Coroner's Finding: Williams, Julie Gaye

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 Julie Gaye Williams Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Julie Gaye Williams (‘Ms Williams’); b) Ms Williams died unintentionally in the circumstances set out in this finding; c) Ms Williams’ cause of death was mixed prescription drug and alcohol toxicity; and d) Ms Williams died on 10 June 2019 at Queenstown, Tasmania.

In making these findings I have had regard to the evidence gained in the comprehensive investigation into Ms Williams’ death which includes:  The Police Report of Death for the Coroner;  Affidavits establishing identity and life extinct;  Affidavit of the State Forensic Pathologist, Dr Donald Ritchey;  Toxicology and Analytical report prepared by Juliette Tria of Forensic Science Service Tasmania;  Affidavit of Murray Barrett, partner of Ms Williams;  Affidavit of Angela Darcey, daughter of Ms Williams;  Affidavit of Kerry Tatnell; partner of Angela Darcey;  Affidavit of Susan McKenzie, sister of Ms Williams;  Affidavit of Constable Hannah Kaye;  Affidavit of First-Class Constable Fabienne Jamieson;  Affidavit of Constable Alisha Esam;  Affidavit of Constable Kerri-Anne Talbot;  Affidavit of Detective Senior Constable Shane Askew;  Affidavit of Detective Senior Constable Claire Lucas;  Affidavit of First-Class Constable Caroline McGregor;  Affidavit of Constable Justin Bennetts;  Affidavit of First Class Constable Stephen Barrow;

 Affidavit of Constable Sean Dougan;  Medical records and reports obtained from the Queenstown General Practice; and  Forensic and photographic evidence.

Background

1. Ms Williams was born Julie Gaye Polley in Hobart on 7 November 1959. She had four siblings and three children with her former husband Steven Williams. At the time of her death, Ms Williams had separated from her husband1, and was in a personal relationship with Murray Barrett. Ms Williams was in receipt of a disability pension and lived alone at Queenstown in Tasmania.

2. Ms Williams grew up in South Hobart and attended South Hobart Primary School and then Ogilvie High School. During her childhood Ms Williams was a victim of sexual abuse for a number of years and this had a profound effect on her mental health. The perpetrator was said to be a serial offender. Ms Williams did not disclose this abuse to anyone else until many years after it had occurred.

3. Ms Williams met her husband when she was about fifteen and they married when she was eighteen years of age. Sadly, their first child together was still-born. They went on to have another three children together.

4. Over the years, and in addition to the child sexual abuse and losing a child, Ms Williams experienced a number of traumatic events. First, prior to the family moving to Queensland where they resided for 12 years , Ms Williams and her friends found a friend who had suicided. After moving to Queensland Ms Williams was the first person on the scene of a fatal motorcycle crash. In addition, her father passed away in February 2000 from heart disease and lung cancer and she separated from her husband after 33 years of marriage. In 2008, Ms Williams’ sonin-law died as a result of injuries he received in an assault by a neighbour. For a period of approximately two years after her son-in-law’s death Ms Williams resided with her daughter and her daughter’s two children in an effort to assist 1 According to Ms Williams’ sister, Ms McKenzie, this occurred in or about 2010.

them to overcome this terrible tragedy. There is also evidence on file that legal difficulties one of Ms Williams’ children faced had resulted in Ms Williams suffering, in 2018, from intrusive past memories of being sexually abused as a child.

5. In or about 2013, Ms Williams met Murray Barrett at a concert at the Midway Point Tavern. They commenced a long-distance relationship not long after, as Mr Barrett lived in Northern Tasmania. Mr Barrett visited Ms Williams at her home in Sorell on weekends or when he had time off and he continued to visit her when she moved to Queenstown in 2018 to live in a home owned by an aunt.

Medical history

6. Ms Williams had an extensive medical history predominantly related to mental health and alcohol-related physical conditions. Prior to her death Ms Williams suffered from angina, thiamine deficiency, magnesium deficiency, iron deficiency, hypercholesterolaemia, alcohol addiction, nicotine dependence, anxiety, chronic depression, post-traumatic stress disorder (PTSD), and bipolar affective disorder.

Ms Williams took various prescribed medications to address these health issues.

She also had a history of self-medicating with alcohol to manage her chronic depression and PTSD.

7. Ms Williams was first diagnosed with depression in 1979. She, as set out in paragraphs 2 to 4, experienced various stressors in her life which contributed to her declining mental health. She was admitted to hospital multiple times for treatment for major depression, including ECT treatments and various psychotropic medications. In more recent years there had been some stability in Ms Williams’ mental health, however from 2018 there was an exacerbation of her past stressors which led to a decline in her mental wellbeing, with increased depressed mood and anxiety. In this period, Ms Williams said she was significantly distressed about one of her children’s legal difficulties and the fact that she herself lost her driver licence for a high range drink driving offence. These factors contributed to her move to Queenstown.

8. Ms Williams was admitted to hospital in August 2018 following a polypharmacy overdose. She was admitted to hospital in respect of an attempted suicide in similar circumstances in 2005.

9. Following her release from hospital in 2018, Ms Williams was referred to and saw Dr Helen Driscoll, a psychiatrist, and she was supported by crisis assessment and treatment team members to address some of her mental health issues. Ms Williams disclosed to Dr Driscoll that she was experiencing intrusive past memories about the child sexual assault she suffered from the ages of five to 11.

The specific trigger for these memories was disclosed to Dr Driscoll by Ms Williams. She told Dr Driscoll she felt overwhelmed and fearful of “going back into the terrible dark hole… I can feel myself slipping… I can’t go there.” The family had experienced social isolation due to the legal difficulties and pending court action against one of her children and they had also had their home physically damaged and broken into. They had been yelled at in the street and in shops by people regarding the court action. Subsequently, they adopted a lifestyle of social isolation and avoidance which necessitated multiple house moves. Notes from an assessment with Dr Driscoll on 21 August 2018 show Ms Williams was suffering the following symptoms associated with depressed mood and exacerbation of

PTSD:  Crying easily;  Panic attacks with increased anxiety;  Hypervigilance and a need to isolate herself from people and stimulus overload;  Guilt that she did not disclose the child sexual abuse when she was a child, hence blaming herself that there were further victims;  Irritability and fatigue; and  Intrusive post-traumatic memories.

At this time, Ms Williams denied feeling “overtly suicidal and said that she was not imbibing in alcohol to try and deaden her severe anxiety… However, she is experiencing a familiar, deep struggle.”

10. Over the years, Ms Williams became dependent on alcohol and admitted that prior to her admission to hospital in 2018 she was drinking alcohol until she passed out approximately three times a week. Mr Barrett knew of Ms Williams’ drinking problem ever since they met. He had also spoken to her in the past about her mental health. Mr Barrett knew “she had previously and was still suffering from bouts of depression.” He stated that “[i]t did not seem to affect her all of the time.” Mr Barrett was also aware Ms Williams had attempted suicide in the past.

He reported that she “had read somewhere that a few glasses of alcohol would improve depression.” Unfortunately it is well known using alcohol as a way to selfmedicate depression can significantly impact physical and emotional well-being.

Previously, Mr Barrett had located a wine glass in one of the kitchen cupboards which smelt of alcohol. Other members of Ms Williams’ family were also aware Ms Williams had issues with alcohol and suicidal ideation. According to Ms Williams’ sister, Ms Williams had been intercepted by police and charged with drink-driving in 2018 after she consumed a bottle of vodka and drove with the intention of jumping off the Tasman Bridge.

11. On 4 February 2019, Ms Williams fell at home and broke her left wrist. She attended her general practitioner on a number of occasions in relation to this injury. Mr Barrett understood that this injury occurred when Ms Williams was making her bed and holding up a sheet. He stated that she tripped over a power cord and fell on her wrist.

12. On 19 February 2019, Ms Williams attended an appointment with her general practitioner to discuss a management plan for her ischaemic heart disease, iron deficiency, and bi-polar disorder diagnoses. At this appointment, she said she had been a heavy drinker but had not had a drink since last year.

13. On 2 March 2019, Tasmania Police attended Ms Williams’ home after her cousin raised concern for her wellbeing. Ms Williams had told her cousin that she “would not be here tomorrow.” Attending police officers located Ms Williams and determined she had consumed alcohol and she was in a highly emotional state.

Given what the officers observed they had concerns for Ms Williams’ safety so they therefore transported her to the North West Regional Hospital in Burnie

where she was admitted for treatment. First-Class Constable Barrow says while at the hospital Ms Williams informed the triage nurse she had intended to attempt to take her life through an overdose of sleeping pills. While in hospital Ms Williams returned a blood alcohol reading of 0.195 grams of alcohol in 100 mL of blood. She said she had been drinking to ‘numb her feelings’ as she felt useless and guilty. Ms Williams was discharged from hospital at midday the next day.

14. On 3 April 2019, Ms Williams was prescribed amongst other things acamprosate.

Acamprosate, sold under the brand name Campral, is a medication used along with counselling to treat alcohol use disorder. Acamprosate is thought to stabilize chemical signaling in the brain that would otherwise be disrupted by alcohol withdrawal. This is a medication used along with counselling and support to help alcohol-dependent individuals to not drink alcohol.

15. On 16 April 2019, a Home Medication Review ‘Report and Management Plan’ was conducted by Dr Matt Despot. This involved a discussion between Dr Despot and Ms Williams as to what medications she was taking at home. At this review, the following matters were discussed:  Monitoring of adverse metabolic effects of quetiapine;  Alcohol abstinence therapy – increase dose of acamprosate;  Reduce dose of nicotine replacement therapy;  Monitoring for episodes of angina;  Monitoring of ferritin levels; and  Adherence to therapy.

Ms Williams’ dose of acamprosate was increased due to the hospital admission in March 2019 as it was thought the increase “would be warranted to minimise the risk of readmission.”. Regarding Ms Williams’ adherence to therapy, Dr Despot was “comfortable with the notion that she is adhering well to current therapy” because she uses a dosette box to ensure she remains compliant and she packs the dosette box at least once per week.

16. Mr Barrett says Ms Williams was on a lot of prescription medication and as far as he knew she took her medication regularly. Mr Barrett did say she tended to take her medication in private and so he did not often see her physically take it.

17. On 5 June 2019, Ms Williams was referred by her general practitioner to the Adult Community Mental Health Service in Burnie for an opinion and management of her complex PTSD. She was also prescribed diazepam. The referral response form from the Department of Health and Human Services (Mental Health Services South)2 shows that department requested the referral be forwarded to Psych2U (tele-health) or Dokotela (tele-health) for consultation instead given Ms Williams had been discharged from that organisation’s service in Hobart. The registered psychiatric nurse believed this and the fact she was located in Queenstown meant a tele-health service was the most appropriate option for treatment.

18. Ms Williams last visited her general practitioner on 6 June 2019. At this visit, her care plan was reviewed. At the time of her death, Ms Williams’ next appointment was scheduled for 11 June 2019.

Circumstances of Ms Williams’ death

19. Prior to her passing the evidence is Ms Williams had been planning the food for her granddaughter’s 18th birthday. In addition she was looking forward to her grandson’s Jiu Jitsu competition in Launceston and she was planning on travelling to Hobart to stay with her mother.

20. Mr Barrett arrived in Queenstown mid-afternoon on Friday 7 June 2019 to spend time with Ms Williams. He did not see her drink alcohol on that day or over the weekend of 8 and 9 June 2019.

21. On 8 June 2019, while at home Mr Barrett noticed Ms Williams was “staggering around the house” but she seemed otherwise happy. In the past, Ms Williams had told him that her medication made her “dizzy.” 2 Also dated 5 June 2019.

22. On 9 June 2019, Ms Williams and Mr Barrett spent the day either in Queenstown or at the house. The spent time together in the afternoon relaxing. Ms Williams cooked the two of them dinner at about 7.30pm. Mr Barrett observed that evening Ms Williams was beginning to slur her words and become unsteady. He did not see her drink but, in his opinion, “she looked as if she was getting drunk.”.

Mr Barrett was not aware of any alcohol in the house at the time except for an unopened bottle of Jim Beam in one of the kitchen cupboards which belonged to him. Mr Barrett did not see her take any medication that evening but, as stated earlier, this was not unusual because she usually took her medication in private.

23. After dinner, Ms Williams and Mr Barrett went outside together to smoke a cigarette. Mr Barrett “told her to go to bed” because she was unsteady on her feet and he told her he thought she had been drinking. Ms Williams calmly went back inside and locked the door, telling Mr Barrett that she did so to keep him out of the house. This had happened before and Mr Barrett says he lets her go when he thinks an argument is about to happen. On this occasion he let her go inside alone in order to avoid an argument. As a result they did not argue or shout at one another.

24. While waiting outside, Mr Barrett could hear the water running in the kitchen sink so he thought Ms Williams was washing the dishes. He waited outside until he saw the bedroom light go off which suggested to him she had gone to bed.

25. At approximately 8.30pm, Mr Barrett used a spare key hidden outside to let himself back into the house. He went into Ms Williams’ bedroom and observed her lying flat on her stomach on the bed. He could hear her snoring. He then left the bedroom, closed the door, and went to watch television. He fell asleep on the couch until he woke up later and turned the cricket on. He is not sure what time this occurred. He watched the game until the last over and then checked his phone at 3.00am3. Mr Barrett then went to Ms Williams’ bedroom door and could hear her snoring. He did not go into the bedroom or open the door because he did not want to wake her. He went back to the couch where he slept 3 On 10 June 2019.

for the rest of the night. He did not hear any noises during the night. Mr Barrett describes himself as a light sleeper who wakes easily.

26. Mr Barrett woke up at approximately 8.30am on 10 June 2019. He smoked cigarettes outside and did some housework until approximately 11.00am. He then went to the petrol station to check if it was open and returned half-an-hour later.

He did not want to disturb Ms Williams because she normally “sleeps in late”.

27. When Mr Barrett returned at approximately 11.30am she was still not up so he went into her bedroom to tell her that he was returning to his home. As he entered the bedroom he observed Ms Williams deceased and lying on the floor wrapped up in a blanket. He noticed her legs were a blotchy colour. He saw part of her arm from under the blanket and it was lying on a “funny angle”. All he could see was her legs from the knees down and about half of her left arm. He knew something was wrong. He pulled the blanket from under her which was difficult because she, including her head, was wrapped tightly in the blanket. When he removed the blanket from her upper body, Mr Barrett observed her head was against her chest and he saw a lot of what he described as very dark/purple bruising on the back of her neck and on the top of her back/shoulder area. Her face and one of her arms was also bruised. The rest of her skin was red in colour.

She was cold and hard to touch. He could not find a pulse. He attempted to find a heartbeat but could not. As soon as he saw her and the way her neck was positioned he knew she had passed away.

28. He immediately left the room and called 000 for the ambulance and police. He asked the operator if he could put a blanket over her and he was told he could.

He went back inside the bedroom and put a white doona that was on the floor over her and he waited outside under the carport until the police and ambulance arrived.

Investigation

29. Tasmania Police4 and Ambulance Tasmania (AT)5 attended the scene together and spoke to Mr Barrett, who was waiting outside the house. The AT officer confirmed Ms Williams was deceased at 12.12pm. Members of the Burnie Criminal Investigation Branch (CIB) and Forensic Services of Tasmania Police6 were contacted and they attended the scene. The scene was examined and photographs were taken.

30. In addition, Tasmania Police searched the house for any items of interest including alcohol, drug paraphernalia or other items that may have been relevant in the investigation of Ms Williams’ passing. Two vehicles which were parked in the driveway were also searched. Two neighbours were spoken to on 10 June 2019 but they said they heard nothing and saw nothing unusual the previous night or that morning. No alcohol was located except for the bottle referred to in paragraph 22. The examination and search of the scene led the two CIB officers to conclude that there were no suspicious circumstances surrounding Ms Williams’ death.

31. The State Forensic Pathologist, Dr Ritchey, performed a post-mortem examination on 12 June 2019. Dr Ritchey did not find any signs of violent injury. In particular he says there was no bruising on the upper back or neck. There were no scalp contusions, skull fractures or intracranial collections of blood. An examination of the soft tissues of the neck revealed no neck trauma. There was no haemorrhage within the strap muscles or base of the tongue and the hyoid bone and thyroid cartilage were intact. The bruising described by Mr Barrett is explained by Dr Ritchey as being “fixed pink lividity is present on the anterior surfaces of the body including the face except in areas exposed to pressure consistent with the position in which the body was reportedly found.” Dr Ritchey found food debris in the trachea and he says the lungs were markedly heavy and congested. Microscopic sections of lung confirmed large volume aspiration of probable gastric content; 4 Constables Kaye and Jamieson.

5 Officer Gamblin.

6 Dectective Senior Constable Askew, Detective Senior Constable Lucas and First Class Constable McGregor.

that is something that has been swallowed, for example food, has “gone down the wrong way “, that is into the lungs rather than the stomach. Dr Ritchey goes on to say that toxicology testing of samples obtained at autopsy revealed markedly elevated blood ethanol in addition to several prescription medications. He says “ethanol and the medications are all central nervous system depressants that, in combination, cause stupor during which time the airways are vulnerable to aspiration of gastric contents and oral secretions”. Dr Ritchey concluded that Ms Williams’ cause of death was mixed prescription drug and alcohol toxicity (ethanol, diazepam, fluoxetine, and quetiapine). Chronic alcoholism and major depression were contributory factors. He also notes Ms Williams had moderate atherosclerotic coronary vascular disease. I accept the opinions of Dr Ritchey.

32. The toxicology report indicates Ms Williams had a very high blood alcohol content of 0.314g of alcohol in 100ml of blood. The level, as expected, was higher in the vitreous humour (.375g/100ml) and higher still in the urine sample (.400g/100ml). The report says that although blood alcohol concentrations in excess of 0.400g/100ml are potentially fatal, deaths have also been reported at concentrations as low as 0.200g/100ml. Such concentrations of alcohol can cause death from a combination of respiratory, cerebral and cardiac depression.

Depression of respiration is the most serious toxic effect of alcohol at higher concentrations. These effects along with underlying conditions such as cardiorespiratory disease and/or obstructed airways can cause death at the lower blood alcohol concentrations. Therapeutic levels of Atorvastatin, fluoxetine, and quetiapine were also detected in addition to sub-therapeutic levels of diazepam.

The presence of these drugs at these levels is consistent with Ms Williams’ use of her prescription medication. I accept the opinions set out in this report.

33. The toxicology results are consistent with Mr Barrett’s observation that Ms Williams “looked as if she was getting drunk”. The results also suggest it is likely Ms Williams had hidden alcohol on the property which she consumed on the evening of 9 June 2019. Ms Darcy notes her mother started hiding alcohol around the house as long ago as 2001 and Ms McKenzie says she was aware that over the years her sister was drinking a lot of alcohol and she was trying to hide it.

34. Ms Darcy and Mr Tatnell have, in their statements, raised a number of concerns with respect to Ms Williams’ death and Mr Barrett. These included the level of detail Mr Barrett was telling people with respect to Ms Williams’ death including the location and position she was found, he attempted to close her bank accounts, he re-made the bed in the bedroom where Ms Williams died with fresh blankets and questions over whether Ms Williams died on the bed or the floor where she was located by police. In addition they raised a concern of possible family violence between Ms Williams and Mr Barrett. The investigating officer, Constable Kaye, has advised there is no family violence history between Ms Williams and Mr Barrett on police systems and no incidents involving them have been reported to police. In addition, I am satisfied given the investigations set out in paragraphs 29 to 33 there are no suspicious circumstances surrounding Ms Williams’death.

Comments and Recommendations

35. I am satisfied given the evidence set out above Ms Williams died at some time after 3.00am on 10 June 2019 as a result of the cause identified by Dr Ritchey.

Despite Ms Williams’ mental health difficulties and her previous suicide attempts, the circumstances of her death and the plans she had for the future which are set out in paragraph 19 lead me to the conclusion that her death was unintentional.

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

Acknowledgements

37. I extend my appreciation to investigating officer Constable Hannah Kaye for her investigation and report.

38. I convey my sincere condolences to the family and loved ones of Ms Julie Williams.

Dated: 20 June 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner