by Forensic Science Service Tasmania of drug exhibits found the scene; and  Information from Tasmania Police records.

Background Anna Maree Parsons was born Anna Maree Gul on 20 June 1964. At the time of her death, she was aged 53 years and lived by herself in Newnham, Launceston. She had married twice and was divorced in both instances. However, she remained in a close relationship with her second husband, William Parsons. She did not have any children.

Mrs Parsons reportedly had a difficult and traumatic childhood. During her working life, she held various jobs in hospitality. At the time of her death, she was not employed and was in receipt of a disability pension.

Mrs Parsons and William Parsons had a turbulent marriage, both coming to the attention of Tasmania Police on a regular basis from 2011 to 2017 for incidents occurring between them.

Police records indicate that both parties abused prescription medication and were regularly intoxicated with alcohol. There was no recorded physical violence between them in the police records, and I am not required in this finding to consider this issue. They separated in mid-2014 and remained in the same residence for about 12 months before Mrs Parsons moved out into her Newnham home in early 2016. Mr Parsons nevertheless continued to visit Mrs Parsons and they continued to have a sexual relationship.

Mrs Parsons had a long history of medical issues and regularly attended her general practitioner at Civic Square Surgery. Her history included chronic pelvic pain, post-traumatic stress syndrome, back issues, anxiety, depression, panic disorder, cerebral aneurysms and migraine. She had undergone surgery for the aneurysms, had a mental health plan and was prescribed regular medication to address her medical issues.

Mrs Parsons was a long term and heavy smoker and suffered advanced lung disease caused by smoking. She was also a long-term user of illicit and prescription drugs over many years. She was under the care of her regular general practitioner, who regularly prescribed her Endone (oxycodone) and Valium (diazepam) to manage her pain. The prescription of oxycodone as a schedule 8 drug required the approval of the Pharmaceutical Services Branch (PSB).

Mrs Parsons’ chronic pain became more severe in the last six months of her life. She last attended her general practitioner on 11 May 2018 to receive a repeat prescription of her regular oxycodone and diazepam.

In October 2017 Mrs Parsons met Ian Baldwin, aged 64 years, and they became good friends. Mr Baldwin had undergone a full laryngectomy and, as a result, could not speak. For this condition, he was prescribed Ordine 10 (liquid morphine) at a dosage of 10 mls twice per day. He was also prescribed diazepam. His prescription enabled him to collect three 200ml bottles per month.

Mrs Parsons visited Mr Baldwin’s residence regularly and, during some visits, Mr Baldwin gave her “as a gift” a 10ml dose of his Ordine which she would take with no obvious detrimental effects. Mr Baldwin also gave Mrs Parsons diazepam tablets on approximately six separate occasions. Further, Mr Baldwin gave Mrs Parsons, on occasions, jars of Ordine to take home with her to share with Mr Parsons. I note that Mr Parsons had previously been prescribed oxycodone for a chronic pain condition, although the PSB records indicate that, in 2008, this substance ceased to be prescribed. The PSB records for Mr Parsons at that time indicate that his doctor was concerned that he was misusing oxycodone and his prescribed benzodiazepines. It is apparent from police records and from Mr Parsons’ own police interview in this investigation that he continued to use illicit drugs, often in the company of Mrs Parsons.

Circumstances surrounding the Death In the days leading up to her death, Mrs Parsons spent most of her time at her home with Mr Parsons undertaking domestic tasks. On 28 May 2018 Mr Parsons sent a message to Mr Baldwin requesting Ordine for himself and Mrs Parsons. It is unclear upon the evidence whether Mr Baldwin supplied them with any of the substance at that time.

On 31 May 2018 Mr and Mrs Parsons awoke and went about their normal daily routines. Mrs Parsons consumed her prescription dose of Endone and diazepam. At approximately 1.00pm Mrs Parsons, accompanied by Mr Baldwin, attended her scheduled appointment at St Vincent De Paul in Mowbray where she discussed her ongoing financial difficulties. Mrs Parsons was described as upset during the meeting by staff of that organisation. She was provided with food vouchers and a hamper. Staff members also attempted to organise an appointment with her general practitioner, but that was not possible. Instead, a follow-up call was scheduled for later in the week. The staff members dealing with Mrs Parsons at that time did not believe that she was at immediate risk of harm.

Although she suffered mental health conditions, there is no evidence that Mrs Parsons was prone to suicidal ideation. Specifically, in the days before her death there is nothing to suggest that she was contemplating ending her life.

After visiting St Vincent De Paul, Mrs Parsons returned with Mr Baldwin to his home in Kingsmeadows. Mrs Parsons told Mr Baldwin she was in pain. She asked him for and was given 10ml of Ordine. Mr Baldwin supplied a further small jar to take home with her for use by herself and Mr Parsons. No payment was made by Mrs Parsons and Mr Baldwin described it as a gift. Mr Baldwin was with her when she consumed the 10ml Ordine dose at his home. He said that he measured it out for her and that she responded to the drug as she had when he had provided it to her on previous occasions. Mr Baldwin stated that she showed no signs of intoxication and he dropped her home at around 4.00pm.

In contrast, Mr Parsons stated that Mrs Parsons returned home appearing uncoordinated and under the influence of what he surmised to be morphine. Over the next three hours, Mrs Parsons became drowsy and suffered co-ordination issues. Mr Parsons said that she fell off a chair in the lounge room. Mrs Parsons told Mr Parsons that she had Ordine for him, although she did not give the bottle to him until 6.00pm. At that time, Mr Parsons said that the bottle was full and he put it in his bag without consuming any of it. He said that at approximately 7.00pm Mrs Parsons walked upstairs to her bedroom intending to go to sleep. Mr Parsons remained downstairs until he later went to check on her, finding her on the floor next to her bed. He put her into bed and she did not talk to him at that time. He told police in his interview that he checked her a second time and, on that occasion, gave her a shake and found her to still be “coherent”. He said, however, that she also did not talk at that time.

Mr Parsons said that he checked her once again at about 10.00pm, at which time she was lying on her side with “slime” around her and apparently unconscious. He said that he wiped her mouth out and pulled her to the shower to sit her in cold water to try and revive her. This was unsuccessful and he started CPR, which he continued for about 10 minutes. He said that she still had a pulse at that stage, although I cannot determine whether or not this assertion is correct.

He asked the neighbours to phone an ambulance and the call was made at 10.14pm. Ambulance Tasmania paramedics arrived at 10.18pm and Mrs Parsons was determined to be deceased.

Investigation The coronial investigation immediately commenced into the circumstances of Mrs Parsons’ death.

This was led by officers of Tasmania Police, who arrived at 10.45pm to examine the scene and collect exhibits.

An autopsy upon Mrs Parsons was conducted by forensic pathologist, Dr Donald Ritchey, on 4 June 2018. Dr Ritchey observed that Mrs Parsons had no apparent anatomical cause of death but she did have advanced lung disease caused by her heavy smoking (active respiratory bronchiolitis). Dr Ritchey had regard to toxicological testing of Mrs Parsons’ post-mortem blood samples indicating that she had both morphine and diazepam in her system at the time of death.

Dr Ritchey concluded that Mrs Parsons’ death was due to morphine and diazepam toxicity, with a contributing factor being her advanced lung disease caused by smoking. He said that both medications are strong central nervous system depressants and, in this case, their combined toxic effects resulted in respiratory depression and arrest. I accept the opinion of Dr Ritchey as to the cause of Mrs Parsons’ death.

I am satisfied that no suspicious circumstances were involved in Mrs Parsons’ death. I am satisfied that Mr Parsons did not administer morphine or diazepam to Mrs Parsons with or without her consent. Although his account to police was not consistent in all respects, I accept the substance of it as credible. He did not appear to the attending police officers to be affected by substances.

The bottle of Ordine supplied by Mr Baldwin was seized by attending officers at the scene and noted to still be full. It was subsequently analysed and determined to be liquid morphine. It is therefore unlikely on the evidence that Mrs Parsons took any substances at all after she returned home from Mr Baldwin’s residence. Nothing else was found in the house to indicate that this was the case. Two syringe plungers were found with morphine residue from past use. I am also satisfied that Mrs Parsons had no intention of ending her own life and did not deliberately take excessive quantities of substances for this purpose.

It is feasible upon the evidence that Mrs Parsons may have only consumed 10 mls of Ordine (provided by Mr Baldwin at his house) before she died. This quantity, combined with diazepam and her lung disease, could well have been sufficient to cause death. I am not able to determine whether the diazepam in her system was prescribed to her or was provided by Mr Baldwin.

Alternatively, there is evidence to suggest that Mrs Parsons may have taken a further 40-50mls of Ordine from a bottle in Mr Baldwin’s house during the afternoon when he went out to buy cigarettes and she was left alone. Mr Baldwin told police that a quantity was missing. A police search of his house and his remaining Ordine supplies indicated that this may have been the case.

It would explain Mrs Parsons being significantly more affected than she usually was. If she did take his Ordine, I am satisfied that it was without Mr Baldwin’s consent and that he did not encourage her to take it.

I conclude upon the evidence that Mrs Parsons died unintentionally and that no other person was involved in her death.

As a result of the police investigation, Mr Baldwin was charged with supplying Mrs Parsons with Ordine and Valium tablets over a two-month period before her death. He was also charged with selling a controlled drug within the same period to another person and possessing cannabis. He pleaded guilty to the charges in the Launceston Magistrate’s Court. In sentencing on 11 September 2019, Magistrate Cure did not record a conviction and required Mr Baldwin to give an undertaking to be of good behaviour for 12 months.

PSB cancelled the authority to prescribe Schedule 8 substances to Mr Baldwin 5 days after the death of Mrs Parsons.

Comments and Recommendations In this investigation, I obtained evidence concerning the prescribing and supply of Schedule 8 substances to both Mrs Parsons and Mr Baldwin by their respective health professionals. There may or may not have been deficits in practices. I formed the view, however, that any such issues were not sufficiently connected to Mrs Parsons’ death to make further comment in this finding.

I am appreciative of the reports compiled by PSB for this investigation.

I am grateful to Constable Stephenson, investigating officer, for her report.

The circumstances of Mrs Parsons’ death are not such as to require me to make any recommendations pursuant to Section 28 of the Coroners Act 1995.

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

Dated: 11 October 2021 at Hobart Coroners Court in the State of Tasmania.

Olivia McTaggart Coroner