Finding into death of Rajesh Pala

IN THE CORONERS COURT

OF VICTORIA ‘AT MELBOURNE

Court Reference: 2148/09

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of RAJESH PALA

Hearing Dates:

Appearances.

Findings of: Delivered On:

Delivered At:

25 August 2011

Senior Constable K. Ramscy, Police Coronial Support Unit - Assisting the Coroner

Mr Bill O’Shea, General Counsel - on behalf of Alfred Health

AUDREY JAMIESON, Coroner

_ 12 April 2012

Level 11, 222 Exhibition Street, Melbourne

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I, AUDREY JAMIESON, Coroner having investigated the death of RAJESH PALA AND having held an inquest in relation to this death on 25 August 2011

at Melbourne

find that the identity of the deceased was RAJESH PALA born on 22 January 1975

and the death occurred on or about 24 April 2009

at 52 Haig Street, Southbank, Victoria 3006

from: la. MIXED DRUG TOXICITY

in the following circumstances:

BACKGROUND CIRCUMSTANCES:

1. Mr Rajesh Pala was born on 22 January 1975. He was 34 years of age at the time of his death.

He was one of three children to Ramesh and Numala Pala. He was single and in receipt of a Disability

Pension.

2. Rajesh had a long history of polysubstance abuse including heroin. He had taken part in numerous drug rehabilitation and detoxification programs with varied but short term success, He also -had a history of borderline personality disorder, chronic depressive disorder and suicide attempts and had been admitted to psychiatric in-patient units on a number of occasions.

3. In July 2006, he approached Hanover House Southbank, seeking assistance with accommodation and support. Through the Homeless Drug Dependency Program (HDDP), he entered a supported accommodation to work on his drug use and addiction. He resided in a house in the Frankston area through the Windana Program between July of 2008 and April 2009. Intermittently, Rajesh returned to the family home for short periods of time, the most recent being between 8 April 2009 and 20 April

SURROUNDING CIRCUMSTANCES:

4. On 20 April 2009, Rajesh returned to Hanover House, Southbank, seeking their help with his drug addiction, Staff soon became concerned about his mental state and risk of suicide. He was assessed by Homeless Outreach Psychiatric Service (OPS) and subsequently transported to The Alfred hospital psychiatric unit. On admission to the Unit he was agitated, physically aggressive and disorganised. He required seclusion for a brief tiroc.! Te was prescribed Diazepam. for drug withdrawal.

Texnibit 1 - Dr J ianyi Zhang

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3. On 21 April 2009, Rajesh was assessed by Consultant Psychiatrist, Dr Jianyi Zhang. He was making threats to kill himself if he was not prescribed MS Contin or other substitutes for heroin. Rajesh was recommenced on Methadone to which he responded well, The proposed plan was to release Rajesh from The Alfred on medications including diazepam, carbamazepine, dothiepin, methadone and

olanzapine.

6. On 23 Apri! 2009, Rajesh contacted his case worker, Julia Gutbrod, expressing anxiety about being released, He told her that if he was discharged, he would buy enough heroin to overdose. Ms

_ Gutbrod informed hospital staff of Rajesh’s suicidal comments. A Psychiatric Unit Referral Form was faxed through to Hanover House at 2:19pm, At 3:00pm, Rajesh was booked back into Hanover House, Southbank, Ms-Gutbrod spoke to hospital staff regarding the discharge plan for Rajesh to continue to reside at Hanover House and an appointment was made for him to see his local GP - Dr Bruce Ingram, the following day. ‘There was no plan for psychiatric follow-up with the hospital or HOPS.

7. At 7:00pm that evening, Rajesh received his medication from the Crisis Assessment Team in the foyer of Hanover House. He also collected a syringe pack from the Hanover Needle & Syringe Program at the front reception and immediately after, left the building.

8. On 24 April 2009, at approximately 12:00pm, Rajesh’s case worker and another member of staff attended Rajesh’s room. Having received no reply from Rajesh, they entered the room and found him sitting on his bed leaning slightly forward. He was not responsive to cither voice or touch, Staff

contacted 000 and attempted to locate a pulse.

9. The Metropolitan Ambulance Service (MAS) and Metropolitan Fire Brigade (MFB) attended at Hanover House and corifirmed that Rajesh had passed away. Police were contacted and attended. In Rajesh’s room, Police located drug paraphernalia including a used syringe and a spoon.

INVESTIGATION: The medical investigation:

10, | Mr Ramesh Pala lodged an Objection to Autopsy under section 29 Coroners Act 1985 (as it then

was).

11. Dr Paul Bedford, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an external examination and reported to the Coroner that he had not identified any signs of injury except for cubital fossa scarring bilaterally. As these findings were consistent with Rajesh’s history and the reported immediate surrounding circumstances, Dr Bedford ‘recommended to the Coroner that a

reasonable cause of death could be attributed to Drug Overdose.

12. The Objection to Autopsy was upheld.

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13. Subsequent Toxicological analysis identified the presence of heroin metabolites and a number of other drugs including Methadone, Carbamazepine, Chlorpromazine, Olanzipine and three

benzodiazepines.

In his written report, Dr Bedford attributed the cause of death to Drug Overdose including Heroin.

14, The cause of Rajesh’s death was subsequently recorded with Births Deaths & Marriages as "Mixed Drug Toxicity”.

The Police investigation:

15. No suspicious circumstances were identified. No “suicide note" or other expression of intention

was located.

JURISDICTION:

16, At the time of Rajesh’s death, the Coroners Act 1985 (the Old Act) applied. From 1 November 2009, the Coroners Act 2008 (the new Act) has applied to the finalisation of investigations into deaths that occurred prior to the new Act commencement.?

17. Inthe preamble to the new Act, the role of the coronial system in Victoria is stated to involve the independent investigation of deaths for the purpose of finding the causes of those deaths and to contribute to the reduction of the number of preventable deaths and the promotion of public health and safety and the administration of justice. Reference to preventable deaths and public health and safety are

referred to in other sections of the Act.

18. Scction 67 of the new Act describes the ambit of the Coroner’s findings in relation to a death investigation. A Coroner is required to find, if possible, the identity of the deceased, the cause of death and, in some cases, the circumstances in which the death occurred.4 The ‘cause of death’ generally relates to the medical cause of death and the ‘circumstances’ relates to the context in which the death

occurred,

19. A Coroner may also comment on any matter connected with the death, including matters relating to public health and safety and the administration of justice.5 A Coroner may also report to the Attorney General and may make recommendations to any Minister, public statutory authority or entity, on any matter connected with a death which the Coroner has investigated including recommendations relating

to public health and safety or the administration of justice.6

3 Sce for example, sections 67(3) & 72 (1) & (2)

4 Section 67(1) ’ Section G/(3)

6 Section 72(L) & (2)

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THE INQUEST:

20. The identity of Rajesh Pala was without dispute and required no additional investigation.

21. An Inquest into the death of Rajesh Pala was held pursuant to Section 52(1) Coroners Act 2008.

Vive voce evidence was obtained from the following witnesses: .

e DrJianyi ZHANG - Consultant Psychiatrist « -Ms Lisa PHILLIPS - Registered Psychiatric Nurse © Ms Julia GUTBROD - Support worker/Case worker Hanover Welfare Services

22. Dr Zhang spoke to Rajesh on the morning of his discharge from the psychiatric unit at The Alfred hospital. He said that Rajesh was happy about the effect of the methadone and was talking positively about the future, about coming off the drugs but he became upset when his discharge was brought up. Dr Zhang said that the main reason for Rajesh being upset was because he could not afford the cost of the methadone. Rajesh was also concerned about accommodation because he was not sure that Hanover House would take him back and because it was a crisis accommodation facility with a maximum allowable period of 36 days, Rajesh believed his available time left at the facility was limited.

Dr Zhang stated that steps had been put in place for Rajesh to réturn to Hanover House and assistance would be provided by them to secure alternative accommodation for the future.

23. In relation to Rajesh’s threats to harm himself Dr Zhang stated that he had made a lot of threats of killing himself but that it was often in the context of wanting something such as a particular drug. Dr Zhang stated that this kind of suicidal threat is often called conditional (sic) suicidal threats - it’s a way patients communicate with you rather than a plan or intention to do so.? Once Rajesh had been commenced on Methadone, he made no further threats to kill himself until he was advised of his impending discharge. Dr Zhang stated that the same level of assessment of risk is applied to the patient expressing conditional suicidal threats and in ‘Rajesh’s case, looking at his history, removing the perccived crisis or modifying the situational crisis for him reduced his risk. Dr Zhang believed that it was the correct time to discharge Rajesh. He had been given reassurance about his accommodation arrangements to return to Hanover House and arrangements had been made for him to obtain methadone without proper payment, The situational crisis for Rajesh had thus been modified. In addition, Rajesh was future orientated expressing his desire to cease his dependency and improve on his relationship with his family. Dr Zhang stated that future orientation is very important in the assessment of the risk

issues,®

34. Dr Zhang stated that Rajesh had never engaged well with psychiatric services at a tertiary level but had engaged well with Hanover House and his local GP. Dr Zhang anticipated that psychiatric

7 Pranseript of Proceedings (1) @ pa

8p @ ppl5-16

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services would provide ongoing support to Rajesh more through a secondary consultation with the GP, housing worker and crisis assistance services who were engaging with Rajesh. There was no additional

perceived risk by discharging Rajesh shortly after he had been commenced on methadone. He had been

on the drug previously, it is generally commenced in the community rather than a hospital setting and it is considered the safer of other narcotic substitutes.9

25. On 23 April 2009, Nurse Lisa Phillips was Rajesh’s primary nurse on the morning shift commencing at 7:00am. This was-her first and only involvement in Rajesh’s care. Her responsibilities involved performing mental state examination and risk assessment and being his contact nurse. The primary nurse would also contact other people on Rajesh’s behalf and liaise with his medical team and make documentation in his file.!0 Nurse Phillips telephoned Rajesh’s Case Worker at Hanover House to discuss his discharge and also telephoned his family. She completed the Psychiatric Unit Referral Form for Hanover Southbank Crisis Accommodation Service. Much of the information contained in the referral form was obtained from Rajesh’s medical history.1! Nurse Phillips’ reference to “chronic suicide risks” on the referral form meant that Rajesh had a long history of suicidal ideation that can go

“up and down in the context of what is happening around him and stresses that are going on.12 At the time of his discharge, Rajesh was settled and calm. He was neither agitated or irritable according to Nurse Phillips.

26. Ms Julie Gutbrod had worked with Rajesh for approximately 6 months prior to his death. She was present at Hanover House on 20 April 2009 when the Outreach psychiatric services were called to assess Rajesh because of his threats to kill himself. Ms Gutbrod stated that she believed that Rajesh was not coping on a background of the incident that resulted in him having to leave the property in the Frankston area which in turn led to him returning to the family home. Ms Gutbrod described these events as unsettling for Rajesh and causing him a lot of anxiety.!3 He was feeling down and expressing that he wanted to go to hospital. When he rang her from hospital on 23 April 2009, stating he was not ready to be discharged and would kill himself if he was, Ms Gutbrod stated that Rajesh was very heightened in comparison to his presentation on-20 April 2009. Ms Gutbrod communicated Rajesh’s threats to kill himself if discharged to Nurse Phillips who in turn advised her that they were aware of his

statements in this regard.!4

27, Ms Gutbrod stated that it was not her role to determine whether Rajesh was fit to be discharged from the psychiatric unit and she conceded that she was not aware of all that had been going on with him in hospital but was only aware of what Rajesh was telling her, however, she was surprised that he was discharged from the High Dependcncy Unit without any arrangements in place for psychiatric

IT@ pia 10 Exhibit 2 - Statement of Lisa Phillips dated 23 March 2011 & T @ pl8

‘Lp @ p2i 12-7 @ p18 & 20

13 p @ pra

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follow-up.!5 She stated that somewhere between five and six that evening she had met with Rajesh after his return to Hanover House and specifically asked him if she needed to worry about him overnight. Ms Gutbrod recalled that Rajesh had said "No, ’m fine".16 She felt that there was some urgency for him to get out of this meeting with her and stated:

As soon as he came out of the meeting, he went and got the syringe pack and (sic) left the

building. \7

28. Ms Gutbrod did not have any major concern for Rajesh’s welfare following this meeting which might warrant alerting the overnight staff, He had not said anymore about his telephone conversations with her earlier in the day or specifically anymore about his reasons about not wanting to be discharged from hospital.18 Ms Gutbrod reflected that he had seemed reasonably calm but just geared up to leave the meeting with her.19 She was not immediately worried for him and assessed Rajesh as being at low risk20 and although he was obtaining the syringe pack for obvious purposes, Hanover House policy was not to interfere in this process as it was a confidential service,

29, Ms Gutbrod felt that communication from the hospital could be improved upon. She stated that it was difficult to know how to manage Rajesh on his return to Hanover House because she did not know why he was so heightened and not- wanting to be discharged. She stated that she would have preferred if there had been something else in place rather than just an appointment with his local doctor which he may not have gone to.21 However, Ms Gutbrod conceded that, given the timeframe between Rajesh arriving back at Hanover House and the time of his death, arrangements for psychiatric followup might not have made any difference to the outcome.

COMMENT: Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment connected with the death:

1. Ms Gutbtod made some pertinent comments about communication. Thorough communication between health care professionals and carers of all disciplines is the building block for the delivery of effective care and management of patients and clients alike. Ms Gutbrod did not understand why Rajesh was being discharged from the High Dependency Unit at a time when he was still making threats to kill himself. His return to Hanover House was going to be pivotal to his future but Ms Gutbrod did not understand nor was she fully privy to the discussions or the steps the mental health team had put in

15-7 @ p29 16 T @ p30 17} @ pp30-31 18-p @ p38 19-0 @ p32

i

if 3 Statement of Tulie Critbrod datod 25 Augnag 2017 207 @ pal

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place before Rajesh was discharged. The resultant outcome was to disadvantage Ms Gutbrod’s ability to effectively communicate and possibly engage with, Rajesh.

2. The Psychiatric Unit Referral Form/Discharge Plan to Hanover House Southbank is a concise

. but fundamentally an effective communicative document. Having regard to my comments above arising from Ms Gutbrod’s evidence, I recommend pursuant to section 72(2) Coroners Act 2008 that The Alfred Psychiatric Unit and Hanover Welfare Services review the Referral Form/Discharge Plan with the view to including an additional space for “Issues of concern to the patient/client" and "Action Taken". The inclusion of the patient’s subjective concerns and the action initiated, if any, will assist the case workers in communicating with the client on their arrival at Hanover House Southbank and empower the case worker to address, as far as possible, the client’s concerns.

FINDINGS:

The identified shortcoming in communication was not contributory to Rajesh’s death. I find that Rajesh’s death was not foreseeable. He was appropriately treated and assessed for risk at The Alfred Psychiatric Unit prior to his discharge. Appropriate follow-up and support had been put in place prior to his discharge and return to Hanover House Southbank and in all probability, even if psychiatric followup had been included in the discharge plan, I find that it would not have prevented Rajesh’s death on or about the early hours of 24 April 2009.

I find that Rajesh Pala died from mixed drug toxicity.

On the evidence available to.me, I am not able to find to the requisite standard that Rajesh intended to take his own life and as such, I find that Rajesh Pala died of the unintentional consequences of his

intentional use and abuse of illicit drugs and prescription medication.

Pursuant to section 73(1) of the Coroners Act 2008, this Finding will be published on the internet.

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

© Mr Ramesh Pala

e Mr Bill O’Shea, General Counsel, Alfred Health

• Hanover Welfare Services

• Detective Senior Constable Brett Colley

¢ Office of the Chief Psychiatrist

*® Coroners Prevention Unit

Signature:

AUDREY JAMIESON Coroner Date: 12 April 2012

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