Coroner's Finding: TS de-identified

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of TS Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is TS; b) TS died as a result of a traumatic closed head injury likely sustained in a fall from standing; c) TS’ cause of death was a traumatic closed head injury; and d) TS died between 26 and 27 April 2019 at Sandy Bay, Tasmania.

1. In making these findings, I have had regard to the evidence gained in the investigation into TS’ death which includes:  Police Report of Death for the Coroner;  Affidavits establishing identity and life extinct;  Affidavit of Dr Donald Ritchey, State Forensic Pathologist;  Affidavit of Forensic Scientist Neil McLachlan-Troup of Forensic Science Service Tasmania;  Medical records obtained from the Royal Prince Alfred Hospital (RPAH) and Harold Park Medical Centre;  Affidavit of CD;  Affidavit of DN;  Affidavit of JC;

 Affidavit of DT;  Affidavit of Constable Matthew Reardon;  Affidavit of Senior Constable Melanie Redburn;  Affidavit of Sergeant Antony Edmondson;  Affidavit of Senior Constable JC Hyland together with photographs; and  Miscellaneous documentation.

Background

2. TS was born on 11 August 1971 in Hobart, Tasmania. She was the eldest of three children to PN and DN. She had a close relationship with her two younger brothers, DT and JC. TS was married and lived in New South Wales with her husband CD. At the time of her death, TS was 47 years of age and visiting her family in Hobart, Tasmania.

3. TS was a happy, vibrant, and engaging child. She studied painting and photography at the University of Tasmania’s Arts School. After graduating she went on an exchange program to further her studies at the Glasgow School of Art in Scotland where she met her future husband, CD, in 1995. TS moved back to Tasmania to complete her Honours but as she wanted to be with CD she withdrew from that program and returned to Scotland in 1995. The couple were married in Scotland in July 1997 and TS completed her Honours in Glasgow in 2000. TS and CD travelled extensively between 2000 and 2005 before deciding to move from Glasgow to Sydney. For a number of years TS worked in the technical services unit of the art and design faculty at the University of New South Wales.

4. In 1998 TS and CD returned to Tasmania for a holiday at which time they renewed their wedding vows. Her family noted she appeared happy and healthy and she showed no signs of ill health.

Medical history

5. 1n 1996, CD noticed TS had begun “purging” after eating. When he raised this with her, she eventually admitted the behaviour but said she had stopped doing it. CD says everything else seemed fine with her and they lived a happy life.

6. TS visited Tasmania for about 3 months in 2001. During this stay, her brother DT noticed her eating habits had changed and she would only eat small amounts before excusing herself to go to the bathroom. Her youngest brother JC also recalls that this occurred but cannot recall when he was first aware of it. Her mother, DN, suspected she may have been suffering from depression. Her weight declined further in subsequent years. Although her family raised their concerns with her, TS was dismissive and reacted defensively to comments they made regarding her weight and health. Upon her return to Scotland CD noticed TS was drinking a lot more alcohol than she did previously. He says “[t]he drinking was pretty constant from that time.”

7. After TS moved back to Australia her brother DT suspected she was suffering from an eating disorder. Her brother JC says his sister consumed alcohol to excess. He knew when she was intoxicated because she would be incoherent. Her husband believed she was consuming a lot of alcohol and hardly eating and her mother and brother, JC, didn’t see her consume much alcohol but they both say she was affected by it; the inference being she was consuming more alcohol while not in the presence of her family.

8. TS’ apparent alcoholism was well-known in the family but it was not spoken about because she was in denial and could become angry if the topic was raised.

9. I have examined the records of TS’ general practitioner. They cover the period from 21 April 2012 until 12 March 2019. At the commencement of that period her weight was 46 kg and at the end it was 44.7 kg. She was 161 cm tall so for that entire period she was significantly underweight. The suggested healthy weight range for a female at that height is between about 52 kg and 64 kg. TS sought treatment for her eating disorder in 2012. This treatment was provided by the psychologist Dr Cohen. In 2013 she saw her general practitioner on 9 occasions, in 2014 on 19 occasions, in 2015 on 11 occasions, in 2016 on 23 occasions, in 2017 on 13 occasions, in 2018 on 13 occasions and she saw her GP just once in 2019. During those years her weight fluctuated significantly. The lowest recorded weight was 39 kg in May 2016 whereas the highest recorded weight is 53.1 kg in September 2018 however by November that year her weight had reduced to just over 43 kg. Dr Cohen ceased treating TS as he left practice so subsequently she saw the psychologist Dr Elizabeth Hall, the first referral being in February 2014. There were subsequent referrals to her in October 2014, January 2015, September 2015, November 2016 and March 2017. In addition there are a number of referrals to a dietician in March 2014, June 2015 and in May and June 2016. It is clear from this evidence and the anecdotal evidence provided by her family that TS continued to struggle with an eating disorder. A note in these records

dated 28 June 2013 says TS was consuming shots of vodka before dinner to assist her with her anxiety prior to her eating her evening meal and that she was hiding this from her husband. A referral in September 2013 to the eating disorder outpatient service of the RPAH notes an 18 year episodic history of difficulties with restricted eating and purging which had worsened significantly in the time since her return to Australia from overseas.

10. In addition there were referrals to the gastroenterology and liver clinic and to the endocrine clinic both at the RPAH in February 2014. There were further referrals to the gastroenterology and liver clinic at that hospital in June 2016, April 2017, May 2018 and November 2018; the last referral being an indefinite referral because the general practitioner recognised TS would require prolonged and ongoing care.

11. These records disclose that TS also suffered from depression particularly when she lost her employment towards the end of 2017. She was referred to a psychologist at that time to manage that condition.

12. In September 2014 she had been diagnosed with alcoholism, anxiety and depression, anorexia nervosa, dermatitis, fatty liver, dyslipidaemia and amenorrhea. While overseas in 2017 TS had 2 Mallory Weiss tears cauterised after she underwent a gastroscopy. A Mallory Weiss tear is a tear to the lower oesophagus which can be caused by violent coughing and/or vomiting. TS subsequently returned deranged liver function results which were believed to be secondary to likely alcoholic hepatitis. She was later diagnosed with alcohol induced cirrhosis of the liver. At the time of that diagnosis in or about April 2018 blood test results showed the level of her alcohol hepatitis was inconsistent with the history she had provided with respect to her alcohol consumption. The notes reveal TS continually understated the level of her alcohol consumption.

13. TS had a long history of falls, the details of which are as follows: a. In 2007, TS suffered a fall which resulted in a minor fracture to her arm.

b. TS visited her family in Tasmania in December 2015. On Christmas Day, she suffered a fall which resulted in a badly broken upper arm. She underwent an open reduction and internal fixation of the fracture on Christmas day and a subsequent orthopaedic procedure the next day. Her husband did not believe she had been drinking. Instead, he thought she “spun out” due to smoking a cigarette and this was why she fell. However, DN believes she may have been drunk but she was not sure because her daughter would have been too shy to

drink in front of their visitors. However she says some time after this event on 2 separate occasions she found an empty bottle of vodka in her daughter’s room. CD had to return to Sydney for work and TS returned to Sydney in the New Year. She contracted an infection to the left humerus and as a result was admitted to the RPAH on 13 January 2016. She underwent, on the 14th 16th and 19 January 2016, washouts and debridement’s of the wound however the prosthesis was retained. Subsequently she developed a radial nerve palsy which resulted in a right wrist drop for which she required physiotherapy. She experienced significant bouts of pain and in addition there were multiple incidences of her being intoxicated on the ward. She was not discharged until 2 March 2016 after which there were referrals to the infectious diseases clinic of the hospital, due to the infection, on 9 March, 30 March, 13 April and 20 April

2016. On that last occasion it was noted TS was admitted to hospital in the previous week for severe lactic acidosis. She had continued drinking whilst on the medication which was prescribed to counter the infection and she was suffering from ketoacidosis from starvation and anaemia. There was a referral to the rheumatological and orthopaedic clinic on the 1st June that year and in particular to the osteoporosis clinic. Subsequently there was a referral to an orthopaedic surgeon at that hospital in April 2017.

c. Following the fall on Christmas day, TS’ husband mentioned to DT she had suffered another fall which caused a cut on her browline. This cut resulted in a scar. He also mentioned she had been having “dizzy spells.” d. In 2016, TS passed out after drinking heavily. Her mother was visiting at the time and an admission to the intensive care unit was arranged. CD was in Scotland at the time.

e. Also in 2016, TS fell at her home. This fall was unwitnessed as her husband was in Scotland. TS did not seek immediate medical treatment but instead she attended work where staff noted she was in a highly confused state. TS was admitted to hospital and it was found after a CT of the brain was performed she had suffered an occipital fracture which resulted in a bifrontal subdural haematoma and subarachnoid haemorrhages. She was admitted on 27 June 2016 and discharged on 20 July 2016. During this period, and due to CD being away, the Public Guardian was appointed and in fact it appears that a coercive medical guardianship was sought for the purpose of nasogastric refeeding. That application was not granted. TS had no decision-making capacity because she was suffering from delirium secondary to the head injury although it was

thought malnutrition was also a factor. The Public Guardian was removed later that year. The records disclose that during this period TS absconded from the ward on 4 occasions. On one occasion Police returned TS to hospital from her house where she attempted to have alcohol delivered.

14. CD believes TS suffered unwitnessed falls between 2007 and 2016 that she did not tell him about or seek medical treatment for. Her husband was present for other falls during this time that did not result in her suffering any injuries.

15. In November 2017 she was hospitalised for a short period for suicidal ideation in the context of excessive alcohol consumption.

16. TS was hospitalised again on 7 February 2018 after suffering a tonic-clonic seizure at home. The history was this was the third seizure; the first having been suffered in Scotland in July the previous year and the second in December however the notes for that admission indicate she suffered a panic attack only. It was considered that in February 2018 she was suffering from alcohol withdrawal seizures and alcoholic hepatitis. She discharged herself against medical advice but represented and was not discharged until 13 February 2018. On at least 2 previous occasions she insisted on being discharged from hospital against medical advice.

17. TS’ health deteriorated further. On 15 September 2018 she was admitted to hospital with pneumonia and a collapsed lung. TS was placed in intensive care. She fell into a coma and that point it was believed she may not recover. While in intensive care, TS contracted severe sepsis secondary to pneumoccal pneumonia. She was intubated from 15 September until 2 October 2018. She did eventually recover but she remained an inpatient until 26 October that year. On her discharge from hospital she continued to suffer from an ongoing cough. There was a further referral to the respiratory medicine clinic of the RPAH on 27 November 2018.

18. On 20 April 2019, TS presented to the RPAH with a non-productive cough. She did not have chest pain, fever, chills, or shakes. She was not vomiting or showing signs of nausea. Doctors believed she was suffering from a lower respitory tract infection. TS was provided with Doxycycline. A report with respect to this attendance confirms TS’ medical history which included cirrhosis of the liver, previous alcohol withdrawal seizures, anorexia, bulimia, radial neuropathy and a chronic infection of the humerus.

Circumstances of TS’ death

19. On 23 April 2019, TS arrived in Hobart to spend the Russian Orthodox Easter with her family. She was suffering from a cough and so prior to her departure from Sydney CD , as mentioned in paragraph 18, had taken her to hospital where she was examined. Nothing remarkable was found and she was prescribed antibiotics. Her mother took her to the Royal Hobart Hospital the next day but she was advised to see her general practitioner so she didn’t have to wait for a long time. TS visited an after-hours doctor in Sandy Bay on 26 April 2019 at which time she was prescribed the same antibiotic.

20. TS spent the evening of 26 April 2019 talking with her mother in the lounge room.

Her mother did not see TS drink alcohol at all that evening. Her mother was overcome by drowsiness so she went to bed and TS joined her at around 11.00pm. It was usual for them to share a bed, as they often stayed awake talking. On this night, they did not speak as her mother was too tired. The next morning, DN woke up before her daughter and left the family home at around 7.45am to do some community work.

21. JC spoke to his sister on the evening of 26 April 2019 when he heard her return home via the front door to the flat which she stayed in when visiting. That flat adjoins the family home. He did not see her as it was dark. They greeted one another before JC replied by saying he was going to sleep and that he would see her in the morning.

22. At approximately 12.30pm on 27 April 2019, DN returned home and located TS still in DN’s bed. She was cold to touch. Tasmania Police and Ambulance Tasmania were contacted and they attended.

23. In the days after her death, JC located an opened vodka bottle which was hidden in the bedroom where TS had been staying. The bottle was three-quarters full.

Investigations

24. An examination of both the deceased and the scene by officers from Tasmania police found no suspicious circumstances. In particular there were no signs of violence or disturbance.

25. The State Forensic Pathologist, Dr Ritchey, performed a post-mortem examination on 29 April 2019. Dr Ritchey says the following in his affidavit:

“The autopsy revealed a normally developed, markedly thin adult woman with a 4 cm bruise on the scalp of the back of the head. There was no underlying skull fracture.

The cerebellar hemispheres were disrupted by a large volume intracerebellar haematoma that had perforated into the subdural and subarachnoid spaces. Small bruises on the ventral surface of the left frontal brain lobe and the anterior tip of the left middle brain lobe are consistent with contracoup injury sustained in a fall backwards with the impact on the back of the head.”

26. Dr Ritchey also noted TS had advanced liver disease/cirrhosis consistent with a history of chronic alcohol abuse. In addition there was a calloused healing 5th rib fracture consistent with a previous fall or falls. In Dr Ritchey’s opinion the cause of death was traumatic closed head injury likely sustained in a fall from a standing height.

Significant contributing factors to her death were chronic alcoholism and alcohol associated cirrhosis.

27. Toxicological analysis by the forensic scientist, Neil McLachlan-Troup, determined a highly elevated alcohol concentration and a greater than therapeutic concentration of guaiphenesin in TS’ blood. The alcohol concentration was .230 g of alcohol in 100 mL of blood which is a high reading at just over 4 ½ times the statutory limit for drinkdriving offences. At .05 grams of alcohol in 100 mL of blood it has been scientifically established that impairment of a driver’s vision, perception, judgement, co-ordination and reaction time commences. At higher concentrations there is a loss of critical judgement, incoordination, reduced perception and awareness, impaired balance, a decrease in activity including sedation and sleep, nausea and vomiting, reduced responsiveness and decreased intellectual performance.

28. I accept the opinions set out in paragraphs 25 through to 27.

Comments and Recommendations

29. Given Dr Ritchey’s opinion and TS’ medical history which is set out above I am satisfied the TS fell backwards from a standing position and suffered a head injury prior to her death. Because the fall was unwitnessed it is not possible to say with any precision when the fall occurred but it is likely it occurred sometime after she spoke to her brother, JC, on her return home on the evening of the 26 April 2019. Whether this meeting between the 2 of them occurred prior to TS visiting her mother at 11.00pm or after that time cannot be, due to the state of the evidence, positively determined. The fall has however occurred prior to her retiring to bed. Further, DN says she noticed a shawl, she had placed around her daughter’s shoulders that evening

in the lounge room, was lying on the floor outside her bedroom. She noticed the shawl because she “tripped on it myself.” Again whether this was the cause of any fall cannot be determined. There are a number of potential causes for the fall including of course the high concentration of alcohol in TS’ blood.

30. The circumstances of TS’ death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

31. I extend my appreciation to investigating officer Constable Matthew Reardon for his thorough investigation and report.

32. I convey my sincere condolences to the family and loved ones of TS.

Dated: 27 May 2022 at Hobart Coroners Court in the State of Tasmania.

Robert Webster Coroner