Coroner's Finding: XY - deidentified

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased, family, friends, and others by direction of the Coroner pursuant to s57(1)(c) of the Coroners Act 1995) I, Robert Webster, Coroner, having investigated the death of XY Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is XY; b) XY died as a result of an overdose of prescription morphine in the circumstances set out below; c) XY’s cause of death was an overdose of prescription morphine, an action taken by XY acting alone and with the intention of ending his life; and d) XY died on 26 May 2019 at Hobart, Tasmania.

In making the above findings, I have had regard to the evidence gained in the comprehensive investigation into XY’s death. The evidence includes:  Police Report of Death for the Coroner;  Royal Hobart Hospital (RHH) Report of Death to the Coroner;  Affidavits establishing identity and life extinct;  Affidavit and report of Dr Donald Ritchey, forensic pathologist;  Report of Forensic Science Service Tasmania;  Electronic patient care record with respect to XY obtained from Ambulance Tasmania;

 Affidavits from family;  Affidavit of First-Class Constable Grant Cresswell;  Affidavit of Constable Leah Hicks;  Affidavit of Constable Christo Le Grange;  Affidavit of Constable Travis Smith (Glenorchy Criminal Investigation Branch);  XY’s medical records obtained from the Derwent Valley Medical Centre;  XY’s medical records obtained from the Tasmanian Health Service; and  Forensic evidence including a suicide note, XY’s pensioner concession card, and computer downloads.

Background XY was born in Belfast, Northern Ireland on 21 June 1934 and he was 84 years and 11 months at the time of his death. He married his wife of 54 years, TY, in Melbourne on 5 October 1964. TY was born in New Zealand and was on a working holiday in Australia when she met XY in 1963. After they were married, they lived in the United Kingdom where their children were born. Their third child, was born in Tasmania after the family moved to this State in 1969.

When the family first moved to Tasmania, they resided in George Town for seven months during which XY was employed by Comalco. They then moved to Tarraleah for approximately seven and a half years during which time XY worked for the Hydro Electric Commission (HEC) as it was then known. The family then moved to Boyer where XY continued working for the HEC at its substation which was situated at the Australian Newsprint Mill, Boyer. The family then moved to Barnett Avenue, New Norfolk where XY and TY resided for approximately 30 years. XY continued working for the HEC until his retirement in or about 1994.

XY’s Health Status TY says her husband was a heavy smoker all his life. She says XY was diagnosed with cancer of the bowel in or about 2008. That is confirmed by his medical records. XY underwent

adjuvant chemo and radiotherapy before the cancer was removed and a colostomy bag was fitted. Further surgery to remove the rectal stump was performed in 2009. TY says the diagnosis of cancer and subsequent treatment “caused XY to stop going anywhere.” Both TY and the medical records confirm XY’s mobility was also limited by cervical and lumbar stenosis and he suffered from emphysema which steadily worsened. In fact, he was first diagnosed with chronic obstructive airways disease in 2004. In 2011, XY underwent three urological procedures because of lower urinary tract symptoms.

Difficulties with shortness of breath are evident from the medical records for a number of years. TY says “XY’s breathing was shocking but he continued smoking until the time of his death.” On 14 November 2012, his shortness of breath had kept him up all night. By 16 September 2013, it prevented him walking for more than 15 to 20 metres. By 1 February 2019, the history given to his general practitioner is that for the last five to six months there had been a deterioration in XY’s capacity to exercise. The general practitioner noted XY was very frail and suffered from a shortness of breath after walking about 10 metres. They discussed the option of having some further tests to determine the cause of XY’s shortness of breath and to provide some treatment options. The general practitioner has then recorded the following: “but then he decided against any further tests and active management.

He has enjoyed his life and is thankful, is looked after by his wife, and now wants to rest and pass away in peace.” TY says that during the last few months of her husband’s life his breathing “had got so bad that he could hardly walk. He had lost a lot of weight because he found eating a problem and would only eat certain foods.” On 23 May 2019, the general practitioner conducted a home visit because XY’s shortness of breath was preventing him walking any more than five metres and he was unable to change the stoma and use the urethral dilator on the same day as each procedure was very draining.

He was known to have advanced chronic obstructive airways disease and, in addition, he had a sore rectal stump. On examination, he was pale and clearly not a well person. They discussed options for admission to the New Norfolk District Hospital for further care planning and some limited investigations and possibly some palliative care. XY declined all the treatment recommendations but did agree to try Ordine to dampen the feeling of the shortness of breath he was experiencing. He was advised of the maximum dose to take per day dosing at three to four hourly intervals. This drug was therefore prescribed. TY says the general practitioner told her to keep on doing what she was doing for XY as there was

nothing else that could be done. Therefore, I find that immediately before his death XY was a very frail and ill man.

The Circumstances of XY’s death On the evening prior to XY’s death his daughter MN, and her husband CN visited TY and XY and had a meal with them. The daughter describes her father as picking at some food.

After dinner they drank cups of tea, watched TV and discussed politics which the daughter describes as a common feature on her visits to see her father. She says it took him approximately 20 minutes to go to the toilet and on his return she says he looked exhausted. While he was in the toilet, she discussed his health with her mother and she told her mother her father was not looking well. They left at approximately 9.30pm and when they said goodbye to XY he stayed in his arm chair.

MN was contacted by her mother at approximately 6.50am on 25 May 2019. TY advised she could not wake XY who was seated in his chair. MN advised her to telephone an ambulance and MN and her husband immediately drove to her parents’ house arriving at approximately 7.30am. When she arrived she says her father appeared to be unconscious. CN assisted ambulance personnel in the treatment they were providing to XY. TY told MN that her father had left a note which MN read. Ambulance personnel asked her to write down the names of all XY’s medications, which she did. She placed the note, the list of medications, and an empty brown glass bottle of morphine which she retrieved from the left-hand side of XY’s chair into a zip lock bag which she handed to a female ambulance officer. XY was then taken by ambulance to the Royal Hobart Hospital (RHH).

MN and CN drove TY to the RHH where they were met by EL and AO. They all remained at the hospital for the majority of the day until early evening when EL took his mother home. AO and MN remained with their father until he passed away in the early hours of 26 May 2019.

The note which was found by TY on the coffee table in an envelope addressed to her is typed on one sheet of A4 paper. The note is addressed to “My Dearest T” and is signed off in handwriting “X” under which appears a signature. The note describes XY’s poor quality of life as a result of his emphysema, bowel cancer and prostate operations. His “greatest dread” is becoming incapacitated and therefore having to rely on his wife to do everything for him.

He says he has chosen euthanasia while his mind is still functioning. The note ends with the following: “Thank you, my Darling, for fifty four years of marriage, what a lucky man I am.”

TY says she knew her husband was in pain but there was no indication he was considering suicide. EL says, on occasion, his father mentioned that he was becoming a burden on his mother although mentally he appeared to be fine. His death came as a surprise to EL as “I didn’t think it would be something he would do.” AO says something similar. MN says at the time of her father’s death she believed he still had a very sharp mind and she was not aware of any mental health issues or suicidal tendencies.

As to the authenticity of the note found by TY, she says it was signed by her husband and he had also written “X” which he was always known to her as. She is satisfied the handwriting on the letter is his. MN says her father’s signature appears in pen at the bottom of the note.

AO says she read the note and it “was worded how he would speak and I know the signature at the bottom to be his.” In addition, I have been provided with XY’s Commonwealth pensioner concession card with his signature thereon. That signature is very similar to the signature appearing on the note. Given all of this evidence, I am satisfied that XY prepared and signed the suicide note and I therefore make that finding.

Investigation The fact of XY’s death was reported in accordance with the requirements of the Coroners Act 1995. His body was formally identified and then transferred to the RHH mortuary. At the mortuary, XY’s body was examined by Forensic Pathologist, Dr Donald Ritchey. Dr Ritchey also considered XY’s medical records, histology, and toxicological results. Dr Ritchey says “XY was found unconscious in his home adjacent to a typed signed suicide note and an empty bottle of Ordine (oral morphine liquid). An ambulance was summoned and he was given multiple doses of naloxone (opioid antidote) in the field after which he suffered a 30 second period of cardiac arrest. There was return of spontaneous circulation and he was transported to the Royal Hobart Hospital where evaluation revealed complete opacification of the left lung. He died on 26 May 2019, the day following his admission to hospital.” Dr Ritchey goes on to say that the autopsy he performed revealed advanced natural disease of the heart, its major blood vessels and advanced disease of the lungs caused by smoking.

He says there was an adenocarcinoma of the colon identified in the lung (metastatic colon cancer). Dr Ritchey says toxicology testing of samples obtained during XY’s brief hospitalisation revealed an elevated concentration of morphine and naloxone, a morphine antidote, that would have been administered during resuscitation efforts. In Dr Ritchey’s opinion, the cause of death was prescription drug (morphine) overdose. I accept Dr Ritchey’s opinion.

Comments and Recommendations Sadly, it appears XY’s physical health was such that he saw no option but to take his own life. In my view, having considered all of the evidence, none of his loved ones knew or could have been expected to know he had reached that conclusion and therefore there was no action that could have reasonably been taken by any person to prevent him from taking that course of action.

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

I extend my appreciation to investigating officer, Nicholas Ferrall, for his investigation and report.

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

Dated: 18 February 2022 at Hobart Coroners Court in the State of Tasmania.

Robert Webster Coroner