Finding into death of Glenn Leslie Stevenson

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 1390/08

Inquest into the Death of GLENN LESLIE STEVENSON

Delivered On: 11 January 2010

Delivered Ati - Melbourne

Hearing Dates: 11 January 2010

Findings of JOHN OLLE

Representation: Nil .

Place of death: Yarra River at base of Westgate Bridge, End Of Lorimer St, Port

Melbourne, Victoria 3207

SCAU: Sergeant D, Dimsey

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 1390/08

Tn the Coroners Court of Victoria at Melbourne 1, JOHN OLLE, Coroner

having investigated the death of:

Details of deceased: * .

Sumame: . STEVENSON First name: GLENN ; Address: 3 Kennedy Street, Keilor 3036

AND having held an inquest in relation to this death on 11 January, 2010 at Melbourne

find that the identity of the deceased was GLENN LESLIE STEVENSON and death occurred on 6th April, 2008

at Yarra River at base of Westgate Bridge, End Of Lorimer St, Port Melbourne, Victoria 3207

from .

~ Ja, MULTIPLE INJURIES 1b. FALL FROM A HEIGHT

in the following circumstances:

1. Glenn Stevenson was aged 45 years at the time of his death. He lived at 3 Kennedy Street, Keilor. -

2. Shortly prior to 6,00am on the 6th ‘April, 2008, Mr Stevenson drove his vehicle on the West ,

Gate Bridge inbound and parked in an Emergency Stopping Lane. He alighted his vehicle and stood beside a guardrail.

3. D24 received numerous calls from passing motorists. Police attended. Despite their best

endeavours to engage Mr Stevenson and entice him to safety, he climbed over the guardrail and fell to his death.

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Overview of Personal Circumstances

4. Mr Stevenson had a history of depression and alcohol abuse. Despite significant marital difficulties, his wife had attempted to salvage the marriage. Ultimately, in the period leading to his death, it was apparent the marriage was irreconcilable.

5, On the 4th April, 2008, Mrs Stevenson was very concerned for her husband’s welfare, and conveyed him to the Royal Melbourne Hospital. Mr Stevenson’s blood alcohol content was 163%. ‘He had’ made suicide threats and was expressing suicidal ideation. Following assessment, he was transferred to the Sunshine Psychiatric Hospital.

Sunshine Psychiatric Hospital Admission

6. He was admitted to Sunshine Psychiatrie Hospital and remained overnight. The following afternoon, he was discharged for overnight leave. Mrs Stevenson had reluctantly agreed to accept him for overnight leave.

7. At approximately 7.00pm on the 5th April, Mr Stevenson consumed Valium and went to bed, At 11.00pm, Mrs Stevenson was aware that he left the premises. Concerned for his welfare, she

called the Sunshine Psychiatric Hospital who, in turn, contacted police,

8, It was apparent that Mr Stevenson consumed a significant quantity of alcohol and thereafter carried out his decision to commit suicide.

The role of members of Victoria Police

9, Despite the best endeavours of attending police, Mr Stevenson was unable to be persuaded to return to safety, ; ,

10. My investigations revealed that the efforts of attending members to entice Mr Stevenson to —

safety were thorough and deserving of the highcst commendation for their efforts.

11. Itis difficult to-imagine a more distressing scene for police members.

Mental Health Treatment

12, I was concerned to investigate the clinical decisions made at Sunshine Psychiatric Hospital, in particular the decision to grant overnight leave the day following his admission.

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13. All clinicians fully co-operated with my investigation and I received and considered their statements. ,

14, I engaged an independent expert to provide an opinion in respect to the treatment, in particular clinical decisions made by the various mental health professionals at the Sunshine Psychiatric Hospital. /

‘Independent Opinion

15. I have carefully reviewed the’ report of Associate Professor Richard Newton, . Medical Director, Mental Health CSU, Austin Health, dated 2nd November, 2009.

’ 16. Associate Professor Newton considered the police Brief of Evidence, Pathologist Report and medical records for the Royal, Melbourne Hospital and the Northwestern Mental Health Service - at Sunshine.

17. Associate Professor Newton’s report was comprehensive and, for the Purpose of this finding,

I note the following pertinent factors:

(a) Mr Stevenson had been treated since 2004 by his General Practitioner for depression and alcohol dependence, He reported problems with depression for the previous'15 years. He

was treated with Zoloft.

(b). Mr Stevenson presented to the Royal Melbourne Emergency Department on 4th April, 2008, intoxicated with suicidal ideation,

(c) He reported ongoing troubles with depression, low mood and thoughts of killing himself by jumping off the West Gate Bridge. — :

(a) Risk assessment conducted correctly identified the presence of a large number of suicide were the only factors stopping him committing suicide.

(e) It was decided to admit him to his local area Mental Health Service.

Admission to Sunshine Psychiatric Service

(a) Diagnosis of Mild Major Depressive Episode or Adjustment Disorder, with associated alcohol dependence and suicidal ideation, in the context of his relationship breakdown.

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(b) Sunshine area of Mental Health Service rated him at 3 for self harm on the 4th April and 2 on risk assessment of. self harm on the 5th April, requizing a maximum of hourly nursing observations.

(c) Following Consultant Psychiatrist review on the 5th April, he reported feeling better with

only mild withdrawal symptoms and was keen to get marriage counselling. He wanted

_ neither CATT involvement, nor his children, to be made aware of his admission, however, was agreeable to attend the Clinic, He was denying suicidal ideation.

(d) He was not considered to suffer any psychotic symptoms or depressive symptoms, however, was preoccupied with his relationship issues.

(e) He agreed to stay in hospital for a further day whilst his wife was liaised with.

(£) In the early afternoon of the Sth April, he was scen by the psychiatry registrar following repeated requests to go home.

(g) A detailed history and assessment was made.

‘(h) The registrar contacted his wife who was somewhat hesitant to have him home and explained she did not believe they would reconcile. Following discussions with the consultant psychiatrist, the decision was made not to discharge Mr Stevenson but to allow

_ him overnight leave, following a further review by the Consultant Psychiatrist the following day. ,

. (i) His mood at the time was reported to be bright and reactive, but irritated about being in hospital. He appeared to have made a rapid recovery of mental state and consistently reported no further suicidal ideation and, no psychotic symptomatology.

Assessment of the Case by Associate Professor Newton

18. Associate Professor Newton explained that:

"The situation where a middle-aged man with significant alcohol problems presents with suicidal ideation and intent in the throes of a relationship breakdown is a frequent one coming to the attcntion of the Area Mental Health Services, The problem of how to manage somebody who is likely to drink heavily, who is known to be a repeated current heavy drinker and whose suicidal ideation is worse and their likelihood to act on their suicidal ideation is increased when intoxicated, is a common one, Nor is it uncommon for people in this predicament to not feel suicidal when they are not intoxicated."

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19, Further: .

"Mr Stevenson presented with significant alcohol use and with suicidal ideation _ precipitated by relationship difficulties, which he partly acted on by driving to the West Gate Bridge whilst intoxicated the day before-his admission, He subsequently improved very rapidly in hospital, This improvement was probably associated with being free of - ‘ intoxication and a hope that he and his -wife would be able to have relationship counselling and get back together." , :

In thé circumstances when psychiatrists are faced with somebody who is clearly denying suicidal ideation, expressing hope, expressing an agreement to participate in follow-up and in the absence of major psychotic symptomatology, most doctors in most services would have agreed for the person to go out on leave after speaking with the family, as happened in this case," ‘

Two Concerns Identified by Associate Professor Newton;

20. Associate Professor Newton explained he harboured two concerns in respect to the decision made:

1. Mr Stevenson clearly expressed the intent to drive when he went home (the statement that he was going to have one drink had alow level of credibility); and

2. the statement to his wife that she did not believe that a reconciliation was likely to

take place.

21. Both of these factors suggest that a return home to heavy drinking and an inability. to avoid confronting the fact that his marriage was in difficulty was somewhat inevitable, with the high likelihood of return to suicidal ideation.

22. Associate Professor Newton noted the files did not indicate whether the Mental Health Practitioner’s considered these factors, however, in his opinion:

"Even if they had been taken into account, it is my opinion that in these circumstances the : majority of psychiatrists in Victoria would have still made the decision to allow Mr Stevenson to go on leave. Good practice, however, would have included an absolute agreement not to use alcoho!, an agreement that would have had to be shared with his wife.

would have also expected a clear discussion of risk and safety plans to have occurred with Mr Stevenson and his carers. Dr Lograsso, the registrar did discuss risk and ‘safety with Mr

’ Stevenson, his wife and the family friend who picked Mr Stevenson up from hospital and ensured that they knew to call the hospital if they had concerns." ,

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23. Associate Professor Newton raised the potential significance of Mr Stevenson’s concem about his appearance. He noted that it could be a belief held with delusional intensity requiring treatment with antipsychotics. He further noted it could be part of a major depressive illness with psychotic features. Further, he conceded it was possible the concern could have.impacted on decision-making around going on leave, had it been more thoroughly explored by the clinicians.

Ultimately, it was his opinion:

"As I have already indicated, even if these overvalued ideas about his appearance had been explored, it does seem that they had been present for a number of years, and in the absence of clear recent worsening, it is likely that most psychiatrists presented with Mr Stevenson on the day that he requested for leave, would have agreed for leave to go ahead."

24. In all the circumstances, the mental state management of Mr Stevenson whilst an inpatient at both the Royal Melbourne Hospital and the Sunshine Psychiatric Service was not inappropriate.

25. Further, the decision to grant Mr Stevenson overnight leave was not unreasonable.

26. I was concerned to investigate the issue of the absence of suicide barriers on the West Gatc Bridge. As tragic is the death of Mr Stevenson, his death is one of many in similar circumstances at the West Gate Bridge.

27. As part of my investigation, a letter was written to VicRoads in February 2009. In response I received a letter from Mr Kevin Devlin, Project Director, West Gate Bridge Strengthening Project, dated 13 March, 2009.

.28.- Mr Devlin referred to the coronial request to provide:

"a statement in relation to the ongoing upgrade of the West Gate Bridge and any plans to

construct suicide barriers”.

29, He provided the following history:

a. In December 2008 the Victorian Government announced that Public Safety Barriers will be installed on the West Gate Bridge as part of the West Gate Bridge Strengthening Project. : a ,

b. In 2004, VicRoads commissioned a major structural and risk review of the West Gate Bridge. . . :

c. In 2006, a study was commissioned into the effectiveness of Public Safety Barriers in preventing suicide behaviour.

d. The investigation with respect to suicide prevention was completed in 2007. Of note:

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"The investigations support Public Safety Barriers as an option to reduce suicide risk."

e, In mid 2007, VicRoads appointed a number of leading international consultants to: "develop a highly complex and detailed proposal for structural works (including works to install Public Safety Barriers) on the West Gate Bridge. VicRoads submitted the proposal to Government for funding in January 2009." :

30. Mr Devlin further explained: "The design for the proposed Public Safety Barriers for the West Gate Bridge is presently being wind tunnel tested by consultants at facilities in Dctimark. The testing is expected to be completed by the end of March 2009",

31. He further noted:

"Installation of permanent Public Safety Barriers is scheduled to commence in the first quarter of 2010 and scheduled to be completed by the end of 2010."

32. Mr Devlin set out a range of initiatives designed ‘to manage unauthorised activity on the West Gate Bridge. He concluded his statement as follows:

"VicRoads will continue to work closely with the Emergency Services and key stakeholders to effectively manage public safety oh the West Gate Bridge."

Post Mortem Medical Investigation

33. On the 7th of April, 2008, Dr Malcolm Dodd, Forensic Pathologist at the ‘Victorian Institute . of Forensic Medicine performed an autopsy.

34. Dr Dodd found the cause of death to be multiple injuries and fall from a height. He noted the toxicological analysis in blood and vitreous between 0.15% and 0.19% respectively. Further, Sertraline and Diazepam were identified in blood cavity.

CONCLUSION

35. As a result of my investigation, J am satisfied that the treatment received by Mr Stevenson at the Royal Melbourne Hospital and the Sunshine Psychiatric Unit was not unreasonable.

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36. Further, I am aware that temporary public safety barriers have been constructed on the West Gate Bridge. Unfortunately, their construction occurred subsequent to the death of Mr Stevenson. : ‘

37. Without diminishing the tragic loss, suffered by Mr Stevenson's family, it is important to acknowledge the efforts of operational police and the distressing event witnessed by them, and of

course by members of the public, travelling across the bridge.

38. Until permanent barriers are constructed, temporary public safety barriers will have clear and significant community benefits.

Signature:

John Olle Coroner Date: {th January, 2010

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