Coroner's Finding: QR

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, youths and others by direction of the Coroner pursuant to s57(1)(c) of the Coroners Act 1995 I, Olivia McTaggart, Coroner, having investigated the death of QR Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is QR, born 29 November 1978; b) QR died in the circumstances set out further in this finding; c) QRs cause of death was drowning due to combined drug (tramadol, venlafaxine, diazepam, quetiapine and cannabis) intoxication while scuba diving; and d) QR died on 18 September 2021 at Bicheno, Tasmania.

In making the above findings, I have had regard to the evidence gained in the comprehensive investigation into QR’s. The evidence includes:

• The Police Report of Death to the Coroner;

• Affidavits confirming life extinct and identification;

• An opinion of the forensic pathologist who conducted the autopsy;

• Toxicology report of Forensic Science Service Tasmania;

• Tasmanian Health Service records for QR;

• Bicheno General Practice records for QR;

• Medical reports to the Coroner provided by psychiatrist Dr Philip Reid and general practitioner Dr Elizabeth Grey;

• Affidavits of BH and AG, daughters of QR;

• Affidavit of NV, former husband of QR;

• Affidavit of Remy Bailey, friend of QR who went diving with her;

• Affidavit of Andrew Bailey, father of Ms Remy Bailey;

• Affidavits of two witnesses who provided first aid to QR;

• Affidavits of two paramedics attending to QR;

• Affidavits of three attending and investigating police officers, including photographs;

• Affidavit of Bruce Priestley, former dive instructor at Bicheno Dive Centre;

• Diving certification information for QR and dive log;

• Diving equipment report by Karl Price, Hyperbaric Facility Manager at Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital; and

• Review of medical records by the Coronial Clinical Nurse Specialist.

Background QR was 42 years of age at her death, was divorced and was employed in a seafood business.

In 2001 QR moved to Bicheno and commenced a relationship with NV . They married in 2002 before separating in around 2017 and divorcing in 2019. There are two daughters of the marriage.

In 2017 QR took up scuba diving as a hobby and, in that year, gained several dive qualifications from Scuba Schools International. QR became passionate about diving and completed at least 47 dives prior to her death. Her instructor considered her to be an excellent diver. The evidence indicates that she encountered some regular issues with buoyancy and equalising.

QR had a long history of mental illness and had been diagnosed with bipolar affective disorder.

She also had a history of chronic lumbosacral pain, hepatitis C and emphysema due to smoking.

She had been a long-term patient of the Bicheno General Practice and she was prescribed antidepressant and analgesic medication for her conditions. In 2012, and again in 2015, she was referred by her doctor to psychiatrist Dr Philip Reid for treatment of her long standing and severe mood disorder. She continued to consult with Dr Reid until her death.

Medical records indicate that QR had a history of illicit drug use. It seems that, in the several years prior to 2019, she did not use illicit drugs or, alternatively, her use was minimal.

However, in 2019 QR began using methamphetamine and was charged with shop lifting. This behaviour was highly out of character for QR who had no prior history of offending.

QR was known to engage in self-harm and had been taken to the Royal Hobart Hospital in June 2021 due to overdosing on her medications. However, following this incident the evidence indicates QR was positive about life, exercising regularly, creating a vegetable garden and engaging in domestic tasks. She also re-equipped herself with scuba diving gear with a view to resuming diving. She had not engaged in scuba diving for approximately three years.

At the time of her death, QR was prescribed tramadol and asenapine by her general practitioner. Additionally, she was prescribed venlafaxine, diazepam, quetiapine and pregabalin by her psychiatrist.

Circumstances surrounding death QR and her friend, Remy Bailey, planned to go scuba diving on 18 September 2021 at Waubs Bay in Bicheno, starting at the breakwater wall. Although QR had dived in this area on numerous occasions previously, this was her first dive in about three years. The main purpose of the dive was to adjust their weights in light of the length of time since both had last dived.

At 10.45am they entered the water at the breakwater wall and descended to a depth of approximately 2 metres. Ms Bailey stated in her affidavit, that during the very short period they were both underwater at this time, she saw nothing untoward with QR. They both ascended to the surface in a controlled manner. As Ms Bailey returned to the breakwater wall to adjust her weights, she noticed QR very close to shore with her buoyancy vest fully inflated.

Ms Bailey gave QR the internationally recognised ‘ok’ signal using her thumb and index finger.

QR did not reciprocate as expected and only nodded in response. This concerned Ms Bailey somewhat and, after finishing adjusting her weights, she swam over to QR approximately 10 metres away. It is unclear how much time elapsed between her hand signal and reaching QR.

She found QR face down in the water and unresponsive. Ms Bailey noted that QR’s buoyancy compensator was inflated and her regulator was displaced and possibly not in her mouth. Ms Bailey rolled QR over and swam her to shore. She telephoned 000 and sent a text message to her father to help. She waved down passers-by who assisted with performing CPR.

Ambulance Tasmania paramedics and volunteer ambulance officers arrived and continued CPR upon QR until she was airlifted to the Royal Hobart Hospital. Despite vigorous and sustained attempts at resuscitation, QR was pronounced deceased upon arrival at the hospital.

Investigation Police officers attended the scene and seized QR’s dive equipment (cylinder, buoyancy compensator and regulator set) for assessment. A full coronial investigation into QR’s death then commenced.

On 20 September 2021 an autopsy was conducted by experienced forensic pathologist, Dr Christopher Lawrence. Dr Lawrence did not identify any medical conditions that may have directly caused QR’s death. He did observe that her lungs were over expanded with pulmonary oedema, consistent with drowning and there was water in her sinuses. Toxicological analysis of blood samples identified elevated levels of tramadol and venlafaxine, as well as diazepam, quetiapine and THC (cannabis). No alcohol or other illicit drugs were identified.

Dr Lawrence in his report concluded as follows: “The combination of tramadol, venlafaxine, diazepam, quetiapine and cannabis would cause central nervous system depression making drowning more likely. The combination of tramadol, and venlafaxine could predispose to serotonin toxicity. Her tolerance of these drugs is not clear, but I would regard them as the likely cause of the drowning.” I accept the opinion of Dr Lawrence and find that QR died by drowning, contributed to by the effects of the multiple drugs in her system. As central nervous system depressants, these drugs in combination may produce symptoms of sedation, lack of coordination, blurred vision, impaired thinking, slurred speech, impaired perception of time and space, slowed reflexes and breathing, decreased heart rate and loss of consciousness.

QR’s diving equipment was assessed by Mr Karl Price, hyperbaric facility manager at the Royal Hobart Hospital. He concluded that QR’s equipment was in good condition with no signs of failure, poor air quality or breathing restriction. It was noted that the regulator mouthpiece had been bitten hard enough to split six of the eight tooth pads. Mr Price stated that this was suggestive of QR experiencing a medical event such as a seizure causing her to bite on the regulator mouthpiece in a state of altered consciousness. He also noted that, QR had failed to ditch her weights contained within the buoyancy compensator which could have assisted her flotation. In particular, Mr Price stated that QR carried additional weights amounting to 4.1 kilograms in the front zipped pockets of the buoyancy compensator. He suggested that this fact may have caused QR to be pulled face forward into the water whilst unconscious, contributing to her death by drowning.

QR’s medical care Because of the role played by QR’s prescription medications, I requested reports from her psychiatrist and general practitioner for further details concerning their prescribing of her medications. As a result of the reports provided, I am satisfied of the following matters:

• QR’s medication regime as devised by her general practitioner and psychiatrist was necessary for her severe mood disorder and chronic pain.

• QR’s psychiatrist and regular treating general practitioner were sufficiently aware of each other’s prescribing regime. There was adequate communication between them so as to safely monitor her medications.

• QR had been tolerating prescription tramadol combined with antidepressants since 2012.

• QR had been counselled by her general practitioner on numerous occasions regarding the risk of serotonin toxicity due to her prescribed combination of tramadol and antidepressants.

• Both her psychiatrist and general practitioner were aware that QR was a recreational scuba diver. They did not specifically discuss with her the risks of diving with regard to her prescription medication and health conditions. It appears that the topic did not arise as she had not been diving for several years before the incident resulting in her death.

• There is no evidence that QR sought medical advice from the doctors or any health professional when planning to resume diving prior to 18 September 2021.

Conclusion Tragically, QR drowned whilst scuba diving with a friend in very shallow water in Bicheno. Her equipment was in good condition and there were no difficulties presented by the weather or the water at the location of the dive.

As discussed, the effects of her prescription medication contributed to her death. I cannot determine whether QR took an excessive quantity of any of her medication, but it is quite possible that she did so. The prescription drugs in her system, combined with cannabis and her lung disease, are likely to have had a significant effect on her respiratory system. It is plausible that, as a result, she entered into a state of altered consciousness and was unable to protect her airways or ditch her weights.

In addition to the effects of the drugs, it is also plausible that QR’s lack of recent diving experience and lack of familiarity with some of her equipment may have caused her to enter into a panic state and/or take in water. The risk of this occurring may have been higher if she was not wearing a mask. Upon the evidence, I cannot make a positive finding that she was wearing a mask. Unfortunately, the evidence only allows me to speculate as to what occurred in the water immediately before she was found unconscious by Ms Bailey.

The excessive weights held in the forward pockets of her vest are also likely to have played some part in her drowning once her level of consciousness had decreased.

There is no evidence to suggest that she was experiencing symptoms of serotonin toxicity from her medication, as opposed to the general effects of multiple central nervous system depressants.1 If she was experiencing this specific condition she would have been observed by 1 Serotonin syndrome is a serious drug reaction. It is caused by medications that build up high levels of serotonin in the body. Serotonin is a chemical that the body produces naturally and required for nerve cells and brain to function.

Excessive serotonin causes signs and symptoms that can range from mild (shivering and diarrhoea) to severe (muscle rigidity, fever and seizures). Severe serotonin syndrome can cause death if not treated.

others to have been extremely unwell and unable to even prepare for the dive or put on her gear.

The severed tooth pads on the regulator cannot be fully explained. I do not consider it likely that QR experienced a seizure. They may have been broken through application of jaw pressure for another reason.

Finally, I am satisfied that QR’s death was accidental and she did not intend to end her life.

For the reasons outlined above, I make no criticism of QR’s treating general practitioner or psychiatrist in connection with her death.

I extend my appreciation to the investigating officer Constable Christopher Richardson for his investigation and report, and to Mr Karl Price for his expert report.

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

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

Dated: 17 April 2024 at Hobart, in the State of Tasmania.

Olivia McTaggart Coroner