Deceased
David Godfrey Edwards and Nelda Mavis Edwards
Date of death
2016-03-02 and 2016-03-04
Finding date
2024-07-26
Cause of death
David Edwards: disseminated lymphomatosis complicating large B-cell lymphoma. Nelda Edwards: mixed drug (morphine, midazolam, oxazepam and valproic acid) toxicity
AI-generated summary
David Edwards, aged 90, died of disseminated lymphomatosis (advanced lymphoma) on 2 March 2016. His death was natural and expected given his terminal illness. His wife Nelda Edwards, aged 88, died two days later on 4 March 2016 from mixed drug toxicity (morphine, midazolam, oxazepam and valproic acid). Their son Stephen Edwards, a general practitioner, administered lethal doses of drugs prescribed for his father to his mother without medical indication, professional consultation, or her informed consent. Stephen Edwards had obtained injectable medications from a locum GP (Dr Forrester) on 1 March 2016 by misrepresenting his father's condition and requesting palliative care medications. Stephen then administered oral and parenteral drugs to his mother on 4 March with the express intention of causing her death. The coroner found no clinical errors in David's care but identified serious concerns regarding Stephen Edwards' conduct: he concealed his involvement from police and medical practitioners, provided multiple inconsistent accounts of his motivation, and administered potent opioids and benzodiazepines without proper assessment, documentation, or safeguards. A second son, Robert Edwards, was present during the administration and placed his hand over his mother's nose and mouth as she died, though the coroner found this did not contribute to her death. The case highlights the dangers of prescribing potent medications without direct patient assessment and the risks posed by healthcare professionals with insider knowledge misusing their position.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
FINDINGS of Coroner Simon Cooper following the holding of an inquest under the Coroners Act 1995 into the deaths of: David Godfrey Edwards and Nelda Mavis Edwards
Contents
Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the deaths of David Godfrey Edwards and Nelda Mavis Edwards with an inquest held at Hobart in Tasmania, make the following findings.
Hearing Dates 16-18 October and 23 November 2023 15, 16 and 18 January 2024 Representation Counsel Assisting the Coroner – M Allen Dr J Forrester – A Mills Stephen Edwards – L Steer Introduction
An accountant during his professional life, he retired in about 1983.
Mrs Edwards was born 27 February 1928 at Orielton, near Sorell. During her working life she was employed as a mothercraft nurse.
Together, Mr and Mrs Edwards had 4 sons - Robert, Glendon, Stephen, and Leigh.
Glendon (previously a teacher who had apparently stopped teaching in this state for “legal reasons”2) died in Thailand on 20 February 2016 (although his body was not found until 23 February), shortly before his parents. The remaining three sons were 1 Exhibit E 34 A, affidavit of Leigh Graeme Edwards, sworn 8 March 2016, page 1 of 6.
2 Supra, page 2 of 6.
all present at the family home when their mother died; Stephen and Leigh were present when their father died.
Both Mr and Mrs Edwards were naturally enough, given their age, in relatively poor health. Mrs Edwards had been formally diagnosed as suffering from mild to moderate dementia, along with various other ailments. Mr Edwards was, in effect, her carer, although he was far from well himself. The couple received support from their youngest son Leigh, who lived nearby, and from the KinCare organisation, which provided ‘in home’ assistance once a week.
On 2 March 2016, David Edwards died at home, aged 90 years. His death was not reported pursuant to the provisions of the Coroners Act 1995 (the ‘Act’). A Medical Certificate as to Cause of Death (MCCD) was issued. This meant that the matter was not investigated (initially at least) under the Act.
Two days later, on 4 March 2016, Mrs Edwards died, also at home. She was aged 88 years. Her death was reported pursuant to the provisions of the Act, although her son Stephen Edwards, then a medical practitioner, attempted to persuade another medical practitioner to issue a MCCD, but was quite properly refused. Stephen Edwards did not tell that medical practitioner that he had administered any drugs to his mother.
Neither did he tell police he had administered any drugs to his mother, saying in his evidence that he did not consider it was appropriate to discuss that fact with ‘nonmedical people’. That explanation sits uneasily with his failing to discuss the same issue with the medical practitioner whom he attempted to persuade to issue a MCCD.
Initially at least, Mrs Edwards’ death was not thought to be in any way suspicious but the investigation that followed under the provisions of the Act revealed some very suspicious circumstances indeed. An autopsy found that Mrs Edwards had died of mixed drug toxicity. In lay terms, she had been poisoned.
Mr Edwards’ body was retrieved from the UTAS Medical School (it having been donated to science in accordance with his wishes). An autopsy confirmed his death was due to natural cause, namely lymphoma.
The investigation revealed that Stephen Edwards, at the time a medical practitioner, had been ‘treating’ both of his parents in the immediate lead up to their deaths, although he did not initially tell investigating police that.
After an extensive coronial and criminal investigation, in late April 2016 Stephen Edwards was arrested in NSW, charged with the murder of his mother, and extradited to Tasmania.
In January 2018, Robert Edwards was charged, under the Criminal Code, with the assault of his mother as she lay dying on 4 March 2016. That charge was not proceeded with. However, he was subsequently charged on an indictment, along with Stephen Edwards, with conspiracy. The allegation against the brothers was that, in the aftermath of their mother’s death and while it was being investigated, they conspired with one another to obstruct, prevent, pervert or defeat the due course of justice by agreeing to provide misleading and/or false information to investigating police as to the circumstances of her death.
Eventually the prosecution of both men in relation to their mother was discontinued by a nolle prosequi 26 March 2020. The prosecution was discontinued because the Director of Public Prosecutions concluded that there was no public interest in it continuing.
That decision having been made there was, therefore, no impediment to the inquest continuing.
On 23 January 2023 the Chief Magistrate’s Delegate, Coroner McTaggart directed, pursuant to section 50 of the Act that the deaths of Mr and Mrs Edwards be investigated at the one inquest.
It is important to note that after the prosecution was discontinued against him, Stephen Edwards wrote and published a book about his mother’s death.3 He gave media interviews about his mother’s death (presumably to publicise his book).4
In those interviews he was quoted as saying he wanted an inquest to ‘clear his name’.5 Despite expressing a strong desire for an inquest to be held in relation to his mother’s death, through his lawyer he took a number of procedural points. He challenged the direction for the inquests to be heard together, a challenge utterly without merit. He challenged his summons to give evidence at the inquest on the basis the street address on it was wrong. While doing so, he refused, through his lawyer, to provide his current address, because his lawyer said “Dr Stephens [sic] is not obliged to provide his present address or whereabouts to the Coroner, as the Crown has confirmed that he is no 3 Exhibit E 120 - Evil Conjectures, A Sense of Place Publishing 2022 4 Exhibits E 121 - The Mercury 22 November 2022 and E 122 - The Australian 21 June 2023.
5 Op cit.
longer bailed in this matter”.6 While Stephen Edwards had been released on bail in relation to the murder of his mother, he was never on bail in relation to the Coronial Investigation or Inquest. It is trite to observe that the two proceedings are completely separate.
His final procedural point, through his lawyer, was to submit at the inquest that he ‘wished to exercise his right to silence’, which I took to mean that he asserted that he was entitled to lawfully refuse to answer any questions if the answers to those questions might tend to incriminate him.
Given Stephen Edwards was not in a practical sense, at jeopardy of any further proceedings and that he was uniquely positioned to assist me in determining the cause and circumstances of his mother’s death, I did not consider it was unfair to order him, pursuant to section 53(1)(c) of the Act, to answer questions at the inquest. I observe that, having called loudly and publicly for an inquest to ‘clear his name’, it was little short of absurd of Stephen Edwards to then seek to refuse to give evidence at that inquest.
The Coronial jurisdiction
Before considering the circumstances of Mr and Mrs Edwards’ deaths in detail, it is necessary to say something about the general role of the coroner. In Tasmania, a coroner has jurisdiction to investigate any death that appears to “have been unexpected, unnatural or violent or to have resulted directly or indirectly from an accident or injury”.7 A death as a result of the administration of prescription drugs meets this definition.
If a coroner suspects that a reported death was the result of homicide then she or he must hold an inquest.8 The Act defines an “inquest” as a “public hearing”. I held that suspicion, so far as the death of Mrs Edwards was concerned.
When conducting an inquest, a coroner performs a role very different to other judicial officers. The coroner’s role is inquisitorial. An inquest might be best described as a quest for the truth, rather than a contest between parties to either prove or disprove a case. In an inquest a coroner is required to thoroughly investigate the death and answer the questions (if possible) that section 28(1) of the Coroners Act 1995 asks. Those questions include who the deceased was, how they died, the cause of the person’s death, and where and when the person died. It is settled law that this 6 Email Louise Steer LLM LLB BA(Hons), Principal Steer Martin Lawyers, 3 October 2023.
7 Section 3 of the Coroners Act 1995.
8 Section 24 (1) (a).
process requires a coroner to make various findings, but without apportioning legal or moral blame for the death.9 The job of the coroner is to make findings of fact about the death from which others may draw conclusions. A coroner may, if she or he thinks fit, make comments about the death or, in appropriate circumstances, recommendations to prevent similar deaths in the future.10
It is important to recognise that a coroner does not punish or award compensation to anyone. Punishment and/or compensation are for other proceedings, in other courts, if appropriate. Nor does a coroner charge people with crimes or offences arising out of a death that is the subject of investigation.
It is not any part of the role of a coroner to comment upon decisions to lay charges, not lay charges or discontinue a prosecution once charges have been laid.
As I have already said, proceedings under the Act are completely distinct from criminal or civil proceedings.11 This separation is highlighted by a coroner’s obligation to adjourn any inquest in relation to a death once informed that a person has been charged with, inter alia, murder arising out of the death being investigated.12 The Act provides that any inquest cannot be resumed until after the conclusion of the criminal proceedings.13
As was also noted above, one matter that the Act requires, is a finding (if possible) as to how the death occurred.14 ‘How’ has been determined to mean ‘by what means and in what circumstances’,15 a phrase which involves the application of the ordinary concepts of legal causation.16 Any coronial inquest necessarily involves a consideration of the particular circumstances surrounding the particular death so as to discharge the obligation imposed by section 28(1)(b) upon the coroner.
The standard of proof at an inquest is the civil standard. This means that where findings of fact are made, a coroner needs to be satisfied on the balance of probabilities as to the existence of those facts. However, if an inquest reaches a stage where findings being made may reflect adversely upon an individual, it is well-settled 9 R v Tennent; Ex Parte Jager [2000] TASSC 64.
10 Section 28 (2).
11 See Pearce v McTaggart [2023] TASSC 37. Although that case was concerned with the intersection of the jurisdiction of the Coroner with the role of WorkSafe Tasmania in investigating and prosecuting breaches of the Work Health and Safety Act 2012, the principle I think the judge was trying to explain is sound.
12 Section 25 (2)(a).
13 Section 25 (3).
14 Section 28(1)(b).
15 See Atkinson v Morrow [2005] QCA 353.
16 See March v E. & M.H. Stramare Pty. Limited and Another [1990 – 1991] 171 CLR 506.
that the standard applicable is that expressed in Briginshaw v Briginshaw, that is, that the task of deciding whether a serious allegation against anyone is proved should be approached with a good deal of caution.17
A coroner is not bound by the rules of evidence in holding an inquest and may be informed and conduct an inquest in any manner the coroner reasonably thinks fit.18 To be properly received at an inquest, the evidence must be capable in some way of assisting the coroner to determine the matters under section 28 (1) or, in appropriate circumstances, to assist in making a comment or recommendation. A coroner has significant latitude in receiving evidence, providing the evidence is something more than “mere supposition, guess or intuitive hypothesis”.19 The question of weight to be given to any evidence tendered at an inquest is a matter for the coroner after receiving submissions from interested parties.
It should be highlighted that the coronial process, including an inquest, is subject to the requirement to afford procedural fairness.20 A coroner must ensure that any person who might be the subject of an adverse finding or comment is made aware of that possibility and given the opportunity to fully put their side of the story forward for consideration. Stephen and Robert Edwards and Dr Forrester were identified as such persons in this inquest. In accordance with this requirement, they were apprised of the fact of the inquest and that the potential existed for an adverse finding. Each was provided complete disclosure of all documentation relevant to the investigation.
Each was also afforded the opportunity to appear at the inquest and to have legal representation.
Finally, it should also be noted that the Act expressly provides that a coroner ‘must not include in a finding or comment [sic] any statement that a person is or may be guilty of an offence’.21 Offence in this context must also include ‘crime’.22 Investigation
As I have already pointed out initially, the fact of Mr Edward’s death was not reported pursuant to the provisions of the Act. No criticism should be made of anyone for not reporting his death in its immediate aftermath. There was no reason to do so. In 17 (1938) 60 CLR 336 (see in particular Dixon J at page 362).
18 Section 51.
19 See my ruling and reasons in the Inquest into the deaths of Craig Nigel Gleeson, Alistair Michael Lucas and Michael George Welsh dated 1 February 2018, and the authorities referred to therein. The ruling was upheld in both the Full Court and the High Court.
20 See Annetts v McCann (1990) 170 CLR 596, Attorney General v Copper Mines of Tasmania Pty Ltd
21 Section 28 (4).
22 See also section 46 of the Acts Interpretation Act 1931.
contrast, the fact of Mrs Edwards’ death was reported to police at about 9:20pm on the day of her death, Friday, 4 March 2016. Police attended the family home and took the details necessary to complete a formal report of death to the coroner.
During the attendance of police, Stephen Edwards, Robert Edwards and Leigh Edwards were all present. The evidence is that Stephen Edwards and Robert Edwards did the talking, mostly Stephen Edwards. As I have already said, he did not tell police that he had been “treating” his mother (or for that matter his father). He did not tell police that he had administered medication which had been prescribed for his recently deceased father to his mother and that following the administration of doses of drugs his mother became unconscious. He did not tell police that after his mother became unconscious, he administered more IV morphine and more IV midazolam and she then died. Despite subsequent interviews, a detailed letter to me,23 publication of the book, and media interviews, no coherent reason has ever been advanced by Stephen Edwards as to why he did not advise police of those matters in the immediate aftermath of his mother’s death. The failure to provide a coherent reason did not change when he gave evidence at the inquest.
Initially, nothing suspicious about the death of Mrs Edwards was identified. Given her age, the probability that she had died of natural causes seemed likely, although the fact that her death so quickly followed that of her husband was thought a little unusual. In any event, the usual direction was made by me for an autopsy to be carried24 out by forensic pathologist, Dr Donald Ritchey. Dr Ritchey duly carried out that autopsy. He could not find any pathological cause for her death. It was only after toxicological analysis of samples taken at autopsy showed that Mrs Edwards had died as a consequence of mixed prescription drug toxicity25 that the matter began to be looked at in closer detail.
Stephen Edwards was quickly identified as a person of interest in relation to his mother’s death. At the time of her death, he had been a General Practitioner practising in coastal New South Wales. He was spoken to by police and initially denied knowing the cause of his mother’s death or having any knowledge of any medication being administered to her. He told police his mother had indicated a wish to be with his father and he described talking with his mother and holding her hand when she 23 Op cit.
24 See section 36 (1).
25 Exhibits E 13 and 14.
died. In his first account, Stephen Edwards said he suspected ‘renal failure may have been the reason she passed away.’26
In that second interview, he made a number of admissions to his having administered significant doses of morphine, midazolam and clonazepam to his mother on the day of her death.27
Evidence at the inquest
The witnesses who gave evidence at the inquest, in order, were: a. Detective Constable Andrew Peterson – Investigating Officer; b. Dr Jonathan Forrester, General Practitioner; c. Dr Donald Ritchey, Forensic Pathologist; d. Mrs Vivian Edwards; e. Mr Leigh Edwards; f. Mr Robert Edwards; g. Cassandra Edwards; h. Ms Miriam Grist, Forensic Scientist; i. Dr Elizabeth Monks, General Practitioner; j. Professor Carol Douglas; and k. Mr Stephen Edwards.
In addition to the witnesses who gave evidence at the inquest a significant amount of other evidentiary material in the form of affidavits, recordings, medical records and suchlike was tendered. A complete list of the documentary exhibits received by me at the inquest is attached to this finding and marked as Annexure 1.
Associate Professor Maurice O’Dell also reviewed the circumstances surrounding Mrs Edwards’ death and provided a comprehensive report. He was unavailable as a witness. Mr Stephen Edwards and Dr Forrester both objected to Dr O’Dell’s report being received as evidence at the inquest.
The starting point in determining any question of admissibility of evidence at an inquest is section 51 of the Coroners Act 1995 which provides that “a coroner holding an inquest is not bound by the rules of evidence and may be informed and conduct an inquest in any manner the coroner reasonably thinks fit”.
26 Exhibit E 54 27 Exhibit 76A
Neither suggested that Associate Professor O’Dell was not qualified to express the opinions that he did. I am satisfied that he was more than qualified to express the opinions that he did. Nor was it submitted that the report was not relevant to at least some of the issues I am required to determine.
The issue then, properly understood, is one of procedural fairness and weight. Several witnesses were questioned about whether they agreed (or disagreed) with aspects of the report. This fact is directly relevant to the exercise of my discretion whether to admit the report as evidence and what weight it should be afforded.
I am satisfied it is entirely appropriate to have regard to the report. It will be formally admitted into evidence.
Circumstances of the Death of David Edwards
Mr and Mrs Edwards were both under the care of Dr Elizabeth Monks, a General Practitioner.28 In the immediate lead up to their deaths, Dr Monks was absent from her practice and a locum, Dr Jonathan Forrester, was providing their care. He had commenced at the practice on 14 December 2015.
Dr Forrester first saw Mr Edwards on 28 January 2016 for a routine appointment. He saw Mrs Edwards on the same day and checked her blood pressure.
On 24 February 2016, Mr Edwards saw Dr Forrester. He was accompanied by Mrs Edwards and Leigh Edwards. Mr Edwards had been unwell for several days, suffering constipation, a slightly raised temperature and swollen ankles. Dr Forrester ordered blood tests and arranged to see him two days later.
Later that night, Leigh Edwards was advised by Tasmania Police of the death of his brother Glendon in Thailand. Leigh contacted his brothers Stephen Edwards and Robert Edwards and advised them of Glendon’s death. Stephen was in New South Wales and Robert in Queensland.
The following day, 25 February 2016, Leigh Edwards told his parents of Glendon’s death. The news was a terrible shock to them both. Mr Edwards, who as I have already said was ill, evidently deteriorated rapidly.
28 Exhibits 109, 110
On 26 February 2016, Mr Edwards soiled his bed. He had an appointment that day with Dr Forrester but did not keep that appointment. After it was cancelled, Dr Forrester telephoned the Edwards’ home. He spoke to Mrs Edwards. She explained that Glendon had died, that her husband was in bed and did not want to come to the telephone. Dr Forrester suggested because of the blood test results Mr Edwards should go to hospital. Mr Edwards refused – a decision Dr Forrester respected.
During their telephone discussion Mrs Edwards told Dr Forrester that she ‘wanted to die’ and asked him to ‘come around and give her an injection’, something Dr Forrester understood to be with the view to ending her life and which, naturally, he explained he was unable to do.29
Saturday 27 February 2016 was Mrs Edwards’ birthday. Both she and her husband spent the day, or most of it, in bed.
On Monday 29 February 2016, Leigh Edwards rang Stephen Edwards and apprised him of the condition of their parents. Stephen Edwards telephoned and spoke to Dr Forrester. In the conversation Stephen Edwards told Dr Forrester that: “He had spoken with his mother and siblings and felt his father was refusing to eat, feeling generally unwell and sleeping a lot. Stephen told [Dr Forrester] that he was in Sydney at this point but was flying home to Tasmania that evening. [Dr Forrester] offered to do a home visit to see David which Stephen declined. He then requested [Dr Forrester] prescribe two medications, Ordine oral solution 2mg/ml as well as Clonazepam liquid 2.5mg/mL to help with palliative care. [Dr Forrester] agreed to do this as when someone is dying [he considered it to be] … a reasonable request.”30 Dr Forrester then entered the details of the prescription into the practice computer.
Leigh Edwards collected the prescription from the medical centre later that day.31
On 1 March 2016, Stephen Edwards flew to Hobart. Upon his arrival at the family home, he immediately administered a dose of oral morphine to his father. Since he did not keep any records of the doses of medication, type of medication and the time such medication was administered to his father, it is unclear how much he administered.
Later that day, Stephen Edwards went to Dr Forester’s practice and met with him in person. Dr Forrester said that Stephen Edwards told him that his father was Cheyne 29 Exhibit E112, Statutory Declaration – Jonathan Forrester, 8 March 2016, page 2 of 4.
30 Supra.
31 Supra.
stoke breathing, taking nothing orally and was dying. He also told Dr Forrester during that conversation that he was a general practitioner and, prior to becoming a doctor had worked as a nurse. He said he had experience in palliative care. It does not seem to me unreasonable for Dr Forrester to have taken Stephen Edwards at his word. He knew from other staff at the practice that Stephen Edwards had previously worked there.
Stephen Edwards requested Dr Forrester prescribe midazolam injections 5mg/1mL, morphine sulphate injections both 10mg/1mL and 30mg/1mL. Dr Forrester considered this to be a reasonable request in light of Mr Edwards’ reported inability to swallow medication. Accordingly, he prescribed 10 x 1mg midazolam injections. Those injections came in individual glass vials. In addition, at Stephen Edwards’ request, Dr Forrester prescribed 5 x 10 mg morphine vials and 5 x 30 mg/1mL vials. He also gave Stephen Edwards (again at his request) between four and six syringes and between four and six 25 gauge needles.32 Stephen Edwards left with the prescription, syringes and needles.
At around midday on 2 March 2016 Mr Edwards died. The fact of his death was communicated to Dr Forrester. Dr Forrester telephoned the Edwards’ home and spoke to Stephen Edwards who confirmed his father’s death and requested that Dr Forrester issue a death certificate. Dr Forrester went to the home at lunchtime, arriving about 1:00pm. He confirmed Mr Edwards was dead and then issued a death certificate. He described the scene as follows: “David was lying in bed in the first room on the right from entry. David had the doona up to his neck. I can’t recall what he was wearing. David had his eyes and mouth shut.
I had no suspicions about the death.
I noticed that there was [sic] Stephen, Leigh and Nelda as well as the daughter/ daughter-in-law whose name I don’t remember. Nelda was sitting on the couch in the living area with the daughter/daughter-in-law having what I believed was an alcoholic drink. I only spoke to her briefly. She was upset and crying but chatting small talk. I left after about 20 minutes. In my opinion Nelda appeared emotional but did not appear any different from when I saw her on 28 January 2016.”33 32 Supra, page 3.
33 Supra. Contextually, the reference to "daughter/daughter-in-law" can only be describing Mrs Vivian Edwards, the wife of Robert Edwards.
Circumstances of the Death of Nelda Edwards
Robert Edwards, and his wife Vivienne, arrived at the family home on 3 March 2016 at about 10.00am. At that time although obviously very upset, Mrs Edwards was not, according to Stephen, obviously dying as his father had been.34 She was ‘socially appropriate’,35 out of bed, dressed and interacting with family and vistitors. The evidence is that Mrs Edwards went to bed at about 5.00pm that evening.
At about 5.00am (or perhaps 5:30am – there are different accounts as to the precise time which are broadly speaking, irrelevant) on the last day of his mother’s life, Robert Edwards got into bed with her and cuddled her, which seemed to provide some comfort until Mrs Edwards realised that the person in bed with her was not her late husband.
Around 8.30am, Stephen Edwards began to administer drugs prescribed for his father to his mother. His description of what occurred was as follows: “I didn’t fancy another argument with the palliative care service. My mother would have hated the assessment with strangers in and out of her bedroom. My parents have always been very private, don’t-make-a-fuss people. I succumbed. Who needs to know? At 8:30am I gave her a decent dose of clonazepam 2.5mg. Propped up by pillows, she waited. Half an hour later I gave her another dose.”36
In a formal record of interview with investigating police officers, Stephen Edwards said he administered 2mg clonazepam, which ‘didn’t work’37 so he increased the dose to 2.5mg and then gave a third dose. According to him, and there seems no reason to doubt him on this point, the doses were administered roughly 30 minutes apart.38 Stephen Edwards said he began administering the drugs to help his mother sleep.
Naturally enough, the clonazepam, a benzodiazepine tranquilizer, had an impact on Mrs Edwards; her breathing slowed and she fell into a light sleep from which she awoke roughly 30 minutes later. When she awoke Stephen Edwards described himself as “despairing” and giving her “another dose [presumably of clonazepam] along with 10mg of morphine syrup, praying for a synergistic effect.”39 34 Supra, page 31.
35 Supra, page 32.
36 Evil Conjectures, page 78, Letter E 77, page 4.
37 Supra, page 33.
38 Supra.
39 Evil Conjectures, supra, Letter E 77, supra.
His mother was not dying – as he himself acknowledged. She had no need of palliative care. Even if she did require palliative care, there were no circumstances in which her son should have been providing it.
Discussion and conclusion
There was no emergency. The events leading up to his mother’s death took place during the day of Friday, 2 March 2016, a normal work day, during normal work hours. In addition to there being no emergency there was not even any sense of urgency. There was absolutely no reason why Stephen Edwards could not have made contact with Dr Forrester, or indeed any other medical practitioner.
I also note that this evidence was inconsistent with what he told police when formally interviewed and inconsistent with the affidavit he made under the Act, in the immediate aftermath of the death of his mother.
So far as inconsistencies of accounts on the part of Stephen Edwards are concerned, I note that when interviewed by police in April 2016 he made a claim his mother was suffering from what he described as “existential distress” and that was the reason why he administered the drugs. In his evidence at the inquest he asserted, without any evidence at all, that she died as a result of something which he was unable to identify but thought was a heart attack or a stroke. This in turn is inconsistent with his first version given to police in March 2016 when he said he suspected the cause of his mother’s death was renal failure.
Equally confusing was his evidence about the letter he drafted to me, and which was found on his computer by police. He said in his evidence that the letter was not for publication – despite the fact that he reproduced it, in full, in his book “Evil Conjectures”.
40 Supra.
41 Supra, page 79.
I unhesitatingly reject Stephen Edwards’ evidence at the inquest that he gave his mother a cocktail of Schedule 8 drugs to help her sleep and for back pain. Despite making a statutory declaration in the aftermath of the death of his parents (in which he failed to make any mention of giving his mother any drugs at all), participating in two lengthy police interviews and writing, publishing and promoting a book, he had never suggested that was his motivation until he gave evidence at the inquest.
In my assessment, Stephen Edwards when giving his evidence, was frequently querulous, argumentative and indeed arrogant. Having carefully listened and watched while he gave his evidence (and even allowing for the disadvantages that can attend the giving of evidence remotely by AVL, and making due allowance for his ill-health), I found him a singularly unimpressive witness. I have no hesitation in concluding he was lying – not mistaken or confused, but deliberately lying – during his evidence at the inquest in relation to his involvement in his mother’s death, and in particular his motivation for administering large doses of opiates and benzodiazepines to her.
The evidence is very clear that Robert Edwards was present when his brother administered drugs to his mother. I am satisfied that at some stage in the afternoon, he placed his hand over his mother’s mouth and nose as he ‘couldn’t stand’ what was happening, as he later told his wife and who confirmed that conversation in her evidence at the inquest.
I am satisfied on the evidence at the inquest that there are no suspicious circumstances, anomalies or inconsistencies associated with the death of David Godfrey Edwards. I accept Dr Ritchey’s opinion as to the cause of Mr Edwards’ death was disseminated lymphomatosis (cancer of the lungs and central nervous system and not prostate cancer as appeared on the original MCCD). I am satisfied also that his lymphoma was sufficiently advanced as to require palliative care given his death was imminent. Although toxicological analysis of samples taken at autopsy showed Mr Edwards had an elevated level of morphine in his body at the time of his death, that was consistent with him receiving palliative care which in the circumstances was not inappropriate.
I am satisfied to the requisite legal standard that Nelda Mavis Edwards died as a consequence of the administration to her of lethal doses of midazolam and morphine by her son, Stephen John Edwards. I am satisfied that the administration of those drugs by Stephen John Edwards was done by him with the express intention of causing his mother’s death.
While it is true that Mrs Edwards was found, at autopsy, to have a number of comorbidities (atherosclerotic and hypertensive cardiovascular disease in particular), the evidence establishes to the requisite legal standard that the operative cause of her death was the medication administered to her by Stephen John Edwards.
I am also satisfied on the basis of the evidence at the inquest to the requisite legal standard that at about the time of the death of Nelda Mavis Edwards, Robert David Edwards placed his hand on her nose and mouth. The evidence that supports this conclusion came from both Vivian and Robert Edwards.
I reject the suggestion that Robert Edwards used a pillow on his mother. The only evidence that Robert Edwards used a pillow on his mother was given by Cassandra Edwards. Her evidence was hearsay upon hearsay and her conduct as a witness was so bad that I consider any reliance upon her testimony (absent strong, corroborating evidence – of which there was none) would be extremely unwise.
The evidence does not support a conclusion that the application of Robert Edwards’ hand to his mother’s nose and mouth caused or contributed to her death. I do not know what to make of his claim that he thought that the fact that as his mother lay dying, he putting his hand over her mouth and nose and saying ‘go to Dad’ was somehow inconsequential or unimportant. I do not accept his categorisation of this act as somehow akin to holding his mother’s hand, giving her a cuddle or rubbing her feet. Any of those actions could, and likely would, provide comfort. Basic common sense recognises that placing a hand over the nose and mouth of someone must obstruct their breathing and as a result will result in distress and not comfort.
Although, as I have said, Robert Edwards was present at all relevant times and knew Stephen Edwards was administering drugs to their mother, I am not satisfied to the requisite legal standard that he knew that his mother’s death would occur because of the administration of those drugs.
In reaching the conclusions set out immediately above I have had express regard to the so-called Briginshaw standard.42 I have also based the conclusions upon the fact that despite being afforded an opportunity to provide an account on oath at the inquest inconsistent with this conclusion, neither Stephen Edwards nor Robert Edwards did so; in fact the evidence that they gave at the inquest completely supports my findings.
42 Op. Cit.
Formal Findings
On the basis of the evidence at the inquest, I make the following findings pursuant to section 28(1) of the Coroners Act 1995 in relation to the death of David Godfrey Edwards a) The identity of the deceased is David Godfrey Edwards; b) Mr Edwards died in the circumstances set out earlier in this finding; c) The cause of Mr Edwards’ death was disseminated lymphomatosis complicating large B-cell lymphoma originating in the retroperitoneal lymph nodes. Significant contributing factors were atherosclerotic cardiovascular disease, squamous carcinoma of the lung and adenocarcinoma of the prostate; and d) Mr Edwards died on 2 March 2016, aged 90 years, at 8 Aotea Road, Sandy Bay in Tasmania.
On the basis of the evidence at the inquest, I make the following formal findings pursuant to section 28(1) of the Coroners Act 1995 in relation to the death of Nelda Mavis Edwards a) The identity of the deceased is Nelda Mavis Edwards; b) Mrs Edwards died in the circumstances set out earlier in this finding; c) The cause of Mrs Edwards’ death was mixed drug (morphine, midazolam, oxazepam and valproic acid) toxicity; and d) Mrs Edwards died on 4 March 2016, aged 88 years, at 8 Aotea Road, Sandy Bay in Tasmania.
Concluding remarks
It is very obvious that Mr and Mrs Edwards were intensely private people. That this inquest occurred, and much personal information was publicly aired, would undoubtedly have caused them a great deal of distress. The circumstances of their deaths unfortunately made an inquest unavoidable.
The circumstances of the deaths of Mr and Mrs Edwards do not require me to make any comments or recommendations pursuant to the Coroners Act 1995.
Dated: 26 July 2024 at Hobart in Tasmania Simon Cooper Coroner
MAGISTRATES COURT of TASMANIA
CORONIAL DIVISION Record of investigation into the death of Nelda & David Edwards Annexure 1 List of Exhibits No. TYPE OF EXHIBIT NAME OF WITNESS E1 POLICE REPORT OF DEATH – NELDA CONSTABLE Olivia PEARCEEDWARDS TOMES E2 POLICE REPORT OF DEATH – DAVID 1/C CONSTABLE Kathryn
EDWARDS LUCK E3 ID AFFIDAVIT – NELDA EDWARDS CONSTABLE Olivia PEARCETOMES E4 ID AFFIDAVIT – DAVID EDWARDS CONSTABLE Jessica HAIGHT E5 LIFE EXTINCT AFFIDAVIT – NELDA Dr Raymond CHAN
EDWARDS E6 LIFE EXTINCT AFFIDAVIT – DAVID EDWARDS E7 ID AFFIDAVIT – NELDA EDWARDS – Anthony CORDWELL
MORTUARY AMBULANCE E8 ID AFFIDAVIT – DAVID EDWARDS – MORTUARY AMBULANCE E9 INTERIM POST-MORTEM – NELDA Dr RITCHEY
EDWARDS E10 INTERIM POST-MORTEM – DAVID Dr RITCHEY
EDWARDS E11 POST-MORTEM – NELDA EDWARDS Dr RITCHEY E12 POST-MORTEM – DAVID EDWARDS Dr RITCHEY E13 TOXICOLOGY REPORT 16-3-16 – Miriam CONNOR (FSST)
NELDA EDWARDS E14 TOXICOLOGY REPORT 1-4-16 – NELDA Miram CONNOR (FSST)
EDWARDS E15 TOXICOLOGY REPORT 16-3-16 – DAVID Miram CONNOR (FSST)
EDWARDS E16 TOXICOLOGY REPORT 4-4-16 – DAVID Miriam CONNOR (FSST)
EDWARDS E17 FORENSIC BIOLOGY REPORT 5-9-16 Kerryn GRAY & Dr Jason
BUCHAN E18 STATUTORY DECLARATION 19-3-16 & Tom BAWLE (Dr Syntax Hotel)
HANDWRITTEN COPY E19 STATUTORY DECLARATION 20-3-16 Ben BARRATT (Dr Syntax Hotel) E20 STATUTORY DECLARATION 29-3-16 Valerie BARRATT (Dr Syntax Hotel) E21 STATUTORY DECLARATION 23-3-16 Luke BELL (RYCT) E22 STATUTORY DECLARATION 23-3-16 & Paul BONNICHA (Duke of HANDWRITTEN COPY Wellington Hotel) E23 STATUTORY DECLARATION 21-3-16 Shaun RICHARDSON (Taroona Hotel)
E24 STATUTORY DECLARATION 9-3-16 David BLOOM (Point Revolving Restaurant) E25 STATUTORY DECLARATION 15-3-16 Ellie CAIRNS (Hair O Dynamix) E26 STATUTORY DECLARATION 23-3-16 Keith CRIPPS (Taxi driver) E27 STATUTORY DECLARATION 26-4-16 & Marrise OMANT (Neighbour)
HANDWRITTEN COPY E28 STATUTORY DECLARATION 10-3-16 Andrew JOHNSTON (Turnbull Family Funerals) E29 STATUTORY DECLARATION 9-3-16 Nicole BRYAN (Chemmart Pharmacy) E30 STATUTORY DECLARATION 17-3-16 Sophie SANGWELL (Bayside Pharmacy)
E30A PATIENT HISTORY – DAVID EDWARDS BAYSIDE PHARMACY E31 STATUTORY DECLARATION 18-5-18 Gregory EDWARDS (cousin of deceased) E32 STATUTORY DECLARATION 18-5-18 Mark EASDALE (colleague of Gregory Edwards) E33A STATUTORY DECLARATION 11-3-16 Cassandra EDWARDS (cousin) E33B AUDIO INTERVIEW 18-4-18 Cassandra EDWARDS (cousin) E33C TRANSCRIPT AUDIO INTERVIEW 18-4- Cassandra EDWARDS (cousin) E34A AFFIDAVIT 9-3-16 Leigh EDWARDS (son) E34B VIDEO INTERVIEW 1-4-16 Leigh EDWARDS (son) E34C TRANSCRIPT VIDEO INTERVIEW 1-4-16 Leigh EDWARDS (son) E35 AFFIDAVIT 9-3-16 Jennifer EDWARDS (daughterin-law)
E36 STATUTORY DECLARATION 25-4-18 DETECTIVE SENR CONST Jessica GOLDING E37 VIDEO INTERVIEW 22-1-18 Vivienne EDWARDS E37A TRANSCRIPT VIDEO INTERVIEW 22-1- Vivienne EDWARDS E38 STATUTORY DECLARATION 8-3-16 Amanda TREANOR (nee
MARRIOTT) E39 AGED CARE ENTRY RECORD Amanda TREANOR (nee
MARRIOTT) E40 STATUTORY DECLARATION 12-10-16 Amanda TREANOR (nee
MARRIOTT) E41 DEPOSITIONS 11-12-17 Amanda TREANOR (nee
MARRIOTT) E42 STATUTORY DECLARATION 21-3-16 Amanda BEZUIDENHOUT (KinCare) E43 STATUTORY DECLARATION 8-6-16 Amanda BEZUIDENHOUT 11:15 (KinCare) E44 STATUTORY DECLARATION 8-6-16 Amanda BEZUIDENHOUT 12:15 (KinCare) E45 DEPOSITIONS 11-12-17 Amanda BEZUIDENHOUT (KinCare) E46A STATUTORY DECLARATION Jason HOWIE (CEO KinCare) E46B KINCARE LETTER 27-2-17 KinCare/Jason HOWIE E46C HOME CARE AGREEMENT 17-4-14 KinCare/Jason HOWIE E46D HOME CARE AGREEMENT 13-3-15 KinCare/Jason HOWIE E46E SPECIAL FEE CONSIDERATION KinCare/Jason HOWIE E46F CUSTOMER CASE NOTES KinCare/Jason HOWIE E46G DHHS AGED CARE FEES KinCare/Jason HOWIE E46H INTER-DISCIPLINARY REFERALL FORM KinCare/Jason HOWIE
E46I TUNSTALL INFORMATION FORM KinCare/Jason HOWIE E46J SERVICE RECORD KinCare/Jason HOWIE E47 INCOMPLETE STATUTORY Kerry SPENCER
DECLARATION E48 AGED CARE ASSESSMENT TEAM Kerry SPENCER
(ACAT) E49 STATUTORY DECLARATION 15-3-16 Dr Andrew BLAKNEY E50 GP ASSIST REPORT 4-3-16 Dr Andrew BLAKNEY E51 SUPPLEMENTAL PROOF OF EVIDENCE Dr Andrew BLAKNEY E52 AFFIDAVIT 9-3-16 Const Olivia Pearce-Tomes E53 AFFIDAVIT 9-3-16 Const Sophie MASTERS E54 AFFIDAVIT 4-3-16 Stephen EDWARDS E55 SUPPLEMENTAL PROOF OF EVIDENCE Const Sophie MASTERS E56 PROOF OF EVIDENCE 19-12-18 Snr Const Luke GRIFFITHS E57 STATUTORY DECLARATION 8-3-16 Robert EDWARDS (son) E58 AFFIDAVIT 9-3-16 Sgt Michael ERTL E59 AFFIDAVIT 17-3-16 Const Kathryn LUCK (Coroner’s Associate) E60 AFFIDAVIT 11-9-18 Const Kathryn LUCK (Coroner’s Associate) E61 LETTER TO Mr R EDWARDS Const Kathryn LUCK (Coroner’s Associate) E62 STATUTORY DECLARATION 9-3-16 Tracey WALLS (UTAS Body Bequest Program) E63 STATUTORY DECLARATION 17-12-18 Detective 1/C Const William
PATMORE E64 STATUTORY DECLARATION 7-11-16 Detective Const Martin RITSON E65 PROPERTY SEIZURE RECEIPT 129915 Detective Const Martin RITSON E66 STATUTORY DECLARATION 14-12-18 Snr Const Jillian MOORE E67 STATUTORY DECLARATION 13-3-17 Snr Const James CRAIG E68A STATUTORY DECLARATION 2-11-16 Const Tania CURTIS E68B SCENE PHOTOGRAPHS Const Tania CURTIS E69 STATUTORY DECLARATION 11-9-18 Snr Const Karina LANE E70 STATEMENT 4-7-17 Paul FRANCIONE (Telstra) E70A CALL RECORDS: A – STEPHEN Paul FRANCIONE/Telstra
EDWARDS E70B CALL RECORDS: B – ROBERT Paul FRANCIONE/Telstra
EDWARDS E70C CALL RECORDS: C – LEIGH EDWARDS Paul FRANCIONE/Telstra E70D CALL RECORDS: D – 8 AOTEA ROAD Paul FRANCIONE/Telstra E70E CALL RECORDS: E – LEIGH EDWARDS Paul FRANCIONE/Telstra E70F CALL RECORDS: F – LONGBEACH MED Paul FRANCIONE/Telstra E70G CALL RECORDS: G – REVERSE CCR Paul FRANCIONE/Telstra E71 STATUTORY DECLARATION 19-12-18 Snr Const Dean SHAW E71 A EXTRACT MOBILE PHONE RECORDS Snr Const Dean SHAW
PAGES 157-203 E72 AUDIO INTERVIEW 20-4-16 Robert EDWARDS (son) E72A TRANSCRIPT AUDIO INTERVIEW 20-4- Robert EDWARDS (son) E73 AUDIO INTERVIEW 22-1-16 Robert EDWARDS (son) E73A TRANSCRIPT AUDIO INTERVIEW 22-1- Robert EDWARDS (son) E74 CARDS TO STEPHEN EDWARDS Robert EDWARDS (son) E75 INSTRUMENT APPOINTING ENDURING Robert EDWARDS (son)
E76 VIDEO INTERVIEW 28-4-16 Stephen EDWARDS (son) E76A TRANSCRIPT VIDEO INTERVIEW 28-4- Stephen EDWARDS (son) E77 LETTER TO THE CORONER Stephen EDWARDS (son) E78 LETTER TO CLAIRE Stephen EDWARDS (son) E79 DOSAGE NOTES Stephen EDWARDS (son) E80 STATUTORY DECLARATION 22-2-17 Prof Michael ASHBY E81 STATUTORY DECLARATION 2-3-18 Det 1/C Const Andrew
PETERSON E82 STATUTORY DECLARATION 19-9-18 Det 1/C Const Andrew
PETERSON E83 STATUTORY DECLARATION 1-11-18 Snr Sgt Penelope REARDON E84 STATUTORY DECLARATION 10-9-18 Sheree MAKSIMOVIC E85 STATUTORY DECLARATION 14-9-17 Sgt Alastair WATSON E85A PHOTOGRAPHS 14-9-17 Sgt Alastair WATSON E86 STATUTORY DECLARATION 28-4-16 Graham DELLER (partner of Stephen) E87 STATUTORY DECLARATION 5-5-16 Sue-Ann GARDINER (RN) E87A HANDWRITTEN NOTES 4-5-16 Sue-Ann GARDINER (RN) E88 TASMANIA POLICE STATEMENT 16-5- Marnie HAMILTON (RN) E88A HANDWRITTEN STATEMENT 16-5-16 Marnie HAMILTON (RN) E89 AUDIO INTERVIEW 8-5-18 Marnie HAMILTON (RN) E89A TRANSCRIPT AUDIO INTERVIEW 8-5-18 Marnie HAMILTON (RN) E90 STATUTORY DECLARATION Darren CONABEER (Tasmania Prisons) E91 RISDON PRISON CALL ACTIVITY Tasmania Prison Service
REPORT: 30-4-16 – 15-5-16 E92 RISDON PRISON CALL ACTIVITY Tasmania Prison Service
REPORT: 16-5-16 – 25-5-16 E93 RISDON PRISON CALL ACTIVITY Tasmania Prison Service
REPORT: 26-5-16 – 8-6-16 E94 RISDON PRISON CALL ACTIVITY Tasmania Prison Service
REPORT: 8-6-16 – 12-7-16 E95 ARUNTA TELEPHONE Stephen EDWARDS/Graham
CONVERSATION: 27-5-16 – DELLER E96 ARUNTA TELEPHONE Stephen EDWARDS/Graham
CONVERSATION: 27-5-16 DELLER E97 ARUNTA TELEPHONE Stephen EDWARDS/Graham
CONVERSATION: 6-6-16 DELLER E98 ARUNTA TELEPHONE Stephen EDWARDS/Robert
CONVERSATION: 6-6-16 EDWARDS E99 ARUNTA TELEPHONE Stephen EDWARDS/Robert
CONVERSATION: 6-6-16 EDWARDS E100 ARUNTA TELEPHONE Stephen EDWARDS/Graham
CONVERSATION: 7-6-16 DELLER E101 ARUNTA TELEPHONE Stephen EDWARDS/Graham
CONVERSATION: 25-6-16 DELLER E102 ARUNTA TELEPHONE Stephen EDWARDS/Graham
CONVERSATION: 9-7-16 DELLER E103 CERTIFICATE OF ANALYSIS 1-6-16 Claire FULTON (FSST) E104 PHOTOGRAPHS Claire FULTON (FSST) E105 PHOTOGRAPHS RE E17 FORENSIC Kerryn GRAY & Dr Jason
BIOLOGY REPORT BUCHAN E106 DEPOSITIONS Miriam GRIST (FSST)
E107 STATEMENT 21-6-16 Dr Morris ODELL E108 MEDICAL REPORT 6-9-16 Dr Carol DOUGLAS E108A CURRICULUM VITAE 1-4-15 Dr Carol DOUGLAS E108B MEDICAL REPORT 6-9-16 – N.EDWARDS Dr Carol DOUGLAS E108C UPDATED - CURRICULUM VITAE Dr Carol DOUGLAS E109 STATUTORY DECLARATION 10-3-16 Dr Elizabeth MONKS (Bupa GP) E110 DEPOSITIONS 13-12-17 Dr Elizabeth MONKS (Bupa GP) E111 VIFM CERTIFICATE OF ANALYSIS Kerryn CRUMP (VIFM) E112 STATUTORY DECLARATION 9-3-16 Dr Jonathan FORRESTER (Locum GP) E113 AUDIO INTERVIEW 16-8-16 Dr Jonathan FORRESTER (Locum GP) E113A TRANSCRIPT AUDIO INTERVIEW 16-8- Dr Jonathan FORRESTER 16 (Locum GP) E114 DEPOSITIONS 18-12-17 Dr Jonathan FORRESTER (Locum GP) E115 STATUTORY DECLARATION 3-6-16 Karen BAKER (RN Long Beach Med) E116 MEDICAL RECORDS – NELDA Long Beach Medical
EDWARDS E117 EMAIL CORRESPONDENCE RE: NELDA Mick ALLEN/Dr RITCHEY
EDWARDS AUTOPSY E118 LETTER RE DAVID EDWARDS Linda MASON
AUTOPSY E119 DIARY ENTRIES Robert EDWARDS E120 EVIL CONJECTURES – BOOK Stephen EDWARDS E121 “I WANT TO CLEAR MY NAME” The Mercury, Bianca HEALEY E122 “INQUEST THE LAST HOPE FOR DYNG The Australian, Jamie WALKER
DOCTOR: I DIDN’T KILL MUM” E123 “SITE-, TECHNIQUE-, AND TIME- Journal of Forensic Sciences, RELATED ASPECTS OF THE LEMAIRE et al 2017
POSTMOTEM REDISTRIBUTION OF DIAZEPAM, METHADONE, MORPHINE, AND THEIR METABOLITES: INTEREST OF POPLITEAL VEIN BLOOD SAMPLING” E124 “POST MORTEM REDISTRIBUTION OF Current Pharmaceutical Design, DRUGS: CURRENT STATE OF SASTRE et al 2017
KNOWLEDGE” E125 COMMENTS ON THE CARE OF THE Dr Frank NIKLASON
ELDERLY PERSON – 27-9-16 E126 MEDICAL RECORDS – DAVID LONG BEACH MEDICAL EDWARDS E127 DR RITCHEY NOTES DR RITCHEY E128 AMA CODE OF ETHICS REVISED 2016 E129 EVALUATION OF THE NATIONAL SEPTEMBER 2016 FINAL PALLIATIVE CARE STRATEGY 2010 PREPARED FOR FINAL REPORT COMMONWEALTH DEPARTMENT OF HEALTH E130 COMPASSIONATE COMMUNITIES: A DEPARTMENT OF HEALTH TASMANIAN PALLIATIVE CARE AND HUMAN SERVICES POLICY FRAMEWORK 2017-21
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