Finding into death of Carl Ranthe

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST

Section-67 of the Coroners Act 2008

Court reference: 13/09

Inquest into the Death of CARL RANTHE

Delivered On: 28th February 2011

Delivered At: Coroners Court, Melbourne

Hearing Dates: . 16 September and 17 September, 2010 Findings of: CORONER JOHN OLLE Representation: Mr R Appudurai for Susan McIntyre

Ms S Ellis of Counsel for Peninsula Health

Place of death: West Gate Bridge - Lorimer Street - Gate of Salmon Street, Port Melbourne, Victoria 3207

PCSU: Sergeant David Dimsey

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 13/09 In the Coroners Court of Victoria at Melbourne L,JOHN OLLE, Coroner

having investigated the death of:

Details of deceased: Summame: RANTHE First name: CARL Address: Peninsula Health Community Care Units

4 Spray Street, Frankston, Victoria 3199

AND having held an inquest in relation to this death on 16th and 17th September, 2010 at Melbourne

find that the identity of the deceased was CARL PAUL RANTHE

and death occurred on Ist January, 2009

at West Gate Bridge - Lorimer Street - Gate of Salmon Street, Port Melbourne, Victoria 3207

from la. MULTIPLE INJURIES

In the following circumstances:

1. Carl Ranthe (Carl) was aged 26 years at the time of his death. He lived at a Community Care Unit in Frankston.

2. An inquest into Carl’s death was conducted on the 16th and 17th September 2010. I am satisfied that the circumstances of death have been fully addressed.

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Background

3. Carl first-presented to Psychiatric Services (PS) in October 2002. Following examination by Peninsula Health Crisis Assessment Team (PHCAT) a provisional diagnosis of Prodromal Schizophrenia was made. Carl did not wish to engage with treatment at this time. The following year he presented at PS with psychotic symptoms, suicidal and aggressive behaviour, which resulted in his involuntary admission to the In Patient Unit.!

Characterisation of Carl’s Mental Health Ilness

4. Dr Smith explained:

"Over 6-7 years of his illness Carl experienced frequent relapses characterised by auditory hallucinations, thought disorder, ideas of reference and persecutory delusions.

When unwell he also exhibited suicidal and aggressive behaviour and had. a gradual reduction in function in all areas of his life. At times Carl had significant .co-morbid alcohol and marijuana abuse. Substance use often triggered his psychotic relapses. A further trigger to relapse was interpersonal stress or conflict. At times during relapses, Carl had attempted to harm himself with a knife and had also made an assault on his mother, assaults on staff and co-patients of inpatient units and also an assault on a@ Coresident at a supported residential service. All of these appeared related to psychotic symptoms.

Carl had lived in a variety of residential settings due to the impact of his illness making it untenable to live with his mother. At times, he had lived in a supported residential service, He was admitted to the Peninsula Health CCU in July 2008.

During his time at the CCU, the focus was on a rehabilitation program to improve his independent living skills, reduce his drug and alcohol use, assist him in medication

management and control of his mental illness and help him obtain employment. Carl had |

progressed well at the CCU and immediately prior to his death he was on a transitional discharge plan with the view to moving out to a private rental unit.” *

Discharge planning

5. Dr Smith explained that during December 2008, there were a number of meetings and

discussions involving herself, other CCU clinical staff, Carl and Mrs McIntyre, to discuss discharge plans.

I Statement, Dr Lucinda Smith 2 Statement, Dr Lucinda Smith

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6. Dr Smith had noted that during late 2008, Carl’s risk issues had diminished, he was abstaining from substances and a plan was formulated to monitor potentially stressful interpersonal contacts. Dr Smith explained:

"Carl had also been given the option of some "time out" during which times he would stay in a hotel in Melbourne near his father. Carl’s insight and judgement into when he would benefit from this time away from the CCU environment appeared to be improving.”

7. Following the aforesaid discussions of December 2008, Dr Smith explained:

"Carl had reached the point where he found the CCU environment to be detrimental to his mental state and a plan had been negotiated for him to spend two nights per week at the CCU and he spent the rest of the nights staying with his girlfriend in the local area.

There was a clear plan he would meet CCU staff at least twice a week to allow monitoring of his mental state and to finalise plans for his private rental accommodation.

A referral had been made for case management. Carl was still receiving his depot from CCU staff, however he was managing his oral tablets by himself in a dosette box. CCU staff, Carl and his mother were all in agreement with this plan."

Contact with CCU staff 1st January 2009

8 I have heard the evidence of Gordon McRae, Manfred Rapp and Dr Lucinda Smith, in respéct to events of the 1st January 2009.

Involvement of Gordon McRae, CCU

9, ° Mr McRae was an experienced psychiatric nurse. I was satisfied that Mr McRae had a good professional relationship with Carl, -

10. At about 7.00pm on the Ist January 2009, ‘Cart returned to the CCU. Earlier, Mrs McIntyre had telephoned Mr McRae, informing him of Carl's stressful evening and potential agitated state. Mr McRae noted:

"His presentation, although a little agitated, did not suggest the use of illicit drugs or over indulgence in alcohol.

On discussion with Carl, he informed me that his agitation was due to being involved in a fight with Mark, a friend of his friend Christiana after having an argument with her. He had assaulted Mark by punching him in the face."4

3 Statement, Dr Lucinda Smith 4 Statement, Mr Gordon McRae

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il, Mr McRae had known Carl for two and a half years. He was acutely aware of Carl’s propensity to react to high stimulus situations in this manner. He explained:

"A recent incident involved Carl throwing his amplifier through a window. We spent

"approximately 30 minutes discussing this incident after which I was satisfied that he was setiled and was now at no risk to himself or to others. Even though he was initially agitated, he calmed down during our discussion. "5

12, On 1 January, Carl declined Mr McRae’s offer of diazepam. Mr McRae accepted Carl’s intention to return to his unit for the evening.

13. Mr McRae and Carl had spoken for approximately half an hour. Mr McRae had no reason to disbelieve Carl.

14. | Mr McRae was notified by Mr Rapp at Frankston Hospital that Carl had attended the hospital.

15. Under cross-examination by Mr Appudurai, Counsel for Mrs McIntyre, Mr McRae could not recall being asked by Mrs McIntyre to remove Carl’s keys. It is not necessary for me to determine the issue. Mr McRae explained although he had no power to remove Carl’s keys, if he considered Carl a risk of driving, he would have asked Car! for his keys. He explained that he has previously asked residents to provide keys, but saw no need on this occasion. 6

16. Although Carl subsequently left the unit without notifying Mr McRae, there is no basis to criticise Mr McRae’s judgement.

17. In my view Mr McRae displayed Carl empathy and professionalism. His dealings with Carl were appropriate.

Manfred Rapp

18. Carl subsequently presented to the Frankston Emergency Department.

19. A social worker with vast experience in clinical liaison, Mr Rapp was employed at Peninsula Health for twelve years.

5 Statement, Mr Gordon McRae Transcript pages 67-68

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Carl was well known to him. There were many prior presentations to the Emergency

Department. Further, Mr Rapp knew Carl during the time he worked for the CAT Team in 2003.

The Assessment

21,

"During my initial assessment, I found him not to be psychotic, with no significant depressant markers. He was a tall man in casual clothes. He was restless and agitated but I was able to calm him within five minutes. We established rapport easily due to our long association. He was upset about the fight he had earlier in the day, He requested admission to 2 West but he was unable to explain to me why this would be preferable to returning to CCU, Mr Ranthe told me that he had gone for a drive to "clear his head" and he had a few drinks in the last hour. He did not appear to be affected by alcohol although I could smell alcohol on his breath.

He told me that he had a "silly fight" with a male friend. He had returned to the CCU and had a conversation with the nurse, Gordon McRae. After this conversation he said

he got in his car and drove to the hospital. a

The initial assessment took approximately 15 minutes. Mr Rapp then telephoned Gordon

McRae who expressed surprise. Mr McRae explained that he believed Carl had settled down

prior to returning to his unit.

22,

Mr Rapp noted:

"T had already formed an opinion at this stage that Mr Ranthe would not need admission to 2 West as this seemed to he situational crisis so I asked Gordon if someone from CCU could come and pick Mr Ranthe up and take him heme. At this time it was just before the night duty handover at CCU, Gordon told me that it was not possible for anyone to leave and pick up Mr Ranthe." 8

The assessment continued

Following the phone call to Mr McRae, Carl accompanied Mr Rapp to the interview room

to complete the assessment. Mr Rapp questioned Carl:

" closely about any plan or intention to harm himself or others.’ He categorically denied this." 9

7 Seatement, Mr Manfred Rapp 8 Statement, Mr Manfred Rapp 9 Statement, Mr Mantred Rapp

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24. Mr Rapp rated him very low on the assessment. scale of suicide or self harm. He explained that Carl can be a volatile person and thus rated him medium risk of harming others.

Carl denied to Mr Rapp any auditory hallucinations and Mr Rapp noted Carl’s medication regime was up lo date.

25. Mr Rapp explained to Carl that he was welcome back at the.CCU: He ‘explained admission to hospital was not warranted. Further, given the good support available at the CCU, Mt Rapp considered it was appropriate that-Carl return to the CCU.

26. He carefully explained his plan. In particular, he would arrange a taxi to collect Carl having smelt alcohol on Carl's breath, he asked Carl to provide his keys. Carl declined.’ Mr Rapp assured Carl that his car would be safe overnight in the carpark. Importantly, Mr Rapp noted; :

"Mr Ranthe seemed happy with this plan and he agreed to go back to CCU in the taxi.

He was a lot-calmer than when he arrived an hour ago. He asked me if he could 20 outside to wait for the taxi and have a cigarette. As I assessed that he posed no risk to himself or others I was agreeable for him to wait outside. We shook hands and I returned inside the ED to attend to my other patients. He left the ED at 2110..

I was unaware until later that Mr Ranthe did not get a taxi. Usually, when taxi drivers arrive and there is no one waiting they come inside the ED to ask the administration staff to find the patient, This did not happen.

At about 2205, the staff at the CCU rang me to say that Mr Ranthe had not arrived there.

I made a phone call to the taxi company and they told me that Mr Ranthe was not in the ED area when they arrived. I then went outside and checked the carpark with the security staff We failed to find him. CCU staff informed me that they would ring his friends and family and try to locate him" 19

27. At inquest I expressed to Professor Keks my assessment of Mr Manfred Rapp:

“For your benefit, Professor, I make it clear. I felt he (Manfred Rapp) was a very impressive witness and vastly experienced clinician, In addition he knew Carl and I have no doubt that he was able to erigage him."!!

28. In evidence Mr Rapp explained he was unaware of an incident of the 4th December,

29. He stated had he known, the incident would have been discussed with Carl. However, he did not consider the prior incident would have altered his management plan on 1 January.

10 Statement, Mr Manfred Rapp Ut Transcript 223

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29, Dr Smith and Dr Keks considered Mr Rapp’s assessment was appropriate. Further, the prior incident would not alter the plan. Carl did not meet admission criteria on 1 January.

30. The presentation of Carl on the 4th December, 2008 was significantly different to his presentation on the Ist January, 2009. On the earlier occasion, Carl was highly agitated and concerned he would assault someone at his unit. His presentation on 1 January 2009 was in stark contrast,

Overview of dealings between Carl and Mr McRae and Mr Rapp

31. T consider Carl received professional and caring interaction with both Gordon McRae at the CCU and Manfred Rapp at the hospital.

32, Further, | consider the judgement exercised by both clinicians to have been reasonable.

33. IT have found that both Mr McRae and Mr Rapp to be impressive witnesses. I endorse the following overview of Professor Nicholas Keks:

"In my opinion, from my review of the clinical notes, Mr Ranthe's overall comprehensive psychiatric care from Peninsula Health was entirely appropriate, and of a high clinical standard in comparison to Australian standards.

I do not think it likely that Mr Ranthe would have obtained a better standard of psychiatric care from any other Australian service or facility.

Mr Ranthe was receiving appropriate medication in an appropriate manner, and his psychotic illness had been stabilised, at the time of his death.

There are no indications that Mr Ranthe was abusing substances at the time of his death.

He was siill “consuming alcohol, though consumption appears to have been moderate, certainly on January 1, 2009, given clinical observations and post-mortem toxicology report.

Most patients in similar circumstances would not achieve an acceptable degree of control over their alcohol/substance abuse, in nty experience,

Mr Ranthe was clearly prone to impulsive and aggressive behaviour both to others and himself in stressful situations, including relationships with his family.

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Such behaviour was exacerbated by relapses of psychotic illness and substance use, but in my opinion there is no indication Mr Ranthe was experiencing illness relapse at the time of his death.

Neither Mr McRae nor Mr Rapp found any evidence of relapse of illness or relapse of substance/alcohol abuse at the time in Mr Ranthe.

Mr Ranthe had consumed some alcohol on January 1, 2009, and it is possible that even modest alcohol consumption led to a degree of disinhibition, but experienced clinicians and others did not assess Mr Ranthe as intoxicated or behaviourally affected by alcohol when he was seen prior to his death," 12

34, T endorse the following summation of Professor Keks:

"Mr Ranthe’s case posed a high level of clinical complexity, given issues with co-morbid alcohol/substance abuse and aggression, as well as schizophrenia/schizoaffective disorder." 13

35. Carl’s mother Susan McIntyre has provided the investigation a large volume of material.

I thank her for her contribution. ;

36. Susan Melntyre was.a devoted and selfless mother, who provided Carl unstinting love and support. The nature of Carl’s mental health illness led to conduct directed toward his mother, which often belied the love and support she offered him.

37. Nonetheless, Carl would not have doubted his mother’s commitment to him, often in very difficult circumstances, throughout the course of his life.

38, T fully accept Mrs Mclntyre’s belief that more should have been done for Carl. However, I do not resile from my view that Carl reccived appropriate and professional care and attention on 1 January 2009, ,

39. 1 endorse the opinions of Professor Keks and Dr Smith that the clinical decisions exercised on Ist January 2009, were comprehensive. That there was no reasonable basis either individual could have forecast Carl’s tragic decision.

12 Statement, Professor Nicholas Keks 3 Report Professor Keks, page 10

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Conclusion

1. Carl was agrecable with the plan to take the taxi home to his unit;

2. Carl was not suicidal when he shook hands at their parting;

3. When and why Carl chose to end his life is not known.

Post Mortem Medical Examination

40. On the 6th January, 2009, Professor Stephen Cordner, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an external examination only on the body of Carl Ranthe.

41, . Professor Cordner found the cause of death to be multiple injuries.

42. Fle noted the following background: "The deceased has a history of chronic schizophrenia. He drove from the city to the Westgate Bridge, where he was seen to stop the car, run immediately to the railing and jump. He was found on the ground lying on his front.”

Comment

43. Mrs McIntyre has provided a number of suggested recommendations following the death of Carl, [acknowledge her valuable contribution:

44, — Her suggestions have been provided to Peninsula Health, Through its Director, Shaun Jespersen, I have received considered responses. Further, Mr Jespersen gave evidence and provided a very detailed statement with annexures.

45. I do not consider it appropriate or necessary to make recommendations in this case. Iam satisfied that the suggested recommendations of Mrs’ Mcintyre, a number of which have previously been implemented by Peninsula Health, have been fully considered by Peninsula - Health Mental Health Service.

46. — Loffer Mrs McIntyre my sincere condolences.

47, I thank Counsel for their assistance throughout the course of the inquest.

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Signature:

Finding

I find the cause of death of Carl Paul Ranthe to be multiple injuries, in circumstances in which he committed suicide.

John Olle Coroner

28th Febru

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