Finding into death of Rebecca Lazarus

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2007/2529

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, JUDGE JENNIFER COATE, State Coroner, having investigated the death of REBECCA

LAZARUS

without holding an inquest find that the identity of the deceased was REBECCA LAZARUS born 15 June 1982 and the death occurred 4 July 2007 at Angliss Hospital, Albert Street, Upper Ferntree Gully, Victoria, 3156 from: 1 (a) STAB WOUNDS TO THE CHEST AND ABDOMEN

Pursuant to section 67(2) of the Coroners Act 2008, I make findings with respect to the following circumstances:

Background

1. Rebecca Lazarus was 25 years old at the time of her death. She was described as having a cognitive impairment that had been present since birth. It was reported that Ms Lazarus’ mother had experienced cerebral palsy and her father had been her primary carer. Following his death when Ms Lazarus was five years old, Ms Lazarus lived in a series of foster-care

placements.’

' Inquest Brief p.i

Ms Lazarus completed her education at Rossbourne School in Hawthorn.” After leaving school, she received assistance from Anglicare to obtain employment in a recycling depot and

as a shop assistant, however, she was not working prior to her death.

Ms Lazarus had a half-brother, Andrew Grice, with whom she first made contact with as an adult in 2002. This was prompted by the death of their mother and the division of her assets.

Mr Grice stated that this meeting had been a positive event in his life and he had maintained regular involvement with Ms Lazarus from this point onward. In his statement, he described

Ms Lazarus as a very gentle and happy person.?

In respect to Ms Lazarus’ disability, Mr Grice noted that she had received assistance to manage her finances from State Trustees and was vulnerable to being manipulated by others.

Further, he stated:

“Rebecca was able to function normally, she was very independent and to look at her you wouldn’t know she had a disability. She was a bit slower in her speech than other people but otherwise her disability wasn’t obvious.

Rebecca had a very happy personality. af

Ms Lazarus resided at Hazelwood Supported Residential Services,” located in Boronia. She

had lived there since April 2002.°

In early 2006, Ms Lazarus formed a relationship with a man named Travis Cooke after he moved into Hazelwood Supported Residential Services. Mr Cooke was a 31 years of age and had a lengthy history of paranoid schizophrenia, complicated by periods of poly-substance abuse and medication non-compliance.’ As a result of his mental illness, he experienced a range of delusional beliefs and auditory hallucinations, with his illness described as “chronic

and treatment resistant.”®

The Rossbourne School website indicates that it provides special assistance to students with additional learning needs.

3 Statement of Andrew Grice, Inquest Brief, p.39-43

*Thid

p.41

5 Supported residential services are privately operated services and provide accommodation and support for people who are frail, have a disability, or otherwise require additional assistance.

® Statement of Sena Dharumasena, Inquest Brief, p. 52

7 Correspondence from Eastern Health, 24 August 2010

5 Ibid

iE

Mr Cooke was on a Community Treatment Order and was receiving mental health assistance from the Eastern Health Maroondah Mobile Support and Treatment Service (MMSTS). He had been a client of the MMSTS since 15 October 2006.

Events of 4 July 2007

13:

On the morning of 4 July 2007, Ms Lazarus and her friend, Daniel Penny (a co-resident of

Hazelwood Supported Residential Services) attended the Zagames Hotel in Boronia.

On their arrival at the hotel, Ms Lazarus and Mr Penny met another patron, Mr Matthew Bell, who was previously unknown to them. Ms Lazarus and Mr Bell struck up a conversation and commenced playing the gaming machines. Mr Bell purchased several alcoholic beverages for

Ms Lazarus and the pair exchanged images via their mobile phones.

Mr Bell’s statement indicates that while he was with Ms Lazarus, she informed him that she

had a boyfriend and that they were having difficulties. Specifically, he stated:

“She said that she was having troubles with him and that he had hit her. She said that he had broken her nose one time...When she told me that he hit her T said to her that she shouldn’t be with someone that keeps hitting you. She

told me that she was going to leave him in the next week or so. ap

According to Mr Bell, there had been some “flirting” between himself and Ms Lazarus, which

included hugging, but things had not gone any further than that.’°

At around 12:45pm, Ms Lazarus asked Mr Penny, who was returning to their shared residence, to give a message to Mr Cooke inviting him to meet her at the hotel. Ms Lazarus also telephoned Grace Dharumasena, one of the managers of Hazelwood Supported

Residential Services, and requested Ms Dharumasena also tell Mr Cooke to attend the hotel.!!

A short time after, Mr Cooke met Ms Lazarus at the Zagames Hotel. On his arrival, he had a conversation with Ms Lazarus and Mr Bell in the smoking area of the premises. There was no

report of any disagreement having occurred between the parties at this time.

° Statement of Matthew Bell, Inquest Brief, p.64

° Ihid

"! Statement of Grace Dharumasena, Inquest Brief, p.47

14. Shortly after 3.00pm, Ms Lazarus and Mr Cooke left the hotel together. Coincidentally, they were observed by Sena Dharumasena, co-manager of the Hazelwood Supported Residential Services, walking through a supermarket car park. Ms Lazarus greeted Mr Dharumasena, but

Mr Cooke made no comment and continued walking.”

15. The couple were captured on video surveillance entering the K-Mart department store in Boronia at 3.11pm. Evidence later collected by police indicates that Mr Cooke stole a knife

while he was in the store.

16. Ms Lazarus and Mr Cooke were next sighted at approximately 3.40pm on Central Avenue, Boronia. As they walked down the street, Ms Lazarus was heard to moan loudly. Residents of Central Avenue later informed police that Ms Lazarus was seen lying on the ground with Mr Cooke leaning over her. After several seconds, he stood up and walked away, picking up his

pace to a jog as he proceeded along the street.

17. Police and ambulance officers were called to the scene. Ms Lazarus was conscious when emergency services arrived and stated that Mr Cooke was responsible for the stab wounds inflicted to her chest, abdomen and left hand.!? She was transferred to the Angliss Hospital in Upper Ferntree Gully where she received emergency medical treatment. Regrettably, this was

not successful and she died at 4.50pm on 4 July 2007.

18. Mr Cooke was arrested by police later that day and charged in connection to the death of Ms Lazarus. On 23 June 2009, under s.21 (4) of the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997, Her Honour Justice King returned a verdict of not guilty by reason of mental impairment. Mr Cooke was ordered to serve a supervision order at the Thomas

Embling Hospital for a nominal period of 25 years.’ Mr Cooke’s history of threatening behaviour

19. Mr Cooke was described as having a history of verbal and physical aggression.’ He had made threats to kill his parents in June 2006, after experiencing delusions arising from non-

compliance with his medication. In December 2006 he was admitted to the Adult Inpatient

2 Statement of Sena Dharamasena, Inquest Brief, p.53

'3 Injuries sustained by Ms Lazarus are described in her autopsy report prepared by Dr Noel Woodford date 8 August 2007, Inquest Brief, p.12-26

4 Re Cook [2009] VSC 263 (23 June 2009) per King J

'S Correspondence from Eastern Health, 24 August 2010

De

Unit at Maroondah Hospital following an incident in which he threatened a co-resident with a knife.'© Mr Cooke reportedly stated that he did this so that the person would leave him alone, but he had no intention of harming anyone with the knife. In February 2007 he was found to have a knife under his pillow in his bedroom, which was thought to have occurred as a result of his anxiety about an upcoming court appearance. As a result of his mental illness, polysubstance use and non-adherence to prescription medication, Mr Cooke was described as being a “Jong standing risk of harm to both himself and others in view of his chronic treatment

. ; 17 resistant illness.”

Witness statements provided by those living and working in close proximity to Ms Lazarus and Mr Cooke commented on what they observed in regard to their relationship. For instance,

Ms Dharumasena stated:

“Rebecca has always been there for Travis. At times Travis would tell Rebecca to go away...He would say to us that she would be in his face and he didn’t want her company. I never saw him assault her, and she has never complained of him assaulting her, although she did tell us he hit her nose but this was before we came into the business. I have never seen her with

bruising or marks on her. She was very caring.

Mr Dharumasena’s statement notes:

“Travis was usually in a bad mood but never usually talked much. He had a pretty bad temper and we would hear him ordering Rebecca around and callfing] her names. He would often swear at her, but Rebecca was very soft natured and would go out of her way to please him...This pattern continued

. é 1 since we took over the business.”

The observations of Mr Penny were that Mr Cooke was often antagonistic toward Ms Lazarus.

Specifically, he noted:

“Over the year and a half that I have known them they were always arguing.

He would go to punch her in the face but would stop before actually hitting

6 Ibid Tid

'S Statement of Grace Dharumasena, Inquest Brief, p.48 '° Statement of Sena Dharumasena, Inquest Brief, p.52

Dd

her. He would do this every now and again when they were arguing. She would just sit there. She never ‘arked’ up back at him, she was always calm.

She would just ask him to settle down.”

Mr Penny also added that a few weeks prior to the fatal event, he had heard Mr Cooke threaten Ms Lazarus. He added that he thought Mr Cooke was a “jealous guy” and went on to describe an incident in which Mr Cooke had accused Ms Lazarus of being interested in

another man.”

Information provided by Eastern Health indicated that the relationship between Ms Lazarus and Mr Cooke was considered by the service to be intermittent, and as a result, clinical staff

and case-managers had not engaged with her in depth. Further, it was noted that:

“MMSTS staff talked with her informally on numerous occasions and at no

stage was there thought to be any significant risk to her.””?

While it appears Ms Lazarus was exposed to ongoing threats and harassment within her intimate relationship, it seems that those working in close proximity to her did not recognise that she was being exposed to family violence. As a result, no assessment of her level of risk

or specific assistance to manage this situation was offered.

Mr Cooke’s mental health proximate to the death of Ms Lazarus

During the course of Mr Cooke’s illness, he had been hospitalised on 11 occasions between 1999 and 2006. He was described as having periods of being non-compliant with his medication, resulting in his Community Treatment Order being revoked and involuntary hospital admissions taking place. For the most part, it appears that Mr Cooke was never without some of the symptoms of his illness, despite a range of modifications to his

medication regime having been tried.

From early February 2007, Mr Cooke’s mental health fluctuated. He had expressed thoughts of suicide and a hospital admission was planned in order for him to commence the medication Clozapine: a medication that had been considered from June 2006 but was strongly resisted by

Mr Cooke. Following his mother’s observations’ that he had become less irritable and anxious,

0 Statement of Daniel Penny, Inquest Brief, p.59 2 Ibid p.60 2Correspondence from Eastern Health, 24 August 2010

Dor

Bile

32:

the admission was delayed. Mr Cooke was reviewed by a clinician from the MMSTS on 14 February 2007, and while he expressed ongoing delusions, he appeared to be settled and compliant with medication.”* On 30 March 2007, Mr Cooke was described as speaking openly

about his psychotic symptoms and his medications were adjusted.

On 20 April 2007, Mr Cooke was expressing delusional beliefs and auditory hallucinations, and further adjustments to his medication occurred. He was visited by members of the MMSTS four times in the three weeks that followed, during which time he reportedly showed

some signs of improvement and acceptance of social support."

Mr Cooke was interviewed by his psychiatrist on 6 June 2007 for the purpose of a statutory review of his Community Treatment Order. He was described as cooperative with the interview, although guarded when asked about his psychotic symptoms. Compliance with his medication was not identified as a problem at the time. However, he was still considered to be psychotic with poor insight into his illness and unable to give informed consent.

Subsequently, his Community Treatment Order was extended for a further 12 months.”°

On 12 June 2007 Mr Cooke’s mental state was thought to have deteriorated. He had broken his television and radio the previous evening, and stated he had done this out of frustration with his girlfriend. Mr Cooke was described by MMSTS clinicians as being irritable and difficult to engage on 14 and 19 June 2007. During contact on 26 and 28 June 2007, it was reported that Mr Cooke was “in good spirits” and there was apparently no indication of any

increase in risk to himself or others at this time.7°

On 3 July 2007 Mr Cooke was visited by a MMSTS case manger, whom he did not know, and he was said to be less open to communication. This was the last contact Mr Cooke had with

the MMSTS proximate to the death of Ms Lazarus.

Risk assessments dated 7 February 2007 and May 2007 completed by Eastern Health for Mr

Cooke document his description of risk as:

“History of thoughts of suicide which was noted to significantly increase

with paranoia due to depot medication. History of verbal abuse and physical

3 Thid 4 Ibid °5 Tid 6 Thid

35:

threats towards his parents when unwell. Has made homicide threats when

unwell,” In terms of his risk to others, it was noted Mr Cooke was assessed as being an:

“Ongoing chronic risk of harm to others due to ongoing paranoid and persecutory

delusions.”

The documented risk management strategies for Mr Cooke included MMSTS liaising with staff at Hazelwood Supported Residential Services in order to provide support and education, and to determine when Mr Cooke became “disorganised and agitated in behaviour.?”® Further, it was noted that Mr Cooke’s Community Treatment Order should be revoked and he

should be transported to hospital if:

“His behaviour becomes too disorganised and the risk of self harm or harm

to others is increased due to unpredictable behaviour. 28

For the purpose of this investigation, psychiatric reports prepared for Mr Cooke and submitted in evidence to the Supreme Court in connection to the charges he faced concerning the death of Ms Lazarus were requested. The Office of Public Prosecutions advised that these would not be provided, as to do so may contravene s75 of Crimes (Mental Impairment and Unfitness to

be Tried) Act 1997.°°

In the absence of these reports being produced, I have noted the sections of King J’s sentencing remarks wherein Her Honour reflects on these reports. In brief, it appears that they confirmed Mr Cooke had suffered from schizophrenia for a period of 10 years and that this was characterised by delusions, hallucinations and disorganised communication. As a result of his mental illness, it was determined that he had been unfit to stand trial for a period of 18 months. Further, it was noted that when Mr Cooke arrived at Thomas Embling Hospital (after the death of Ms Lazarus), he was incoherent and unresponsive to what was asked of him. It was only proximate to the time of his hearing in 2009 that he accepted Ms Lazarus had died.

Mr Cooke’s prognosis was not thought to be overly promising, despite some improvement

27 Rastern Health Clinical Risk Assessment and Management for Travis Cooke, dated 7 February 2007

°8 Ibid Ibid

30 Correspondence from Mr Richard Lewis, Legal Prosecution Specialist, Office of Public Prosecutions, | June 2010

following new medication trials. Regardless, it was expected that he would be left with an

indefinite psychiatric disability.*!

The evidence is that Mr Cooke was experiencing a severe mental illness at the time of Ms Lazarus’ death. While this was undoubtedly a significant factor in respect to his actions toward Ms Lazarus, it does not diminish the importance of Ms Lazarus’ vulnerability in terms of her exposure to family violence in her relationship and living arrangements. To this end, I

make the following comments.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected

with the death:

Supp

orted Residential Services

Supported residential services provide accommodation and assistance to people who are aged, frail, or have additional needs arising from a disability or mental health condition. They are privately operated businesses and must be registered according to the requirements of the Supported Residential Services (Private Proprietors) Act 2010 (Vic). Some services target specific population groups, while other facilities cater for a diverse client mix across age,

gender, level of support needs, disability or health conditions.”

As outlined above, Mr Cooke had a longstanding and serious mental illness. It had been identified that he could be a risk to both himself and others, and he had previously made threats against other residents. The Eastern Health MMSTS was aware of these incidents and recognised this risk, as documented in Mr Cooke’s clinical risk assessment and risk management plan. Similarly, staff at Hazelwood Supported Residential Services appear to

have observed Mr Cooke’s apparent irritable demeanour and poor treatment of Ms Lazarus.

The circumstances in which Ms Lazarus’ death occurred raises questions about the appropriateness of Mr Cooke’s placement in a mixed gender and relatively low-care facility,

given his complex presentation and the documented risks that arose from this. The availability

3! Re Cook [2009] VSC 263 (23June 2009) per King J

Ibid

of affordable, stable and supported housing for people with a significant mental illness is recognised as a considerable social problem. While the arrangements for Mr Cooke to reside at Hazelwood Supported Residential Services may have occurred in the absence of suitable alternatives being available, it appears he required a greater degree of psychiatric assistance,

monitoring and support than could be offered in this setting.

Ms Lazarus’ exposure to family violence

The investigation into the death of Ms Lazarus was assisted by the Victorian Systemic Review of Family Violence Related Deaths (VSRFVD).* As a result of that review, some

observations can be made in connection to family violence aspects of this investigation.

Family violence is a widespread social problem, known to affect people of all ages and backgrounds. Sadly, as demonstrated by Ms Lazarus and Mr Cooke, this includes people with complex mental health difficulties and disabilities, who may be even more vulnerable to its

implications and effects.

The death of Ms Lazarus and the circumstances in which it occurred provide an opportunity to consider how the identification and response to family violence can be improved for persons living in supported residential services. These facilities accommodate some of the most complex and vulnerable people in the community, who will, from time to time, establish intimate relationships. It is important that staff members working with individuals in these settings are equipped with an understanding of the nature and dynamics of family violence, the associated risk and contributory factors, signs of escalation, and strategies to ameliorate risk. In addition, it is necessary that proprietors and staff are familiar with the range of services and options available to assist individuals exposed to family violence, so that

appropriate advice can be sought and assistance provided.

The Victorian Government Department of Health is responsible for registering supported residential services and it also produces a range of resources, tools and training to assist

proprietors in maintaining compliance according to the Supported Residential Services

3 Positioned within the Coroners Court of Victoria, the VSRFVD provides assistance to Victorian coroners to investigate the circumstances in which family violence deaths occur. In addition, the VSRFVD collects and analyses information on family violence-related incidents. This contributes to the development of a broader knowledge base for dissemination to the community and agencies working in the area of family violence.

4 See for example: Plummer, S. & Findley, P. 2012, ‘Women with disabilities’ experience with physical and sexual abuse: A review of the literature,’ Trauma, Violence and Abuse, 13:1, pp. 15-29.

(Private Proprietors) Act 2010 (Vic). Given the prevalence and impact of family violence, and relevance of this issue among persons living in facilities of this kind, I make the following

recommendation:

RECOMMENDATION

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation

connected with the death:

1. To continue to develop the skill and knowledge of staff and proprietors of supported residential services, and enhance the support provided to residents of these services, I recommend that the Department of Health, in consultation with the Domestic Violence Resource Centre (Vic) and Women With Disabilities Victoria, incorporate a family violence training module into the current supported residential service training schedule. This should involve a specific focus on the impact and effects of family violence in relation to people with disabilities. Development and delivery of this training should occur in consultation with these

specialist family violence and disability organisations.

Pursuant to rule 64(3) of the Coroners Court Rules 2009, I order that this finding be published on the internet.

I direct that a copy of this finding be provided to the following for action:

Dr Pradeep Philip, Secretary, Department of Health Ms Vig Geddes, Executive Officer, Domestic Violence Resource Centre (Vic)

Ms Keran Howe, Executive Director, Women With Disabilities Victoria

I direct that a copy of this finding be provided to the following for information only:

Detective Sergeant Wayne Woltsche Eastern Health, Maroondah Mobile Support and Treatment Service

Ms Jane Herington, Ageing and Aged Care Branch, Department of Health

Signature:

JENNIFER COATE ATE CORONER ate: 16 November 2012