Coroner's Finding: Linklater, Brian Gary

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 Brian Gary Linklater Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Brian Gary Linklater; b) Mr Linklater died in circumstances set out further in this finding; c) The cause of Mr Linklater’s death was mixed drug and alcohol toxicity (pentobarbitone1 and ethanol); and d) Mr Linklater died on 6 October 2020 at 125 Windermere Road, Windermere in Tasmania.

Introduction

1. In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Linklater’s death. The evidence includes:  The Police Report of Death for the Coroner;  Affidavits establishing identity and life extinct;  Report – Dr Donald Ritchey, Forensic Pathologist;  Proof of Evidence – Mr Neil McLachlan-Troup, Forensic Scientist;  Report – Forensic Science Service Tasmania;  Affidavit – Ms Nelda Aldrete, sworn 8 March 2021;  Affidavit – Ms Kristina Fisher, sworn 6 October 2020;  Affidavit – Mr Timothy Laws, sworn 24 March 2021 1 It is also known as pentobarbital and Lethabarb.

 Affidavit – Detective Senior Constable Dean Rigby, sworn 16 March 2021;  Affidavit – Detective Constable Giuliano Ercole, sworn 1 March 2021;  Affidavit – Constable Michael Grenda, sworn 6 February 2021;  Affidavit – Senior Constable Lucy Melik, sworn 15 March 2021;  Affidavit – Constable Marcus Williams, sworn 17 November 2020 (and photographs);  Affidavit – Senior Constable Tracy Lincoln, sworn 28 October 2020; and  Forensic evidence and body worn camera footage.

Background

2. Mr Linklater was born in Melbourne on 25 December 1969. At the time of his death, he was aged 50 years, unemployed and living with his partner in Windermere, Tasmania.

3. There is evidence to suggest that he suffered from problems with alcohol and poor mental health although he did not have a formal diagnosis and hence was untreated.

4. There is also evidence of at least one previous suicide attempt on Mr Linklater’s part.

Circumstances of Death

5. In the days leading up to Mr Linklater’s death, he and his partner discussed the future of their relationship. Forensic examination of electronic devices belonging to Mr Linklater shows that on 5 October 2020 he carried out Internet searches in relation to pentobarbitone toxicity following self-administration. During the same period he also carried out Internet searches in relation to the availability of rental properties.

6. The following day, 6 October 2020, Mr Linklater was at home. During the course of the day he exchanged text messages with his partner. He was last verifiably alive at 1.24pm when he sent a text message to his father.

7. His partner returned home at about 4.20pm. When she entered the residence, she found an empty bottle of vodka on a bench in the kitchen. She then found Mr Linklater lying on his back on the floor of a bedroom. After initially thinking that Mr Linklater had passed out after drinking the vodka, she checked for signs of life. She found none and called emergency services.

8. Mr Linklater was unable to be revived. A police investigation in relation to his death pursuant to the provisions of the Coroners Act 1995 commenced at the scene. A syringe was found by police lying on the inside of Mr Linklater’s right elbow. A recent

needle mark with blood was seen and photographed. The syringe was seized for subsequent forensic examination. Attending officers noted that the syringe contained traces of a green liquid. The liquid was subsequently identified as being the drug pentobarbitone,2 a central nervous system depressant.

9. The scene where Mr Linklater’s body was located was searched. Electronic devices were seized. No suicide notes or similar were located.

10. Mr Linklater’s body was photographed in situ and formally identified, before being taken by mortuary ambulance to the Royal Hobart Hospital.

Investigation

11. At the mortuary, experienced Forensic Pathologist, Dr Donald Ritchey carried out an autopsy on 8 October 2020. Following autopsy, and receipts of the results of toxicological analysis of samples taken at that autopsy, Dr Ritchey provided a report in which he expressed the opinion that the cause of Mr Linklater’s death was mixed drug and alcohol toxicity.

12. The results of toxicological analysis of samples taken at autopsy indicated that Mr Linklater had a blood alcohol level of at least 0.188g per 100 mL of blood as well as 16 mg/L of pentobarbitone, a level within the reported fatal range for that particular drug, taken alone. Alcohol (ethanol) is, like pentobarbitone, also a central nervous system depressant. Both substances combined, particularly in such high concentrations, results in symptoms such as sedation, lack of coordination, impaired thinking, slowed reflexes and breathing, decreased heart rate, loss of consciousness and ultimately death.

13. I am satisfied to the requisite legal standard that the cause of Mr Linklater’s death was, as Dr Ritchey opined, mixed alcohol and drug toxicity. I am also satisfied on the balance of probabilities that when Mr Linklater ingested the substance of which caused his death, he did so alone, voluntarily and with the intention of ending his own life.

14. Mr Linklater’s partner was at all material times a veterinary practitioner. The investigation into Mr Linklater’s death makes it clear that the source of the pentobarbitone was from her veterinary practice. She told investigators that she had been in possession of the drug to use to euthanise animals.3 That the drug was lawfully in her possession was confirmed by the principal of the practice for whom she worked at the relevant time. It had been stored by her in a refrigerator in her vehicle behind a locked canopy for a period of time prior to Mr Linklater’s death. The evidence does not enable me to determine with any precision for how long the 3 It was also used in several states in America for execution by lethal injection.

pentobarbitone was stored that way, although it is obvious that it was for a period of at least several days. It is evident that Mr Linklater had knowledge of the presence of the drug as well as access to keys to enable him to obtain access to it.

Discussion

15. Other Australian coroners have highlighted the fact that pentobarbitone has been used in a number of cases in this country as a mechanism for suicide. In each case, the source has been a veterinary practice.

16. The storage of the drug at veterinary practices and by veterinary practitioners is regulated by the Commonwealth Poisons Standard.

17. I note that pentobarbitone appears in schedule 4 of the standard ‘when packed and labelled for injection’ (as it was in this case). In all other cases it is in schedule 8. As such it is subject to different regulatory requirements in relation to its storage.

18. As a schedule 4 drug, pentobarbitone is required to be kept in a storeroom or dispensary to which the public does not have access. I observe that the state veterinary board recommends that notwithstanding its appearance in schedule 4, it should be stored as if it were a schedule 8 drug.

19. Schedule 8 drugs must be stored in an approved safe. They may be taken away from veterinary practices but only if they are then securely locked when the veterinary surgeon is not with the drug. The board recommends schedule 8 drugs should not be left in vehicles overnight.

20. I must say that I do not consider that leaving the drug unattended in a refrigerator unit in a vehicle complies either with the letter or spirit of the applicable regulatory requirements so far as they relate to storage of pentobarbitone.

Comments and Recommendations

21. A recent finding of South Australian Deputy State Coroner Schapel dealt with two deaths as a result of pentobarbitone toxicity in that state.4 In both cases the source of the drug was a veterinary practice. His Honour referred to an earlier decision of the Coroners Court of Queensland (also concerned with suicide by means of pentobarbitone obtained from veterinary practice) wherein a recommendation had been made for pentobarbitone in injectable form to be “up scheduled” from schedule 4 to schedule 8.

22. Coroner Schapel said that he considered it was important for the veterinary profession and industry to: 4 Dated 23 October 2019.

“take note that there is a concerning incidence of persons associated with that profession and with that industry utilising liquid pentobarbitone for the purpose of committing suicide”.

23. I respectfully adopt His Honour’s observation.

24. I also consider that the circumstances of Mr Linklater’s death require me, as coroners in South Australia and Queensland have before, to recommend that pentobarbitone in injectable form to be “up scheduled” from schedule 4 to schedule 8.

25. I also recommend, pursuant to section 28 (1) of the Coroners Act 1995 that pentobarbitone in injectable form be stored by veterinary practices and veterinary practitioners in accordance with the requirements applicable to schedule 8 drugs.

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

Dated: 3 August 2022 at Hobart in the State of Tasmania.

Simon Cooper Coroner