Coroner's Finding: Mather, Robert Andrew

__________________ FINDINGS and COMMENTS of Coroner Robert Webster following the holding of an inquest under the Coroners Act 1995 into the death of: Robert Andrew Mather __________________

Contents Notice of Hearing…………………………………………………………………………………………………………………………..3 Investigation……………………………………………………………………………………………………………………………. 15-17

Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of Robert Andrew Mather (Mr Mather), with an inquest held at Hobart in Tasmania, make the following findings.

Hearing Date 14 December 2022 Counsel Assisting Senior Constable Alisha Barnes Notice of This Hearing Notice of the date of this hearing was provided to Ms Cecily Pollard of Mental Health Services in the Department of Health and the Tasmanian Civil and Administrative Tribunal on 16 November 2022.

No one appeared for either of those entities at the hearing.

Contact was made with Mr Robert Mather the son of the deceased on 15 November 2021. He responded by email the next day. In his email he indicated he had consulted his sister, Tara Hester, and his brother Samuel Mather. He advised the last interaction with their father was in 1983 when they were minors. He says they were in a criminally violent and dangerous situation that resulted in an AVO to ensure their safety. Their father’s death, he says, is extremely distressing for them due to the damage imparted on them as children and for these reasons he asked my office not to contact them again. Accordingly no further contact has been made with the deceased’s children.

Finally Mr Mather’s sister, Anne, and his brother, Chris, were contacted. They both indicated they did not wish to attend the hearing.

Introduction

1. Mr Mather died on 11 November 2021, aged 80, at the Royal Hobart Hospital (RHH)

2. Mr Mather’s death is subject to the Coroners Act 1995 (the Act). The Act provides an inquest must be held where a death occurs in Tasmania and the deceased person was, immediately before their death, a person held in care.

3. Mr Mather was, at 08:00 hours on 10 November 2021 attended to by Ambulance Tasmania (AT) personnel. He presented with a minor head injury after falling from a standing position.

He advised the AT officers he had fallen twice that morning; the first being a fall out of bed after which it took him approximately 30 minutes to get off the floor and the second occurred when he walked down the street, felt unbalanced and fell backwards to the ground.

He struck the back of his head on the footpath. He denied any loss of consciousness. He refused some treatment at the scene but agreed to accompany AT personnel to the RHH.

After he arrived at the RHH an assessment order was made under the provisions of the Mental Health Act 2013 arising out of an examination of Mr Mather, at 13:00 hours by Dr Mackey, that Mr Mather needed to be assessed against the assessment criteria and it would be futile or inappropriate to attempt to have Mr Mather assessed with informed consent. At 11:30 hours on 11 November 2021 Dr Tucker examined Mr Mather and concluded he had a mental illness and was in need of treatment, it was urgent he received treatment necessary for his health or safety or the safety of other persons and that treatment is likely to be both effective and appropriate. Finally Dr Tucker concluded achieving the necessary treatment outcome would be compromised by waiting for the urgent circumstances treatment to be authorised by the then Mental Health Tribunal and therefore at 12:30 hours he authorised that Mr Mather be urgently treated with certain medications At 12:30 hours on 11 November 2021 Dr Tucker also indicated he was satisfied Mr Mather did not have the capacity to make a decision under the Mental Health Act 2013 about his assessment and treatment because of an impairment or disturbance in the functioning of the mind or brain and/or because he was unable to use or weigh information relevant to the decision because he was suffering from religious delusions in the context of schizophrenia, he was refusing treatment, he had poor insight and there was a risk of death. At 12:01 hours on 11 November 2021 Dr Baxter independently assessed Mr Mather and extended the assessment order for a period not exceeding 72 hours that is until 12:30 hours on 14 November 2021. Dr Baxter certified Mr Mather met the assessment criteria because he had or appeared to have a mental illness that required or was likely to require treatment for his health or safety or the safety of others, he could not be properly assessed with regard to the mental illness or the making of a treatment order except under the authority of the assessment order and he did not have decision making capacity.1 As a consequence, an inquest in relation to Mr Mather’s death was 1 These orders were tendered at the hearing and are exhibit C5.

mandatory2. The investigation and inquest focused upon Mr Mather’s care, supervision or treatment3. A copy of the list of the exhibits which were tendered at this inquest is attached to this decision.

4. On the basis of the evidence tendered at the inquest I make the following formal findings pursuant to section 28(1) of the Act:

(a) The identity of the deceased is Robert Andrew Mather;

(b) Mr Mather died in the circumstances set out further in this finding;

(c) The cause of Mr Mather’s death was asphyxia due to choking on food; and

(d) Mr Mather died on 11 November 2021 at the RHH, Hobart, Tasmania.

Background

5. Mr Mather was born on 15 April 1941 and was the eldest of 4 children. His father, Robert senior, was elected to the Tasmanian House of Assembly for the seat of Denison in 1964. He served until his retirement in 1982. Mr Mather was privately educated at the Friends School, an institution with which his family had strong links.

6. Mr Mather married Carolyn Margaret Coffey in or about 1968 and they had 3 children. Mr Mather obtained a medical degree and went on to obtain qualifications as an anaesthetist.

His medical career however came to an end in 1983. By then he was subject to psychiatric symptoms. Mr Maher’s increasing difficulties with mental illness lead to a breakdown in his marriage, bankruptcy and subsequently difficulties with the law. He had no contact with his former wife or his 3 children from that point onwards.

Health and Forensic History

7. Mr Mather’s medical records reveal he had a long history of mental health difficulties. They disclose that between 25 May 1983 and 14 June 1983 Mr Mather was detained at the Royal Derwent Hospital (RDH) on what was called an observation order4. The letter of referral to 2 See s24(1)(b) of the Act.

3 See s28(5) of the Act.

4 See ss14, 18 and 19 of the Mental Health Act 1963. An application for admission to hospital for observation was based upon the recommendations of 2 medical practitioners and could be made on the basis the patient was suffering from a mental disorder of a nature or degree that warrants detention in a hospital under observation for at least a limited period and the patient ought to be detained in the interests of his own health

the RDH was from the Medical Commissioner of the Mental Health Services Commission.

That letter advised the psychiatric superintendent of the RDH Mr. Mather was being transferred under an observational order. The letter also advised he had a chronic delusional state embracing religious delusions dating back approximately 2 years although a paranoid personality was evident prior to this time. The letter says:  “The immediate problem was precipitated by his writing 50 letters about 3 weeks ago which resulted in his being suspended by the Royal Hobart and Repatriation Hospitals and by the Medical Board. The letter said that he was going to receive $6 million from a source he would not disclose for religious purposes.

 He had no work or income and has made no effort in any way to support his wife and children, saying that God looks after the families and He will provide. He also says that God will look after his bills, his rates and taxes.

 He is very heavily financially committed, having mortgaged both his properties to the hilt, he has debts, is overdrawn and has also depended on his father. He has been playing the stock exchange.”

8. The discharge summary of the RDH records the central feature of his mental condition was the belief a supreme religious being had specifically chosen Mr Mather to enhance the standing and activity of Christianity, both locally and internationally. Any obstacles to such mission he interpreted as maliciously perpetrated. During treatment he had been free of symptoms of an affective disorder and of disintegration and deterioration of schizophrenia.

He was discharged into the care of Dr Ashley. There are notes of the file of the medical Council of Tasmania which indicate attempts were made to restore his name to the register of medical practitioners however it appears that application was unsuccessful.

9. There is then a gap in the records until 1996 when Mr Mather was charged and convicted of 2 breaches of bail and 8 charges of stalking. Prior to that time his record consisted of a traffic infringement and a drink-driving charge in the early to mid-1970s and an improper language charge, a trespass charge and refusing name and address which occurred in 1990 and which charges were dismissed. It was alleged by police Mr Mather had, since 1992, followed, surveilled, approached and sent offensive material to a number of females 8 of whom made or safety or with a view to protect others. A person could be detained for a period not exceeding 28 days and could not be detained thereafter unless before the expiration of the period the patient had become liable to be detained by virtue of a subsequent application, order or direction under the Act. Urgent applications could be made.

complaints. Over more recent months the frequency and number of letters increased as had their violent and sexual content. On the 8 stalking charges Mr Mather was sentenced to 2 months imprisonment on each charge; that is a total of 16 months imprisonment backdated to 9 September 1996. On one of the breaches of bail Mr Mather was sentenced to 14 days imprisonment which was to be served concurrently with the 16 months imprisonment and on the second charge he received another 14 days imprisonment but again it was to be served concurrently5. While in prison he received treatment for schizophrenia and it seems he spent a considerable amount of time in the prison hospital6.

10. Following Mr Mather’s release from prison he was transferred to the RDH where he remained for several weeks under the care of the former state forensic psychiatrist Dr Lopes.

He then moved into the community and lived at Flint house. It had been arranged for Mr Mather to receive depot antipsychotic medications which were administered by Drs Braithwaite and Graham at a New Town general practice. Despite experiencing side-effects from these injections Mr Mather continued to receive them until 2002. The main side effect was a coarse tremor especially to his right hand.

11. Mr Mather reported to the psychiatrist Dr Sale7 the tremor was the reason he ceased attending his general practitioner for the injections however Dr Sale believed there was another issue which may have played a part. That issue was Mr Mather’s father died early in 2002 and Mr Mather received an inheritance from the estate. His family were concerned as to whether he was capable of managing his finances and that concern led to the involvement of the Guardianship and Administration Board. This caused problems in Mr Mather’s relationship with his general practitioner Dr Braithwaite.

12. For whatever reason Mr Mather ceased taking medication. He had no difficulties for about 4 months but then started to experience hallucinatory voices, he had problems with his sleep and he started to receive messages from the television. He then, about 6 to 8 weeks later, commenced writing letters to some of the complainants who he had earlier stalked and who had obtained restraint orders against him which were valid until 2006. He was charged with 4 counts of breaching those restraint orders. He was unable to recall the content of the letters but did not deny they may have touched on subjects such as religion, politics and 5 Mr Mather’s record of prior convictions is exhibit C15.

6 The records of Correctional Primary Health are exhibit C11.

7 Dr Sale’s report is exhibit C13.

homosexuality. He was again remanded in custody on 7 August 2003 until he was bailed on 29 August 2003. Dr Sale reports by the time he was remanded in custody Mr Mather had started to experience far more extensive symptoms; for example it seemed to him that birds were communicating with him. He also saw a hallucinatory figure in his cell who he referred to as chicken man number 3. This figure was accompanied by aliens, and he received messages. He could also see bright colours through other cell door windows. Medication was resumed while he was in custody and his symptoms settled.

13. Dr Crawshaw, the then state forensic psychiatrist, provided a report in 2003 which addressed the question as to whether Mr Mather was capable of looking after his financial affairs. In Dr Crawshaw’s opinion Mr Mather’s mental state had improved to the extent that he had that capacity. He also advised Mr Mather remained under the supervision of the Forensic Mental Health Service and they intended to case manage him. He therefore had to attend outpatient appointments with Dr Crawshaw and see a psychologist who was appointed as his case manager. This, Dr Sale says, provided a means for monitoring the emergence of any early symptoms of his mental illness which allowed for prompt intervention.

14. Dr Sale was engaged by the Legal Aid Commission of Tasmania who represented Mr Mather with respect to the breach of restraint order charges. Dr Sale was asked whether Mr Mather was fit to stand trial and whether he had a defence to the charges pursuant to s16 of the Criminal Code Act 1924. Before answering those questions Dr Sale said Mr Mather suffered from paranoid schizophrenia and he summarised Mr Mather’s position as follows: “This illness has been present for in excess of 20 years. When he is actively ill he becomes paranoid, subject to perceptual disturbance and thought disorder, and appears prone to write unwanted, rambling and incomprehensible letters to various women.

With medication, positive symptoms of schizophrenia such as delusional thinking and perceptual disorder are well-controlled. However, it is apparent that there has been a considerable decline in social functioning. In the past Mr Mather was a medical specialist from a well-to-do background and a private education.

He now lives in poor quality hotel accommodation, and ties with family members appear to have all but broken down.”

15. Dr Sale expressed the view Mr Mather was fit to stand trial however he probably had a defence under s16 of the Criminal Code Act 1924 as he was mentally disordered at the

relevant time and his behaviour was a product of that mental illness. Dr Sale believed at the relevant time Mr Mather was unable to know his behaviour was wrong. These charges proceeded and Mr Mather was found guilty and convictions were recorded. In addition on 19 May 2004 he was sentenced to imprisonment for a period of 4 months which was wholly suspended for 3 years on condition he be of good behaviour and comply with the conditions of his probation order which also ran for a period of 3 years and which required him, amongst other things, to cooperate with and attend Forensic Mental Health Services and to accept treatment and medication including the administration of antipsychotic medication. I infer he complied with those conditions because there is no record of any application alleging he breached them. Accordingly I can be satisfied Mr Mather received appropriate treatment for his mental health condition until at least May 2007.

16. The Community Forensic Mental Health Records8 cover the period from the 12 September 2007 until 18 November 2021. Until in or about June 2010 Mr Mather’s schizophrenia was largely managed by his general practitioner and Mr Mather attended for regular intra muscular antipsychotic treatment. He was noted to have significant symptoms of Parkinsonism and it was decided his care would be taken over by Community Forensic Mental Health Services. Mr Mather was trialled on oral medication with some improvement in his extra pyradimal symptoms but he eventually became non-compliant. He deteriorated in his mental state over a period of months and eventually required inpatient treatment at the RHH. After that admission he was treated with intra muscular antipsychotic medication and a change of medications meant he only required monthly injections.

17. In late 2012, Mr Mather ceased attending for medication and psychiatric review and he also declined to have contact with his case manager. He was subsequently admitted to hospital in February 2013 and a treatment order was sought. He had previously been under a treatment order from July 2010 to July 2011 but that order was allowed to lapse due to his level of compliance and apparent level of insight. He had also previously been subject to a guardianship order which mandated treatment. He was free of psychosis during a period of regular treatment in 2010 and 2011. Treatment orders were made and reviewed in 2013, 2014, 2015, 2016 and 2017. In 2017 the treatment order commenced on 26 December 2017 and was due to expire on 25 December 2018.

8 These records were tendered at the inquest and are exhibit C9.

18. In the application for renewal in 2017 the psychiatrist Dr Evenhuis indicated Mr Mather continued to assert he does not suffer from schizophrenia and said he would cease treatment and follow-up if the order was lifted. Dr Evenhuis indicated, based upon Mr Mather’s previous history, deterioration would be expected if treatment ceased because Mr Mather has required hospital admission following the last 2 occasions that occurred. The application for renewal was therefore made to facilitate ongoing treatment. It was noted Mr Mather had declined blood tests for metabolic screening and preferred to attend his own general practitioner for ECGs and other investigations. The goal of treatment was to maintain the stability of Mr Mather’s mental state and prevent relapse into psychosis and/or elevated mood. While treated his symptoms were well-controlled but Dr Evenhuis said Mr Mather’s deficits prevented him from gaining insight into his illness. It was anticipated he would relapse in the absence of treatment and would experience grandiose, persecutory and religious delusions which might be associated with an elevation in his mood. The previous stalking behaviour was referred to and a recurrence of that behaviour was considered more likely in the absence of treatment. While treated Mr Mather was able to manage his own affairs and interact reasonably well with co-residents and members of the public. Dr Even - huis believed Mr Mather’s social and personal functioning would decline if he was to relapse.

Mr Mather’s denial that he had a psychiatric condition prevented him from being able to adequately weigh up the risks and benefits of treatment as he was unable to appreciate any possible benefits. He was unable to reflect upon his past symptoms or the effects they have had on his life. Dr Evenhuis considered, at that time, Mr Mather lacked decision making capacity about his own treatment.

19. As a result of documentation filed in the Mental Health Tribunal the treatment order was discharged on 26 June 2018. That documentation records Dr Evenhuis had assessed Mr Mather and was satisfied he did not meet the treatment criteria. That assessment took place on 12 June 2018 and Mr Mather’s long time case manager, Ms Carol Cashion, was present.

The notes of that assessment are as follows: Mr Mather’s “presentation was unremarkable.

He was reasonably cheerful and somewhat more forthcoming than usual. There was no evidence of religious or grandiose thinking or elevated mood. Of note, Andrew9 said that he had reached the conclusion that he would take the IMI regardless of an order as the current 9 The evidence is Mr Mather preferred to be referred to by his middle name Andrew rather than his christian name Robert.

dose caused him no problems. He said that he wouldn't appreciate it if I told him how to give an anaesthetic and similarly he would follow psychiatric advice. There was some discussion of happenings at Flint House including storm damage, fire alarms and rowdy patrons. Andrew denied any issues with sedation on his current dose and his tremor was no worse than usual.

Impression: Remains stable. More agreeable to treatment. Plan: Continue. There is no need to pursue a further TO10 unless he changes his point of view.” On 21 June 2018 a case conference was held which was attended by 10 members of the mental health team. The note of that meeting is as follows: “Andrew Mather: Stable, Compliant with monthly LAI.

Reviewed by Michael Evenhuis last week, and Andrew stated he now accepts psychiatric opinion he needs to be on medication and has schizophrenia even though it is different from his own opinion. 180 day review of T.O is due next week, and Michael E has decided T.O. no longer required.”

20. I have examined the notes of Community Forensic Mental Health Services. Those notes reveal Mr Mather attended for treatment every month from July 2018 until September 2021. He was next scheduled to attend on 27 October 2021 however he did not attend on that day. A psychiatric review was to be undertaken, on that day, by Dr Navin of the Older Persons Mental Health Service. The case manager had a one hour discussion with Dr Navin when Mr Mather did not attend. She advised him she had concerns and planned to visit Mr Mather at Flint House to assess his mental state and arrange an admission to hospital if required. The option of transferring Mr Mather to a geriatric ward from the Department of Emergency Medicine if admitted to hospital rather than a mental health unit was discussed. It was thought geriatric admission would facilitate an assessment with an aged care assessment team (ACAT) and a possible transfer to the Older Persons Mental Health Service. Ms Cashion had a number of concerns because it was unusual for Mr Mather to not attend his monthly meeting, enquiries of the manager at Flint house revealed Mr Mather was in arrears with his rent and his centre pay deductions had been cancelled. Accordingly there was a risk of eviction/homelessness. In addition the manager reported Mr Mather had made reference to “God the Father” when he spoke to Mr Mather about rental arrears which was an early warning sign of a deterioration in Mr Mather’s mental state. The message about the appointment with Dr Navin had been passed on to Mr Mather via the manager at his accommodation and it was thought there would be a risk of non-compliance. There were also concerns with respect to his physical health which appeared to have declined as he was no 10 Treatment order.

longer having meals at Flint house so there was a risk of a decline in his nutrition. In addition Mr Mather was considered to be socially isolated, vulnerable, estranged from his family and he lacked insight. He did not trust psychiatrists, agreed to have treatment but holds a different opinion as to whether or not he needs it. He had declined a transfer of care to the Older Persons Mental Health Service in the past.

21. Mr Mather was contacted at Flint House and agreed to a home visit which took place at 1:30 PM on 27 October 2021. Ms Cashion was accompanied by Ms Bayes. Ms Cashion’s notes of their meeting are as follows: “As arranged home visit this afternoon at 1.30pm accompanied by Naomi Bayes. Andrew invited us into his bed room when we arrived. Room tidy, ordered. Unclean. Using 'Old Spice' fragrance. He was polite. No FTD. Thinking processes coherent, linear. Engaged appropriately in conversation. Expressed dislike of some of other residents at boarding house, but confirmed he was ok. Reason he DNA appt. today for monthly LAI was that he was angry with case manager for arranging psychiatric review with psychiatrist Older Persons MHS. Argued he has been doing ok with 25mg LAI, and not needing to see psychiatrist. Stated he does not think he needs medication anymore, and proposed to continue to see case manager fortnightly for next 8 months or so. When I explained to Andrew, because he is on medication he does need psychiatric reviews, he stated he will see psychiatrist at SCFMHS, not Older Persons MHS.

Agreed to have monthly LAI today at home visit, instead of attending 4 Liverpool St.

tomorrow. Discussed his physical health needs in relation to aging, and wanting to make sure he is linked in with appropriate services for his needs etc. Raised our concerns re his weight loss, and diet, etc. Andrew denied any physical health issues. Claims to shower once a week.

Reminded us he has 2 medical degrees. States he attends Collins St medical practice for annual check or if he needs to. Discussed rent arrears, at Boarding house, and he claimed there had been mess up with centrepay deduction arrangement and plans to pay rent in cash next week. Declined assistance from case manager to attend bank with him to collect rent etc.

Case manager to arrange appt for psychiatric review at 4 Liverpool St., and will notify Andrew of time and date.” Ms Bayes also made very comprehensive notes and she confirms an appointment with a locum psychiatrist was to be arranged for an assessment and future planning which Mr Mather agreed to.

22. A Mental Health Team meeting was held the next day the notes of which are as follows: “Carol C arranged review with Older Persons Mental Health Service (OPMHS) Psychiatrist yesterday. Andrew was given notice of this and did not attend appointment. Carol C spoke to OPMHS regarding potential he has declined and may need admission to RHH would provide opportunity to link him in with ACAT assessment etc. Also advised that at this stage OPMHS would not accept referral and that Andrew needs review by Forensic Psychiatrist but also stated they would provide second medical opinion needed for treatment order if requested.

Andrew has agreed to see CFMHS Psychiatrist at 4 Liverpool Street which Carol C will arrange.

Treatment Order will help to facilitate the transfer to OPMHS. Also query of guardianship.”

23. An urgent appointment was made with the consultant forensic psychiatrist Dr Makesar on 29 October 2021. Mr Mather and Ms Cashion attended. After conducting his assessment Dr Makesar expressed the following view: “Opinion: This octogenarian, who lives at a boarding house, has had gradual physical and functional decline. He has been losing weight, possibly incontinent of urine, given the odour and his gait was slow and shuffling. He has a stutter, and is somewhat slow in cerebration. In terms of risks of aggression to others or for that matter stalking and harassment, the risk is very low, given his physical limitations. Besides he has good insight into his behaviours and is aware of the consequences, which are deterrent factors from recidivism. CFMHS is not geared to meet this man’s healthcare needs , and I am of strong opinion that his needs will be most appropriately be met in Old Age Mental Health System. I strongly recommend that he be transferred to Old Age Mental Health Services.”

24. At a mental health team meeting on 4 November 2021 it was noted Dr Makesar’s opinion was for transfer to the Older Persons Mental Health Service however Mr Mather had refused such a transfer. That service advised Ms Cashion they would require Mr Mather to be on a treatment order before considering a transfer of care. The meeting resolved that Dr Makesar commence the process so that a treatment order could be applied for. That same day Ms Cashion sent an email to the Older Person’s Mental Health Service with respect to the transfer of Mr Mather’s care. Then on 10 November 2021 Ms Cashion sent a further email to Dr Navan advising him of Mr Mather’s admission to the Department of Emergency Medicine

at the RHH. Dr Navan responded on 10 November 2021. He indicated once the necessary order had been made his service would take over Mr Mather’s care. A note of the Mental Health Team meeting on 11 November 2021 records a home visit had been planned in the next week with 2 psychiatrists and the case manager to complete the treatment order application.

25. The records of Mr Mather’s general practitioner cover a 10 month period between July 2015 and 14 October 2016. Within that time he visited the general practitioner on 5 occasions and on 3 of those occasions he was prescribed an antibiotic for cellulitis he had on his upper lip and an abscess he had on his neck. He also attended for a general check-up and for anaemia.

A number of microbiological tests were ordered on 2 of those 5 visits. No mental health treatment was sought or provided.

The Events Leading up to Mr Mather’s Death

26. Mr Mather was residing at Flint House in New Town at the time of his death. At approximately 07:00 hours on the 10 November 2021 police were called as a result of reports of an elderly man who was near the Talbot Hotel in New Town. On arrival police determined the man to be Mr Mather. AT attended and transported Mr Mather to the RHH. The report of AT11 says Mr Mather had a minor head injury as a result of a fall from a standing position. He was located in the company of police sitting outside on a chair. Mr Mather was described as unkempt and he had a strong odour. Mr Mather advised AT personnel he had two falls that morning. In the first fall he had fallen out of bed and he was unable to get up off the floor for approximately 30 minutes. He had then walked down the street and felt unbalanced and he had fallen backwards and struck the back of his head on the footpath. Mr Mather was stating words but not always making sense. He said he had not seen a doctor in 6 months however checks made by my office suggest he had not seen a general practitioner for in excess of 5 years.

27. Mr Mather told RHH staff God had ordered him to fast for the last three weeks, which he did however he started eating 3 days ago. As a result of fasting he lost a significant amount of weight. In the Emergency Department there was minimal history given. Mr Mather was alert but unkempt. He was emaciated and estimated to weigh 50 Kg. He was pale and there was a graze on the occiput. The vital signs were afebrile, pulse rate 88 bpm, blood pressure 98/82 mmHg with no postural drop and oxygen saturation 90% on ambient air. The heart was 11 Exhibit C10.

normal. Mr Mather had a moist cough and diminished breath sound in the lungs. The lower abdomen was distended and a bladder scan showed 2500 ml urine in the bladder. There was evidence of faecal and urinary incontinence. Mr Mather was anaemic with 20% hypochromic red blood cells (iron deficiency anaemia). The white cell count was elevated. Biochemistry showed hypernatraemia, an elevated urea, hypoalbuminaemia and hypercalcaemia. There was significant iron deficiency. The C reactive protein was 245 ng/L (over 100 ng/L is consistent with bacterial infection). The troponin was slightly elevated. A chest x-ray showed chronic obstructive pulmonary disease possibly with overlying interstitial lung disease or multifocal infective changes. A CT scan of the brain showed no acute changes. Mr Mather was placed on a mental health order to enable treatment. He was admitted to the hospital under general medicine and a management plan was made.

28. On 11 November 2021 Mr Mather continued to display evidence of an acute psychosis. A blood transfusion was given. Under code black conditions and sedation a urinary catheter was inserted and it drained 3750 ml urine. At 15:20 hours the medical emergency team (MET) was called. Mr Mather was unconscious, he had bradycardia12, a heart rate of 27 bpm, and no respiratory effort and he had no recordable blood pressure. Mr Mather was not resuscitated due to the medical goals of care plan which had been discussed with him. That plan indicates he was not for CPR or intubation but he was for MET calls. Life extinct was declared at 18:53 hours13.

29. Prior to the MET call Mr Mather had eaten dinner uneventfully and had been assisted to the bathroom. He was sitting back in bed. His sitter then noticed he had become unresponsive and pressed the alarm and the MET call was made immediately.

Investigation

30. The fact of Mr Mather’s death was reported in accordance with the requirements of the Act.

His body was formally identified14 and then transferred to the RHH mortuary. On 15 November 2021 Mr Mather’s body was examined by Forensic Pathologist, Dr Donald Ritchey MD, MSc, American Board of Pathology (Anatomic, Clinical and Forensic Pathology), FRCPA.

12 A slow heart rate.

13 Exhibit C2.

14 Exhibit C3.

Dr Ritchey also reviewed Mr Mather’s Tasmanian Health Service medical records15 and the Tasmania Police Report of Death16. He provided a report which was tendered at the inquest17 in which he summarised his autopsy findings in the following terms: “Mr Mather was admitted to the Royal Hobart Hospital after he fell on the street and was apparently unable to stand. Evaluation at the hospital confirmed the presence of delusional beliefs. He stated that god had been telling him to fast for 3 weeks. He had a background schizophrenia and his case manager had reported that his physical health had been deteriorating over several months.

Evaluation excluded significant traumatic injuries however he was found to have an iron deficiency anaemia for which he received an uneventful blood transfusion. There was marked urinary retention for which an indwelling catheter was inserted and drained a large volume of urine. On the day of his death [he] was assisted to eat dinner and was mobilised to the bathroom after which he was found unresponsive in bed.

The autopsy revealed a normally developed, frail appearing elderly man with profound obstructive uropathy18. The bladder was markedly distended and had innumerable diverticula19 filled with ovoid hard stones. Loose stones were also identified within the urinary bladder. The prostate was markedly enlarged and was the cause of this obstructive uropathy.

The ureters20 and renal pelves21 were distended and there was prominent chronic pyelonephritis.

The obstructive uropathy likely contributed to paralytic ileus causing marked distension and immobility of the gastrointestinal tract. This increased the risk of aspiration and choking that was the ultimate cause of his death.” 15 Exhibit C8 16 Exhibit C1.

17 Exhibit C4.

18 Obstructive uropathy occurs when urine cannot drain through the urinary tract.

19 Diverticula are small, bulging pouches that can form in the lining of your digestive system but in this case they formed in the wall of Mr Mather’s bladder.

20 The ureters are bilateral thin tubes that connect the kidneys to the urinary bladder, transporting urine from the renal pelvis into the bladder.

21 The area at the centre of the kidney. Urine collects here and is funnelled into the ureter.

31. Mr Mather’s medical care and treatment was reviewed by Dr Anthony Bell MB BS MD FRACP FCICM, Medical Advisor to the Coronial Division of the Magistrates Court. Dr Bell provided a report (which was also tendered at the inquest22) in which he noted Mr Mather’s past medical history of significance which included asthma, schizophrenia, weight loss due to fasting and physical deterioration noted by his case manager who was attached to Community Forensic Mental Health. It was also noted Mr Mather had ceased taking his antipsychotic medication in or about June 202123. Having considered this history and the material set out in the RHH records, the AT report and Dr Ritchey’s report Dr Bell was of the view Mr Mather had managed to avoid attention and medical care. His physical deterioration was profound. Dr Bell concluded by saying there were no issues with the medical treatment he had been provided.

32. I accept the opinions of Drs Ritchey and Bell. They are experienced in their respective fields and well qualified to express their opinions.

Conclusion

33. The findings required by s28 (1) of the Act are set out in paragraph 4.

34. In so far as s28(5) of the Act is concerned the evidence tendered at the inquest satisfies me Mr Mather was appropriately treated, supervised and cared for while he was a “person held in care” as defined by the Act. I note he was not a “person held in care” between 26 June 2018 and 10 November 2021.

35. In addition I find the treatment and care provided to Mr Mather for many years by the Community Forensic Mental Health Service was very thorough, attentive and to a high standard. Treatment orders were always sought when Mr Mather’s psychiatric condition regressed and the decision to discharge the treatment order made by Dr Evenhuis in June 2018 cannot be criticised given the manner in which Mr Mather presented at that assessment and the fact he had been on a treatment order without incident for in excess of 4 years. Thereafter Mr Mather consented to monthly psychiatric treatment and review for the next 27 months. The actions taken by the mental health team, and Ms Cashion in particular, after Mr Mather failed to attend his appointment on 27 October 2021 were diligent, swift 22 Exhibit C12.

23 This is incorrect. He missed his appointment on 27 October 2021 but agreed to an injection at the home visit later that day. That injection was administered on that day.

and decisive. But for the fall in the street on 10 November 2021 and Mr Mather’s admission to the Department of Emergency Medicine the assessment and application contemplated in paragraph 24 would have taken place. I am in no doubt, given Mr Mather’s history, a treatment order would have been obtained from the Tasmanian Civil and Administrative Tribunal.

36. The assessment and treatment Mr Mather received at the RHH before his death was, in Dr Bell’s view (which I accept), appropriate medical care.

Comments and Recommendations

37. In the circumstances there is no need for me to make any further comments or recommendations.

38. In concluding, I convey my sincere condolences to all those whose lives were touched by Mr Mather.

Dated: 15 December 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner