Finding into death of Kelvin Lea Swab

Rule 60(1)

FORM 37

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court reference: 4630/08

Inquest into the Death of KELVIN LEA SWAB

Place of death: 3 White Lane, Glen Waverley, Victoria 3150

Hearing Dates:

Appearances:

Findings of: Delivered On:

Delivered At:

4 May 2010 Leading Senior Constable Tania Cristiano, SCAU, Assisting the Coroner Mr Sean Cash of Counsel on bchalf of Dr G. Rudra (Avant Law)

Ms Vanessa Nicholson of Counsel on behalf of Eastern Health (DLA Phillips Fox)

AUDREY JAMIESON, Coroner 11 June 2010

Melbourne

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 4630/08 In the Coroners Court of Victoria at Melbourne, I, AUDREY JAMIESON, Coroner having investigated the death of: Details of deceased: Surname: SWAB

Firstname: KELVIN Address: 3 White Lane, Glen Waverley, Victoria 3150

AND having held an inquest in relation to this death on 4 May 2010 at Melbourne

find that the identity of the deceased was KELVIN LEA SWAB

and death occurred on or about 12 October 2008 at 3 White Lane, Glen Waverley, Victoria 3150 from: ‘1(a) HANGING

in the following summary of circumstances:

1. Mr Kelvin Swab suffered from mental ill health and was under the care of Eastern Health

Mental Health program.

2. On 13 May 2008, Mr Swab was discovered hanging at his place of residence by his landlord, Chung Li.

3, An Inquest was held under section 52(1) Coroners Act 2008.

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BACKGROUND CIRCUMSTANCES:

Mr Kelvin Swab was born on 15 July 1974. He was 34 years old at the time of his death. He lived aloric in-a bungalow at the rear of 3 Whites Lane, Glen Waverley, He was unemployed, He had been married to Cathryn Jackson for 9 years, The couple separated in 2005 but continued to see each other every day.

. Mr Swab had a long history of mental ill health including a psychiatric admission in NSW in

1997, He had been a patient of Southern Health Mental Health Program from October 2005, He was assessed in the Emergency Department (ED) by the Crisis Assessment and Treatment Team (CATT) on 15 October 2005, following an overdose of cold and flu tablets and Nurofen on a background of gambling debts, unemployment and social isolation, At that time, Mr Swab provided a history of recurrent suicidal behaviour from the age of 14 years.

He reported a traumatic developmental history including being raped as a adolescent and being involved in an accident in which his sister was killed. He also had a family history of mental ill health.

_ Mr Swab was initially managed by Southern Health CATT in the communily bul required an admission to the Casey Hospital psychiatry unit in November 2005, He was diagnosed with Major Depressive Disorder and treated with electroconvulsive therapy and the antidepressant Venlafaxine. During his lengthy admission, he attempted to hang himself on several occasions,

On 17 March 2006, Mr Swab was admitted following an overdose of prescription medication. Throughout 2006 he had a number of presentations to the ED with self inflicted injuries, suicidal thoughts and medication overdose. In 2007, Mr Swab had a further period of

hospitalisation following an episode of self harming by cutting and attempting to hang himself. He was commenced on Sodium Valporate and referred to a clinical psychologist and private psychiatrist at Pinclodge Clinic, Dandenong.

Mr Swab’s last contact with Southern Health was on 3 September 2008. He had been referred to the CATT by his treating psychologist because of an escalation in his self harming behaviours, He was noted to have ongoing thoughts of hopelessness and low self esteem, He denied suicidal thoughts at the time. As Mr Swab had recently moved to Glen Waverley, a referral to Central East CATT was made.

On 5 September 2008, Mr Swab was seen by Dr Tom Eimany, Consultant Psychiatrist with Central East Crisis Assessment and Treatment Service (CECATS) after an initial assessment

with CECATS clinicians the previous day, Ms Jackson was also present.

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On 25 September 2008, Mr Swab was seen again by Dr Eimany following a suicide attempt in the context of a recent relationship break-up.

On 27 September 2008, Mr Swab was admitted to the psychiatry unit, Upton House, at Box

Hill Hospital following an attempt to hang himself. He was assessed to be a significant risk of death through misadventure and diagnosed with Borderline Personality Disorder in crisis. On 30 September 2008, he was discharged back to CECATS for support and case management at Waverley Clinic, He was discharged with a prescription of 10 diazepam tablets, to be taken

as needed. Mr Swab had daily contact with the CECATS until his intake appointment at

Waverley Clinic on 3 October 2008.

On 3 October 2008, Mr Swab attended the Waverley Clinical & Continuing Care Service (Waverléy Clinic), Mt Waverley. The clinic had received the Hastem Health CCT referral form. Mr Swab was assessed by Dr Gecta Rudra, Hospital Medical Officer, Eastern Health - Mental Health program, and Registered (Division 4) Psychiatric Nurse (RPN) Kevin Jones.

A Mental State Examination (MSE) was performed. Dr Rudra and RPN Jones concurred with the recent hospital diagnosis of Borderline Personality Disorder. The plan was for short term case management, to provide a link with community services, support and to liaise with Mr Swab's psychologist and Ms Jackson.

.On 7 October 2008, RPN Jones was assigned Mr Swab’s case manager. He telephoned Mr

Swab to advise him that Waverley Clinic would provide him with psychiatric follow-up. An appointment was made for 10 October 2008,

On Friday 10 October 2008, Mr Swab attended Waverley Clinic and was assessed by Dr Rudra and RPN Jones. He was initially seen alone for approximately 45 minutes and then in’ the presence of Ms Jackson. His MSE reflected improvement including being relaxed, good

_self care, euthymic mood, no psychotic symptoms and not currently suicidal. No acute risks

were identified. A Clinical Risk and Assessment Form was completed. Plans were made to link Mr Swab with psychosocial rchabilitation facilities at GlenReach and other programs.

RPN Jones indicated that he would telephone Mr Swab the following week once he had made arrangements with GlenReach for Mr Swab to attend an orientation program.

Ms Jackson’s impression of the appointment was that Mr Swab had been requesting hospital admission. She felt his request had been dismissed and was at odds to the responses Mr Swab had received from Southern Health Mental Health services. As they were leaving the clinic, Ms Jackson heard him say "I won't be alive by the end of the weekend". The couple subsequently sat in the car and talked for approximately 1 hour. Ms Jackson later telephoned Mr Swab that evening. She last spoke to him sometime between 9,30- 10.00pm at which time he seemed more cheerful.

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16. On 11 October 2008, Ms Jackson spent the whole day with Mr Swab. They went shopping, went to a movie and had dinner, She left Mr Swab at approximately 11.30pm at which time he appeared happy. He expressed his love for Ms Jackson and gave her a kiss. The couple

_ had been talking about moving back together, having a holiday and discussing other future

plans.

17, On Sunday 12 October 2008, at around lunchtime, Ms Jackson telephoned Mr Swab. He sounded as if he had just woken up and. reported to her that he had not slept well. Ms Jackson was intending to attend Mr Swab’s home after dinner, At 6.00pm she telephoned again to advise that she was not going to be able to make it as she was studying for an exam on the next day. She rang again at 8.30pm and said that she would sce him tomorrow after her exam.

She asked him if he was feeling safe to which he responded positively.

18. On Monday 13 October 2008, just after Ms Jackson had completed her exam, she retrieved

her mobile telephone to ring Mr Swab. She discovered that she had inadvertently turned her

mobile off. When she turned it back on she discovered a text message from Mr Swab, dated

12 October 2008 at 8.42pm. The message expressed his intention to take his life. Ms Jackson telephoned Mr Swab but did not get a response.

19, Ms Jackson travelled to Mr Swab’s Glen Waverley home. When she arrived, Ambulance paramedics, Police and fire brigade personnel were present. Mr Swab’s landlord, Chung Li had discovered Mr Swab hanging from a rope in the bathroom of his bungalow and contacted Emergency Services. Mr Swab was deceased. Resuscitation attempts were not made. It was apparent that he had been dead for sometime.

INVESTIGATIONS:

20. An autopsy was performed by Dr Melissa Baker, Forensic Pathology Registrar, at the Victorian Institute of Forensic Medicine. No natural discase was identified. The cause of _ death was attributed to hanging. !

21. Toxicological analysis revealed the presence of diazepam in blood at a concentration consistent with therapeutic use, The metabolite of diazepam, nordiazepam was also detected.

IThe mechanism of death in cases of hanging is thought to be due to one or a combination of the following:

• Compression of the airway in the neck,

• Compression of the major vessels in the neck.

Stimulation of the carotid sinus leading to profound bradycardia and cardiac arrest (vagal inhibition).

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The investigating Police Officer, Leading Senior Constable (L/S/C) Andrew Nickson

• examined Mr Swab’s premises. Several hand-written notes and a single printed sheet

_ containing negative thoughts about life were located. L/S/C Nickson reported that the notes

appeared to have been written over a period of time and were not specifically contemporaneous. No "suicide note” was located. No suspicious circumstances were identified.

L/S/C Nickson prepared a Brief of Evidence. A statement from Ms Cathryn Jackson raised concerns about the assessment. of Mr Swab at Waverley Clinic on -10 October 2008. Ms Jackson's statement of events on that day and in particular, her comments that Mr Swab had requested to be admitted was not replicated in the health provider's statements.

THE INQUEST: held under section 52(1) Coroners Act 2008

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Viva voce evidence was obtained from:

« Ms Cathryn Jackson

‘« Dr Geeta Rudra

e RPN Kevin Jones

Ms Cathryn Jackson confirmed that she was not living with Mr Swab but had daily contact with him. She had assumed responsibility for the administration of his medication, taking precautionary steps.to ensure that he only ever had a minimal amount at his premises at any one time. She also took other steps to keep Mr Swab safe in his home environment such as removing razor blades and knives. .

Ms Jackson stated that on 10 October 2008, before Mr Swab went into his meeting with Dr Rudra and RPN Jones, .he told her that he wanted to be admitted, Ms Jackson therefore assumed Mr Swab’s need for admission was being discussed during the first 45 minutes of the appointment while he was being seen alone. Ms Jackson conceded that Mr Swab may not have told others the same as he told her.2

When Ms Jackson joined the meeting, the discussion revolved around getting Mr Swab into programs and services he required for providing him with support. The issue of admission was not mentioned. When the meeting concluded and they were all walking through the reception area, Mr Swab said "I won’t be alive by the end of the weekend", He said it in a loud voice. Ms Jackson heard him. She assumed that everyone would have heard him. Ms Jackson did not seek out the health professionals to discuss this comment. She remained

2 Transcript of Proceedings @ p.8 & p.I5

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concerned throughout the weekend that he was at risk but not to a level] that warranted a call to the CAT team or to insist that they attend a hospital to seek admission. he appeared to improve. His overall behaviour/demeanour was quite positive and included discussions about their plans for the future.

Dr Geeta Rudra was a Hospital Medical Officer (HMO) undergoing the psychiatry program and working under the supervision of Consultant Psychiatrist, Dr Cyril Been. In this position, Dr Rudra had regular contact with Dr Been and telephone access to him and other psychiatrist on a needs basis. Dr Rudra is currently working as a Psychiatric Registrar.

Dr Rudra confirmed that there was no discussion about inpatient treatment with Mr Swab on either 3 October 2008 or 10 October 2008. He did not raise the subject and in Dr Rudra’s assessment, Mr Swab did not need admission. The MSE performed on 3 October 2008, reflected that Mr Swab was a chronic risk of suicide but was not an acute risk at that lime.

The Continuation Sheet notes entry made by RPN Jones on 10 October 2008, reflect a similar assessment - not currently suicidal, no recent thoughts. Dr Rudra considered that Mr Swab’s demeanor had improved between the first assessment on 3 October 2008 and the second on 10 October 2008. She said that:

whe was in a much better mood, he was more receptive to what we were telling him and he was actually looking forward to the next few days.

‘Dr Rudra stated that if Mr Swab had asked for admission to an inpatient facility, the decision

would not have been for Dr Rudra to make. She would have contacted the CAT Team, the consultant on call or the consultant of the clinic to discuss the matter further.4

On reflection about the care provided to Mr Swab, assisted by Dr Rudra’s training since that

time; Dr Rudra stated that providing Mr Swab with a specific date and time for the clinic’s next contact may have altered the subsequent events. She stated that people with borderline personality disorders fear abandonment. This could have been the interpretation given by Mr Swab to the arrangement made that contact would be made with him again "next week” , She had not however been able to identify anything in her review of her engagement with Mr Swab on 10 October 2008, that may have or could have alerted her to his actions on 12 October 2008.

3 Transcript of Proceedings @ p37

4 Transcript of Proceedings @ p.40

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31, Dr Rudra had not received Mr Swab’s clinical notes from Southern Health prior to his death, She has since reviewed them but found nothing that would have provided any assistance to her understanding, diagnosis or management plans for Mr Swab. The information she did have available and the comprehensive history provided by Mr Swab himself had been sufficient.

32, RPN Jones’ evidence was consistent with Dr Rudra’s and his clinical notes in the medical records. He too denied any conversation with Mr Swab about admission to hospital and denied hearing Mr Swab’s reference to not being alive by the end of the weekend. Had he heard such a remark, he stated that he would have invited Mr Swab back into the interview room to explore it further.5

COMMENTS:

Pursuant to section 67(3) of the Coroners Act 2008, | make the following comments connected

with the death :

1. The provision of adequate and effective mental health services to Mr Swab was challenging.

He had a long history of self harm on a background diagnosis of borderline personality disorder. His behaviour and actions towards himself were labile and difficult to predict.

2. . Waverley Clinic, Eastern Health, had only recently taken over the provision of mental health services to Mr Swab. He attended for his first assessment with Dr Rudra and RPN Jones only nine (9) days before his death and met with them again only two (2) days before his death.

The health professionals at Waverley Clinic had little time to form a therapeutic relationship with Mr Swab and he may not have felt that he had reached the same position of “engagement” with the service as he had with Southern Health services but I am satisfied that in that short period of time, he had becn provided with thorough and appropriate assessments, activation of management plans and follow-up was in place. He had not been abandoned and his treatment was not in limbo,

3. The contemporaneous documentation of the service’s involvement with Mr Swab supports Dr Rudra’s and RPN Jones’ evidence of their assessment of Mr Swab’s mental state on 3 October 2008 and 10 October 2008. The standard of the documentation is appropriate and a reflection on the provision of professional services.

Transcript of Proceedings @ p.51

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4, I am satisfied that there was nothing apparent in Mr Swab’s presentation on 10 October 2008, that could have alerted to Dr Rudra and RPN Jones to the actions adopted by Mr Swab on 12 October 2008. The evidence of Ms Jackson supports this - she knew her husband better than anyone. She was very familiar with his changing behaviour but she did not predict or anticipate that he was intending to take his life on this particular weekend. His discussions with her about the future were deceptive although it is not possible to say whether they were intentionally so. Nor is it possible to say whether he was planning his death from the lime he left the clinic on Friday afternoon or whether it was morc spontancous.

5. The circumstances surrounding Mr Swab’s death reflects the very fine line separating an assessment of "not currently suicidal" and one of "acute risk of suicide". Suicidal risk assessments are not an exact science. They reflect risk at the time of the MSE but their

• accuracy beyond the completion of the assessment, is academic. Mr Swab crossed the line sometime from his assessment on 10 October 2008 and 12 October 2008. His timing even surprised Ms Jackson. No one predicted his actual risk at that particular time.

FINDINGS:

I find that KELVIN LEA SWAB intentional took his own life by hanging.

and |

I further find that the medical management of KELVIN LEA SWAB by Waverley Clinical &

Continuing Care Service, a division of Eastern Health, was reasonable and appropriate in the circumstances.

AU een anenson

CORONER Dated: 11 June 2010

. Distribution of Finding: Ms Cathryn Jackson Eastern Health

Chief Psychiatrist - Dr Ruth Vine

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