Finding into death of Ellzbeth Rebecca Robins

IN THE CORONERS COURT OF VICTORIA AT MORWELL

Court Reference: 761/2010

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of Ellzbeth Rebecca Robins

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

Representation:

Police Coronial Support Unit

02/04/2012 Morwell

F A Hayes

Ms K MoFarlane for Craig Robins

Mr C Mylonas for Sara Jowitt Ms A Magee for Bernice Court Senior Constable J Gibbons

IF A Hayes, Coroner having investigated the death of Eflzbeth Rebecca Robins

AND having held an inquest in relation to this death on 28, 29 & 30 November 2011 at Morwell

find that the identity of the deceased was Ellzboth Rebcooa Robins

born on 04/02/2009

and death occurred on 24th Febmary 2010

at Service Rd, Moe

from

la Oxycodone Toxicity

Pursuant to sections 15, 52, 67(2) of the Coroners Act 2008, an inquest into the death was held this day and thore is a public interest to be served in making findings regarding circumstances;

Flizbeth (Elly) Robins was aged onc ycar and 20 days and lived at home with her Mum, Sara Jowitt, her Dad, Craig Robins, and her brothers Jacob (aged 8 years) and Charlic (aged 2 years),

On 24 Februaty 2010, Elly spent the day at home with her mother, father, and her brother Charlie, aged 2 years, It’s not clear whether Jake was home all day or at school,

Elly’s mother gave evidence that Elly had spent the day playing with her brother Charlie and watehing television, during the course of the day, Elly had only recently learned to walk and was gaining in both strength and speed. Elly’s parents were trying to improve her recently poor sleeping pattem, which found her awake well into the early hours of the morning. :

Mr Robins and Ms Jowitt both live with very debilitating physical conditions — Mr Robins with arthritis and Ms Jowitt with fibromyalgia, for which both were prescribed very strong medicine, Mr Robins was prescribed Oxycontin 80mg slow release tablets and Piroxicam, an anti-inflammatory. He took one of each, twice per day, The medications were kept ina high, hard to open drawer in a dresser in his bedroom,

Asa result of his condition, Mr Robins was often in bed for long portions of the day and on 24 Kebruary 2010, he did not rise until approximately noon. He went into the kitchen and asked Ms Jowitt to prepare a sandwich for him. He went to a kitchen cupboard near the paniry to get himselfa glass for milk, which he then (ook to the bathroom where he intended to eat his Jonch. Ms Jowitt brought his sandwich to him in the bathroom, after which sho returned to get lunch for the children,

As she was putting things away after lunch, Ms Jowitt found one of Mr Robins’ Piroxicam tablets on the kitchen floor, near the pantry. She took it to him in the bathroom and queried where the other tablet was. Mr Robins stated to her that he was sure that he had taken it.

Mr Robins, at the inquest, had no specific memory of taking his medication that morning or day. He stated that his memory was badly affected by the strength of the medication he was taking, He told police that he was sure he had taken the Oxycontin, but conceded that it was possible that he had not. In evidence, he stated that he did not feel any more sore than.

narmal that day, which would have been consistent with him taking the medication, He did not feel that he had skipped his medication. sat

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Mr Robins stated that his usual practice was to take one of each of his tablets from the dresser drawer in his room, prior to leaving his room. He would usually put the tablets into the chest pocket of his polo teeshirt, as he was wearing on the day in question, where they would remain until he had eaten the first half or all of his sandwich, at which point he’d consume his medication, He gave evidence that he didn’t like swallowing his tablets and would throw them into his mouth and wash them down as quickly as possible,

Mr Robins’ evidence was that he would usually take his medication while eating lunch in the bathroom, However, if he was minding the children on his own, he would usually eat lunch in the loungeroom, with his tablets on the sandwich plate until he swallowed them.

Ms Jowilt gave evidence that after the conversation with Mr Robins in the bathroom, she looked around the house to see if she could see a fallen Oxycontin tablet, but didn’t find any.

Throughout the day, when she was not in her cot asleep, Elly was free to roam about most of the house, Her parents gave evidence that they kept the bathroom door simt for safety reasons, as were the doors to the bedroom which was being renovated, and the room which held all the renovating materials, Elly and Charlie played together, usually roaming between the kitchen, Jounge and dining rooms, Due to the renovations being undertaken by Me Robins, the beds of all three children were co-located in the dining room.

Ms Jowilt stated that at some point on 24 Febmary 2010, sho became aware that Charlie and Elly had helped themselves to a packet of orange cream biscuits from the pantry in the kitchen. They thon proceeded to eat the cream filling from the biscuits, leaving a trail of halé-eaten biscuits in the loungeroom, Ms Jowitt also thinks that she found half-eaten biscuits in the kitchen, but was not certain about that.

On the basis of this evidence, there is some likelihood that Elly was eating biscuits off the floor, in (he loungeroom and possibly in the kitchen, If Mr Robin’s Oxycontin tablet had fallen to the floor, Eily may well have ingested it as part of this process, at some time that day.

At approximately 7pm that evening, Ms Jowitt went out into their back yard with Charlie, where they stayed until approximately 8pm. As they left the house, to go out, Elly was at the back screen door, orying. Mr Robins heard Elly orying and went lo comfort her, He picked Elly up and took her to the loungeroom, where she fell asleep in his arms after approximately 5 minutes, He noticed that she sounded a bit “snufily” and thought that she might have been getting a cold. He then put her inte her cot in the dining room and he returned to his bedroom,

Bily was next seen by her Mum when she and Charlie came back in from outside, prior to preparing the evening meal. Ms Jowitt stated that she looked in on Elly as she lay in her cot, asleep. Ms Jowitt stated that Elly was asleep on her side and appeared to be brouthing.

She noticed nothing unusual about Elly’s position or condition at that time. Ms Jowitt then went to the kitchen fo prepare dinner, which she stated took approximately 45 minutes.

Once dinner was ready, Ms Jowitt went to wake Elly and on approaching the cot, saw that Elly was lying on her stomach, which was not usual for her. On closer inspection, Ms Jowitt saw that Blly’s face was blue and that she was not breathing, She asked Jacob to get Mr Robins who arrived shortly after and commenced CPR, Ms Jowitt rang “000” and was able to guide Mr Robins, on ihe advice of the Triple 0 operator. On ambulance attendance, Elly was found to be unresponsive and asystole,

Elly was immediately transferred to the ambulance for resuscitation. During that process, it became apparent to the paramedics that Elly may have ingested an Oxycontin tablet. The allending paramedics contacted the Royal Childrens Hospital after which they administered a dose of Naloxone, Elly was transferred to the Latrobe Regional Hospital, where despite continued efforts, she could not be resuscitated,

4,

Ambulance officers Wayne Pearce and Jonathan Moncrieff gave evidence that they overheard mention that Elly bad possibly swallowed an Oxycontin tablet. This was while they were attempting to resuscitate Elly in the back of the ambulance. Mr Moncrieff stated that he thought that the male occupant of his house relayed information that the tablets may have been left on a coffee table and the child may have taken it from the coffee table,

What was the cause of Uly’s death?

Autopsy and Toxicology

An autopsy was performed by Dr Malcolm Dodd, Forensic Pathologist at the Victorian Institute of Forensic Pathology, who formulated the cause of death as “Oxycadone toxicity”, .

Overnight toxicology performed prior to autopsy disclosed Oxycodone in blood at a level of approximately 0.6mg/L. Extended toxicology performed on samples taken at the time of autopsy disclosed Oxycodone in blood at a level of approximately 1.0mg/L, In addition, Oxycodone was identified in gastric contents at a level of approximately 9mg, Dr Dodd concluded that “ the levels identified in blood and gastric. contents are in keeping with the ingestion of a single 80mg Oxycodone tablet”, but also stated that “ingestion of more than one tablet cannot be excluded.”

Dr Dodd also stated in his report that “ingestion of a single 80mg tablet would be sufficient to cause death given the child’s body weight of 10kg and total blood volume being in the order of several hundred millilitres”, He further stated that “ fatalities from Oxycodone ingestion in adults range from 0,3mg/L.”

Other toxicology findings

Asample of Elly’s hair was also taken for toxicological analysis, Oxycodone, Morphine, Codeine, Delta9-tetrahydrocannabinol and Amphetamines were identified in her hair segments,

The presence of these toxicological findings raised issues for police investigators from the Hoinicide Squad which resulted in hair sampics being taken for analysis from Elly’s siblings, Jacob and Charlie.

Results of hair analysis for each of the children

In relation to Elly, the total length of hair taken for analysis was Som. Segmental hair analysis was conducted an 5 x 1om segments of her hair. The results of that analysis were as follows:

Oxycodone was detected in all five segments of hair;

Morphine was detected in all five segments of hai;

Codeine was detected in all five segments of hair;

Delta-9-tetrahydrocannabinol (A9-THC) was detected in all five segments of hair; Amphetamine was detected only in segments 2 and 3 of hair,

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In relation to Jacob Jowilt-Robins, aged 8 years, the total length of hair taken for analysis was 29cm, Segmental hair analysis was conducted on 29 x 1cm segments from the root to be analysed individually. This represented a time frame from approximately 11/01/2008 to 11/06/2010.

‘The results of that analysis were as follows: « Amphetamine was detected in all but 2 segments (28 and 29) of hair; ¢ Oxycodone was detected along segments 2-21 of hair;

• Codeine was detected in the first three scgraents of hair; ¢ Morphine was detected in segments 11-13 of hair.

In relation to Charlie Jowitt-Robins, aged 2, the total length of hair taken for analysis was approximately 3cm, Segmental hair analysis was conducted on 3.x Lom lengths individually. No drugs were detected in Charlie Jowitt-Robins’ hair.

‘The results of that analysis were set out in Dr Dodd’s autopsy report and were also the subject of a separate expert opinion from Dr Dimitri Gerostamoulos, Manager (Toxicology) and Chief Toxicologist at the Victorian Institute of Forensic Medicine, Dr Gerostamoulos also conducted the segmental hair analysis on Elly’s siblings: Jacob Jowitt-Robins and Charlie Jowitt-Robins,

Dr Gerostamoulos’ report describes the drugs found in the hair as follows:

“Oxycodone is a semi-synthetic opiate narcotic analgesic related to morphine used clinically to treat moderate to severe pain. Proprietary medicines containing oxycodone as the Hydrochloride (HCI) and pectinate salts are Endone, Oxycontin and Proladone,

Oxyeodone is a depressant of the central nervous system (CNS), particularly if misused. Jn excess, oxycodone can cause abnormal respiration similar to that experienced with morphine, This will Jead to depressed and slow breathing ultimately leading to coma and possibly death. Oxycodone also has sedative properties.

Morphine is @ highly potent opiate analgesic drug and is the principal active agent in opium. Morphine acts directly on the central nervous system (CNS) to relieve pain.

Morphine is available as morphine tablets or injection, morphine infusions in hospital, or it may derive from the use of heroin or codeine.

Codeine is a narcotic analgesic related closely to morphine but having approximately onetenth the activity of morphine as an analgesic and possessing anti-tussive activity, Codeine is present in numerous proprietary medicines as tablets and syrups often in combination with other analgesics such as aspirin and paracetamol.

Cannabis contains as the main psycho-active ingredients Delta 9 - tetrahydrocannabinol (THC) and 11-OH-Delta 9 — tetrahydrocannabinol, These arc collectively known as cannabinoids,”

What do the toxicology findings in the hair samples mean?

In his report, Dr Gerostamoulos states that “(here is no correlation between concentration of drugs detected. ....with consumption (dosage) and frequency”.

In his evidence at the inquest, Dr Gerostamoulos described the processes by which drugs can make their way into a person’s hair — either by ingestion o by passive transfer. In relation to the former, he stated that “a drug that is ingested normally is in the blood stream, and the blood stream will — there’s a vascular or a blood supply to the hair and as that comes into contact with the hair, the growing hair, that will be incorporated in the hair shaft almost like rings in a tree, for example, aud as the hair grows out the drug will remain in the hair until it’s actually removed, usually through the process of cutting. So once you've cut the hair the drug’s been removed.” Ju addition, Dr Gerostamoutlos stated that drugs which are ingesied take some weeks to appear in the hair through the vascular process.

In relation to drags being found in hair samples as a result of passive transfer, Dr Gerostamoulos stated “passive absorption or contamination, or transfer is the process where drugs find their way onto the hair, either through sweat,,..so leaning on someone who is: using the drug and contaminating the hair, that’s a possibility for transfer. Where the drug is being smoked — so if the drug, such as cannabis, is being smoked, then there is a very good chance that the hair will bs contaminated with cannabis products or cannabis derivates, or drugs that are identified as cannabis, or if an adult comes in with regular contact with an adult who's using a drug, So sleeping the same bed where you've got somcone who's using the drug, that can often resuli in the transfer of drug into the hair of that individual who’s not actually using that drug. So there are ways that the drng can be incorporated through contamination, and we’re not sure why it happens in some hair and doesn’t happen in other hair.” .

Dr Gerostamoulos stated that it was less likely that drugs which are transferred passively could then be absorbed into the blood stream through the skin of the transferee. ‘I’his is because if any drugs were absorbed through this process, which is unlikely, the amounts would be so minimal that the normal elimination processes of the body would be effective enough to reduce the likelihood that any would end up in the transferee’s hair. He stated “it’s seally the concentration gradient or the ability of the drags to transfer onto the hair exogenously or externally, which leads them to being deposited on the hair, rather than absorption through the skin and in the body and through the blood supply to the hair and grown out through the hair, That’s less likely.”

Dr Gerostamoulos was asked whether it was possible to identify whether a drug found in a hair sample was there as a result of ingestion or as a result of passive transfer. His response was that the process of testing could not differentiate betweon whether the drug was contaminating the outside of the hair or was inside the hair, as a result of ingestion, That testing process involves twice washing the hair samples in methanol. The washings are analysed for the presence or otherwise of drugs. Washing the hair does not necessarily remove all of the exogenous or externally bound drug, The hair itself is then analysed by “hydrolysing or cooking, if you like, for waut ofa better term, the hair overnight, at a temperature, which will then enable the methanol fo degrade the hair shaft somewhat, such that you can get a removal of the drug that’s actually incorporated within the hair follicle”.

The “washings” in relation to Elly were tested and did reveal the presence of oxycodone, which, according fo Dr Gerostamoulos, supports the proposition that the drugs found in her hair were present by contamination from others rather than from ingestion by her.

Dr Gerostamoulos was questioned as to whether there could be any correlation between the amount of drugs found in the various segments of tested hair and amounts of drugs ingested or passively transferred. The following points were rade him:

e IPs difficult to work back from concentrations to a dose because hair grows at different rates, sometimes not growing for a period, so when or how much of a drug was taken or over what period of time, cannot be determined;

© Different chemicals bond in different ways to hair, with differing results for extraction, For example, some opioids are more difficult to extract from hair than cocaine, Therefore any amount extracted through testing has no correlation to how it got there initially or how much of the drug was ingested/transferred;

e Studies have measured oxycodone in hair and have concluded that concentrations van be affected by the sex of the person, the race of the person, the colour of that person's hair and whether ii’s been treated in other ways ie bleaching.

Ultimately, Dr Gerostamoulos concluded “we know that, typically, concentrations in hair are low, because there’s not a lot of the dings that’s typically taken up in the hair, They’re typically very — they’re low in concentration, but T ca’t correlate those concentrations with any dose or anything consumption of the drug.”

Dr Gerostamoulos was asked about whether the amount of oxycodone found in Elly’s hair could have been related to the administration, to her, of smaller doses over a period of time, Dr Gerostamoulos stated that “if, for example, the drug was ingested over that time, you’te looking at very constant administration or consumption of that drug over that period, which may represent five to ten months, Now that’s possible but very unlikely with a drug like Oxycodone, I mean, Oxycodone is a very potent drug and it would be unlikely that the child would not exhibit symptoms of unconsciousness or coma or respiratory depression if having been exposed to this drug on a regular basis.”

As to whether a child can tolerate any amount of oxycodone, Dr Gerostamoulos stated that children do not have the same capacity to metabolise drugs as adults — “they don’t have the same enzymic ability at that young age to be able to change those drugs such that the body can eliminate them in a safe way. In any event it’s not a drug that’s presoribed to children.” He went on to state that “so until such an age where — at least two years old , where the child has developed the capacity to be able to metabolise drugs, such as codeine for exatnple can be given to children, they can actually then clear the drug through normal processes, but drugs such as Oxycodone, morphine and other more potent drugs are innately difficult for young children to remove from their blood stream.” Failure to be ablo to eliminate such drugs from their bodies “can then resuit in adverse consequences and cant be coma, respiratory depression or evon death’,

If Fily had swallowed whole the 80mg slow release Oxycontin tablet, Dr Gerostamoulos stated that the tablet would have started to take effect after approximately thirty minutes. If Elly had chewed the tablet prior to swallowing, the slow release coating would have been compromised, resulting in a quicker release of the drug, which would have resulted in effects on her within approximately 10-15 minutes,

The results of the autopsy and toxicology tests on Elly’s blood confirm that Elly ingested, at a time unknown and in circumstances unknown an amount of oxycodone consistent with an 80ing slow release Oxycontin tablet. The results of the toxicology tests on Elly’s hair do not establish how the oxycodone got onto her hair, However, I can exchide the possibility of oral ingestion, given the toxic nature of the drug in question and its likely effect on a child of her age. On the basis of the evidence available, I find that the presence of oxycodone in her hair indicates that her exposure to oxycodone was most likely through passive transfer from her father’s skin to her hair. I do not find that she had on any occasion prior to 24 February 2010, ingested Oxycontin, as there is no evidence to support that propasition,

How can the presence of other drugs in the children’s hair be explained?

Both Elly and Jacob had positive findings for drugs in their hair, Evidence given at the inquest confirms that Ms Jowitt, Mr Robins and Jacob were ail prescribed medication. Ms Jowitt was prescribed Ordine, a morphine mixture and MS Contin, which is morphine sulphate, for the treatment of fibromyalgia. Mr Robins was prescribed Oxycontin, for pain rolief and Piroxicam, an anti-inflammatory, both relating his chronic arthritis, Jacob was prescribed Dexamphetamine, for the treatment of Atiention Deficit Hyperactivity Disorder.

In addition, Ms Jowitt and Mr Robins admitted that they smoked cannabis. From time to time, the children were given Painstop for pain relief, of which codeine is a component.

Dr Gerostamoutos also stated in evidence that Elly may also have had a positive results for drugs in her hair as a result of drinking her mother’s breast milk. Ms Jowitt gave evidenco that she had breast-fed Elly for about her first 14 weeks. Dr Gerostamoulos stated that it would still be possible to detect those drugs in Elly’s hair, at age one, due to the inconsistent nature of hair growth,

The evidence of Dr Gerostamoulos supports the proposition that all of the drugs found present in Elly’s hair, namely Oxycodone, Morphine, Codeine, Deltadtetrahydrocannabinol and Amphetamines, are consistent with those drugs being ingested by other members of her household and passively transferred to her. There is no evidence to support a finding that any other person administered those dings to her.

A similar finding can be made in relation to Jacob, except that he was ingesting, as prescribed, Dexamphetamine and as necessary, codeine in the form of Painstop.

No drugs were found present in Charlie’s hair, either in the methanol washes or the testing, In relation to these toxicology results Dr Gerastomoulous stated that it was an unusual but not unheard of finding, He postulated that “it may be (1) that the child has not taken any drags of course and (2) that the contamination has not happened for this child. So the child hasn't been in contact with the parents or with the environment on as regular a basis as the other two children, Really we don’t know why that — why two children have drugs present in the hair and the other child does not in the same environment.”

‘The evidence is consistent with the ingestion by Elly of an 80mg Oxycontin tablet on the occasion of 24 February 2010.

Other findings on autopsy ‘The autopsy included histology which found that Elly was positive for adenovirus, a

common virus which might be expected to result in a runny nose and chest congestion. One unusual finding in the histology results was that in relation to Blly’s liver, “the portal tracts contain increased numbers of neutrophil polymorphs and occasional non-specific chronic inflammatory cells”, Dr Dodd stated that this was a non-specific finding, but has beon found present in the livers of people who have used drugs. He excluded passive transfer as a cause. The chronic inflammatory cells would have been in place for a week. Dr Dodd stated that any medication could have caused this,

Anothor unusual feature noted by Dr Dodd was the thymus where he noted “evidence of lymphocyte depletion”. Lymphocyte depletion is-a response to stress of some kind and would take days or a week to show up. Again, this was a non-specific finding.

Dr Dodd also noted some bruising to Elly’s head, which he stated were “blunt force trauma” and which could have been consistent with both resuscitation and with learning to walk, Elly’s parents gave evidence that she had, as would be expected, experienced falls while learning to walk and that they had contacted an ambulance to attend on one such occasion to see if Elly was injured. The ambulance paramedics attended, checked Elly and recommended no further treatment.

Dr Dodd found “no evidence of old or recent bone fractures, heritable metabolic disease or significant bacterial or viral isolates that would have contributed to death.”

Were there any other protective issues in relation fo Wily or her siblings

Asa result of Elty’s death and the concerns raised by the detection of other drugs in her hair, the Child Protection Unit of the Department of Human Services (DHS) commenced an investigation. Jacob and Charlie moved from theit family home to live with their grandparents pursuant to orders under the Children Youth and Families Act.

Both DHS and Victoria Police sought an assessment report from Associate Professor David Wells, Head of Clinical Forensic Medicine at the Victorian Institute for Forensic Medicine.

Associate Professor Wells reviewed the medical histories for both Charlie and Jacob, in relation to which he concluded:

1, Both children appear to have presented promptly for assessment and treatment of a range of medical conditions.

2. The episodes of trauma described could be considered minor and although the history and examination findings are Jimited, it is quite conceivable that they could have been sustained in the manner alleged:

3, No comments are made by any medical practitioners regarding neglect of treatment, feeding or clothing, Further, there is no indication that either child presented in a condition that might indicate that they are under the influence of a

” drug;

4. Apart from Jacob’s attention deficit disorder (ADD) there is no chronic medical

condilions identified in these files.”

At the inquest, Associate Professor Wells agreed with Drs Dodd and Gerostamoulos that the most likely cause of Elly’s death was the ingestion of an 80mg Oxycontin tablet.

The inquest also heard evidence from Bernice Court, Maternal and Child Health nurse in relation to Charlie and Elly. Ms Court gave evidence that over the period of time of her involvement with the family, she did not have protective concerns about the children. She was aware of the medications prescribed to Ms Jowitt and Mr Robins and had provided information in the normal course of her duties about the safe storage of medication, Ms Court stated that she had no basis to be concerned about the welfare of the children in their parent's care, Where she was aware of issues, such as Elly’s disturbed sleeping pattern, she referred the family for assistanco and experienced no resistance from the family.

What can be learned from Elly’s tragic death

Bernice Court was asked whether she could identify any recommendations which could be made by me in relation to the better management of highly toxic medications where children are present. She suggested that a recommendation be made that medications be kept in a locked cupboard.

Associate Professor Wells was similarly asked for any suggestions he might have, In relation to the question of a locked cabinet, Associate Professor Wells stated that there are many situations where, particularly for the elderly, that tablets may need to be placed next to a person, with a cup of tea for instance, fo remind them to take their tablets. He was not in favour of a recommendation to keep tablets in a locked cupboard, He stated that there already exist warnings on medication packaging to keep away from children.

He confirmed that the issue with medication is that of safe handling once removed from its storage site, which is not going to be fixed by mandating the requirement of a locked storage facility. Instead, parents and carers need to be vigilant about the potential for human error and to minimise the possibility of tablets getting lost prior to thom being ingested,

Conclusions

I find that Elly ingested an 80mg slaw release Oxycontin tablet on 24 February 2010, which, given her age and size, resulted in her tragic death. It’s not known how Elly obtained the tablet, but it is most likely that it fell, by accident and unknown to him, from her father’s pocket at the same time as the Piroxicam tablet fell onto the kitchen floor. Ms Jowitt checked the floor to see if an Oxycontin tablet fell at the same time, but she did not find one, Tt may also be that the tablet fell ont of his pocket on another day, but there is no evidence to support that.

9,

There is no evidence to suggest that Hily or any of the other children obtained the tablet from the dresser in Mr Robins’ bedroom. It is unlikely that they could have done so given the difficuity in opening the relevant drawer. .

There is no evidence to support that Mr Robins consumed his medication in the lounge room that day, therefore little likelihood that Elly picked it up from a table where he might have left his sandwich plate.

It is probable that Elly ingested the tablet, mistaking it for a picce of biscuit. It probably ocourred Jater in the day on 24 February 2010, as her Mum had noted nothing unusual about her condition prior to going oul into the garden at 7pm,

On realising, at approximately 8.45pm that Elly was not breathing, her parents did everything they could to resuscitate her.

T find that the hair sample resulis establish that the drugs found in the halr of Elly were present due to passive transfer from Jacob, her Mum and Dad. The drugs found present in Jacob’s hair were present for the same reason, with the exception of amphetamine, which was prescnt to his ingestion of a prescribed amount of Dexamphetamine.

1 find that Bemice Court carried aut her duties as Maternal and Child Health Care turse diligently. I have no issue with the level of oare provided by her.

In summary, Billy died as a result of ingesting an 80mg slow release tablet of Oxycontin, which appeats to have accidentally fallen on the floor, Her death is a tragedy for her parents, brothers and extended family, and J find that Ms Jowitt, although aware of the possibility that a tablet had fallen, did what she could to satisfy herself that there were no tablets on the floor and therefore, to minimise any potential risk 10 her children.

Billy was greatly loved by herfamily, who have been devastated by her loss,

Signature:

F A Hayes

Dates 2 YF

Distribution

A copy of these findings are to be directed to the Child Protection Division of the Department of Human Services.