Finding into death of Angela Diane Atkins

Rule 60(1)

FORM 37

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court reference: 1514/07

Inquest into the Death of ANGELA DIANE ATKINS

Delivered On: Delivered At: Hearing Dates: Findings of:

Place of death/

Suspected death:

PCSU:

15th March 2011 Coroners Court, Melbourne 15th March 2011

Coroner, John Olle

Bendigo Police Station, Bendigo, Victoria 3550

Leading Senior Constable King Taylor

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FORM 37 Rule 60( 1)

FINDING INTO DEATH WITH INQUEST | Section 67 of the Coroners Act 2008 Court reference: 1514/07

In the Coroners Court of Victoria at Melbourne

J, JOHN OLLE, Coroner having investigated the death of: Details of deceased:

Sumame: ATKINS

Firstname: ANGELA Address: 10 Edgecombe Street, Kyneton, Victoria 3444

AND having held an inquest in relation to this death on 15th March 2011 at Melbourne find that the identity of the deceased was ANGELA DIANE ATKINS and death occurred on 23rd April, 2007 |

at Bendigo Police Station, Bendigo, Victoria 3550

from

la. UNASCERTAINED

In the following circumstances:

1. Mrs Angela Atkins was aged 51 years at the time of her death. She lived at 10 Edgecombe Street, Kyneton. :

2. A comprehensive coronial brief has been prepared by Senior Sergeant Argall, Ballarat

Police Station. At the time of Mrs Atkins’ death, the coronial investigator was a Detective Sergeant attached to the Homicide Squad.

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3. At my request, Leading Senior Constable King Taylor, of the Police Coronial Support Unit, requested the coronial investigator to address a range of issues in respect to Mrs Atkins’ incarceration. A report with enclosures dated 31 July 2009, has been provided by Senior Sergeant Argall, which I am satisfied fully addresses the issues raised by me.

4, Further, as part of my investigation, 1 requested the opinion of an emergency physician, in respect to the appropriateness of discharging Mrs Atkins from hospital into police custody on the 20th April, 2007. Dr David Eddey, Director of Emergency Medicine at The Geelong Hospital has provided a report. He notes:

1. the treatment of opiate withdrawal is commonly undertaken in the custodial setting and is largely symptomatic;

2, the Victoria Police ’Custodial Drug Guide’ recommends a dose of Diazepam (Valium) 5img tablet 2-3 times per day;

3. the report of Mrs Atkins attendance at Bendigo Hospital relates to a diagnosis of opiate withdrawal and her return to the police cells with a prescription for Diazepam 5 mg 6-8

hourly, A very modest dose in kecping with the Custodial Drug Guide.

5. I am satisfied that Mrs Atkins was lawfully detained and appropriately cared for whilst incarcerated. in the cells at the Bendigo Police Station from the 19th April, 2007 until her tragic death on the moming of the 23rd April. Importantly, Mrs Atkins reccived medical care throughout her incarceration. :

6. On 20th April, Mrs Atkins appeared ill. An ambulance conveyed her to the Bendigo Hospital for examination. The médical assessment revealed Mrs Atkins was suffering from anxiety. Further, she exhibited signs of opiate withdrawal with abdominal cramps, dilated pupils and shivering/goose bumps. There was no diarrhoea/vomiting/lacrimation.

7. Mrs Atkins presentation was otherwise unremarkable with normal blood pressure and heart rate, normal blood glucose and normal electrocardiograph (ECG). Urea and electrolytes showed normal sodium, potassium, urea and creatinme. Mrs Atkins was afebrile.

8. Following the medical assessment, Mrs Atkins was medically discharged to police custody, Upon return to custody, she was managed with 5 mg of oral Diazepam with a script for Diazepam 5 mg t.d.s.

9. On the morning of her death, Mrs Atkins was due to attend court. At 6.15am, police entered her cell and gave her breakfast. Mrs Atkins was awake and walking around her cell; About an hour later, Mrs Atkins was found deceased in her. bed in the cell. An ambulance was called however resuscitative measures were unsuccessful.

Post Mortem Medical Investigations

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Post Moriem Medical Investigations

On the 24th April, 2007, Dr Michael Burke, Forensic Pathologist at the Victorian Institute

of Forensic Medicine, performed an autopsy. Dr Burke found the cause of death to be unascertained.

Dr Burke referred to the Police Form 83 and noted that on the afternoon of Friday, 20th

April, 2007, Mrs Atkins appeared ill and police transported her to the Bendigo Hospital where she was assessed as withdrawing from opiates and suffering anxiety. Dr Burke noted:

Cause

“Post mortem examination showed no evidence of any injury that could have contributed to or led to death,

The post mortem examination showed no evidence of any structural disease process that would have led to death, Microscopic examination of the. heart showed no underlying myocardities or cardiomyopathy.

Toxicological examination on post mortem blood showed no morphine. There was alow concentration of codeine (0.03mg/L). Furthermore, a trace of diazepam was identified within blood. Sertraline (anti-depressant medication) was identified within blood.

Analysis for electrolytes in vitreous humour showed no evidence of a renal impairment.

Toxicological examination on antemortem blood (Bendigo and Northern District Hospital

• hospital lab no. GO6S7,20/4/07, 1855 hours) showed a free morphine concentration of 0.04mg/L. No codeine was identified. There was no alcohol."

of Death

The cause of death of Angela Atkins is unascertained.

Dr Burke commented:

“Drug withdrawal may progress to nausea and vomiting, tremor, confusion and agitation.

If untreated the condition may further deteriorate to delirium, disorientation, hallucinations and seizures.. Deaths may rarely occur.

One notes that Angela Atkins was in a police lock-up cell with the video monitor. She

was observed in the morning when breakfast was served and exhibited no signs to suggest her impending death. There is no objective evidence to indicate the death is directly

related to opiate withdrawal.”

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14. Mrs Atkins’ death is tragic. There is no evidence, however, to find that her death was the result of inadequate care and attention whilst in police custody and/or that the medical assessment and treatment at the Bendigo Hospital was unreasonable,

Finding

I find that the cause of death of Angela Atkins is unascertained.

Signature:

John Olle Coroner

15th March,

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