Finding into death of Paul Gledhill

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 2707/08

Inquest into the Death of PAUL GLEDHILL

Delivered On: 17th March 2010 Delivered At: Melbourne

Hearing Dates: , 17th March 2010 Findings of: Coroner Parkinson Place of death: Frankston Victoria 3199

SCAU Senior Constable Greigory McFarlane

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008

Court reference: 2707/08 In the Coroners Court of Victoria at Melbourne I, KIM PARKINSON, Coroner having investigated the death of: Details of deceased:

Surname: GLEDHILL

Firstname: PAUL

Address: 19/29 Fairway Street, Frankston, Victoria 3199

AND having held an inquest in relation | to this death on 17th March 2010 at Melbourne

find that the identity of the deceased was PAUL GLEDHILL and death occurred on 25th June, 2008 at 29 Fairway Street, Frankston, Victoria 3199

from la. SMOKE INHALATION

in the following circumstances:

1. Mr Paul Gledhill was 37 years of age, born 21 November 1970. He lived at Unit 19, 29 Fairway Street, Frankston, Paul had been diagnosed with Schizophrenia at aged 20, He was

provided with much support by his family, particularly his mother, father and brother.

2. He was also assisted by a case: worker from Frankston Community Mental Health Servicc, Mr Rohan Del Mar. He had been registered with the Penninsula Health Service since May 2001 as an involuntary paticnt, receiving treatment pursuant to a Community Treatment Order. Statements were received from Psychiatrist Dr Pralay Kumar Mazumdar and from Mr Del Mar. Paul was on Flupenthixol 120mg twice weekly, Fluoxetine 20mg daily and Oxazepam 30mg daily. He had multiple admissions to hospital apparently as a result of non-adherence to medication and alcohol and drug use. He had also had involvement with Correctional Services through the criminal justice system.

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3. Paul had a history of substance abuse, including cannabis and alchohol. It is unclear whether his substance abuse was a consequence of his illness or whether it had contributed to his psychiatric illness, Certainly the effective management of his illness and his day to day care was affected by his use of cannabis and alcohol. -

4, On 25 June, 2008 Paul had a conversation with his neighbour, Mr Shane Emmerson at approximately midnight, Mr Emmerson had arrived home and needed money to pay for the taxi fare. As he was owed some moncy by Paul, apparently from a cannabis transaction, he obtained

$25 from him to pay the taxi. There was not apparently any dispute in relation to that money.

5. On 25 June 2008, at approximately midday, Mr Emmerson observed Paul, apparently sitting in the window sill of his bedroom at the property, with his back against the wall and his head down. Mr Emmerson noted a strange smell emanating from the property, which he later realised was smoke, He summoned assistance from other neighbours. Ms Helena Meinderts also , observed Paul sitting in his windowsill. She called for an ambulance. Mr Bethel Okafor broke a window to attempt to gain entry to the premises, but was driven back by the smoke, Both of Ms Meinderts and Mr Okafor attempted to enter the house to assist Paul, however the fumes drove them back, Ambulance officers arrived and removed him from the house through the bedroom ' window and attempted to resuscitate him. They were not successful.

6. The unit was located on the ground floor of a southern block and was constructed of brick with a concrete floor. Forensic examination was undertaken of the premises and the fire investigator Scientist Karen Ireland reported that a slow smouldering fire had occurred in the North Western bedroom next to a heater. The investigator stated that the room was very sooted

and there was very little heat damage. The heater was examined by Forensic Scientists and excluded as the source of the ignition.

7. Investigators concluded that the fire had started by the ignition of the blanket and cushion on the floor, most likely from a match or cigarette lighter. Paul had possibly dropped a cigarette, although there were no cigarette butts located at the source of the fire, there were cigarette filters on the floor,

8. Forensic Pathologist with the Victorian Institute of Forensic Medicine Dr Melissa Baker

conducted an autopsy and reported that the cause of death was smoke inhalation, The

toxicologist reported that post mortem blood analysis revealed a blood alcohol level of 0.230 -

0.238%. Cannabis was also identified. There were no other injuries identified although a

significant degree of coronary artery atherosclerosis was identified at autopsy which the ’ pathologist commented was quite advanced for a man of his age.

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9. On 4 June 2008 an incident had occurred at Paul’s house where he reported that youths had broken his window, entered his premises and graffitied and stolen from him, After intervention from his mother and case worker the window was repaired and no further events ‘have been reported to have occurred, It is likely that this was a one off incident. There is no evidence to suggest that it was connected to the fire and police report no suspicious circumstances. ; ,

10. Mrs Gledhill in her statement reports that although she felt his mental statc was deteriorating, that he showed no sign of being depressed. There is no evidence to suggest that Paul deliberately lit the fire or that he deliberately remained inside the premises.

11. The blood alcohol levels reported were significant. They were almost five times the legal limit for operating a motor vehicle and would have impaired his capacity to respond to a fire, Combined with smoke inhalation and fumes, if conscious, Paul would have been likely disorientated and confused, I am satisfied that the fire was accidental and that Paul’s death as a result of smoke inhalation was accidental. . ,

12. It is appropriate to note the efforts made by Ms Meinderts and Mr Okafor in attempting to enter the premises and assist Paul,

13, I find that Paul Gledhill died on 25 June 2008 as a result of smoke inhalation and that his death was accidental.

Signature:

Kim Parkinson Coroner

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