Coronial
VICcommunity

Finding into death of Mark Robert Scott

Deceased

Mark Robert Scott

Demographics

41y, male

Coroner

Coroner Kim M. W. Parkinson

Date of death

2011-07-21

Finding date

2013-01-16

Cause of death

Effects of Fire

AI-generated summary

Mark Robert Scott, a 41-year-old man with chronic pain, substance addiction, and recent depressive illness, was admitted to Frankston Hospital on 15 July 2011 following suicidal ideation. During admission, he disclosed to his sister that he would take his life by setting fire to himself and his car. He was discharged on 19 July 2011 after psychiatric assessment concluded he had an adjustment disorder, with plans for GP follow-up and drug rehabilitation referral. Two days later, he purchased petrol and tape, drove to a camping ground, and set a fire in a vehicle in which he was found. The death was determined to be intentional self-harm by fire. Clinical lessons include: maintaining heightened vigilance when patients disclose specific suicide methods; ensuring robust post-discharge safety planning and follow-up for patients with recent suicidal ideation; and considering the adequacy of community support and detoxification processes for complex patients with co-morbid substance abuse and psychiatric illness.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrygeneral practice

Error types

delaycommunication

Drugs involved

methadonediazepam

Contributing factors

  • chronic pain from longstanding back injury
  • severe substance addiction (prescribed and illicit substances)
  • recent depressive illness
  • suicidal ideation
  • adjustment disorder
  • financial stress
  • inadequate post-discharge safety planning and follow-up
Full text

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2011 2662

FINDING INTO DEATIIT WITH INQUEST

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

Inquest into the Death of; MARK ROBERT SCOTT

Delivered On: 4 DECEMBER 2012 and PUBLISHED ON 16

JANUARY 2013.

Delivered At: MELBOURNE Hearing Dates: 4 DECEMBER 2012 Findings of: CORONER K.M.W. PARKINSON

Place of death/Suspected death: ROSEBUD

Counsel Assisting LEADING SENIOR CONSTABLE ANTOLINI

VICTORIA POLICE

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I, KM. W. PARKINSON, Coroner

having investigated the death of MR MARK ROBERT SCOTT

AND having held an inquest in relation to this death on 4 December 2012 at MELBOURNE

find that the identity of the deceased was MARK ROBERT SCOTT born on 9 MARCH 1970

and the death occurred on 21 JULY 2011

at WEST ROSEBUD

from:

la. Effects of Fire

in the following circumstances:

i.

A summary inquest was conducted on 4 December 2012 into the circumstances of the death of Mr Mark Robert Scott. An extensive brief of evidence was prepared by the investigating police officer Detective Senior Constable Eaton which included scene photographs, forensic fire examiners evidence, witness statements and reports from forensic pathologists. The

investigating police officer gave evidence in the proceeding.

Mr Scott was 41years old and he was born on 9 March 1970 and his usual employment was

catpentei/shop fitter. Mr Scott resided with Ms Briony Baker and their son in Rosebud.

" Mr Scott had a medical history which included severe pain from a longstanding back injury,

severe substance addiction and a recent history of depressive illness. He was admitted to the Frankston Hospital on 15 July 2011 for suicidal ideation. He was admitted to the inpatient

psychiatric wnit and remained in hospital until his discharge on 19 July 2011.

During the course of his admission, including in the day prior to his discharge from hospital, clinicians report that he continued to indicate suicidal thoughts. His sister, Ms Jennifer Scott reports that during a visit on 16 July, Mr Scott advised that if he were to take his own life he would do so by setting fire to himself and his car. However he then. indicated that he was not

intending to harm himself and their conversation moved to other matters.

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  1. A psychiatric assessment on 16 July 2011 concluded that Mr Scott suffered chronic polysubstance abuse (of both prescribed and illicit substances) leading to a mood disorder and

suicidal thinking.

  1. The clinician concluded that no clear psychotic or major mood disorder was present. The treatment plai was a short term admission in order to contain the suicide risk and commence detoxification. A referral was made to a drug rehabilitation support agency (PENDAP) and it was considered that a referral for residential drug and alcohol support and treatment should be considered after discharge. A social worker review concluded that he had good support in the community and that he was more optimistic about the financial matters which

had been concerning him.

7, He was discharged on 18 July 2011, after assessment by a psychiatrist who concluded Mr Scott suffered from an adjustment disorder, into the care of his GP for continuing methadone therapy and ongoing review by PENDAP. Ms Baker arranged to collect him from the hospital. They drove home and Ms Baker states that Mr Scott appeared quiet and

‘seemed down’.

  1. His sister reports that during the course of a telephone conversation on Wednesday 20 July 2011, he advised her that he was having ‘panic attacks’ and was worried about bills.

However that evening, Mr Scott spent some time with his father, Mr Anthony Scott who stated that his son appeared to be calm and that he had made significant progress in resolving a number of financial issues on his son’s behalf. He reported that his son appeared

to be in good spirits and not affected by substances.

  1. Ms Baker left for work at approximately 4.45pm on 20 July, to attend work. Mr Scott remained at home with their child. When she returned at approximately 8.30pm that evening Mr Scott was sitting on the couch, He stated that he was ok but tired. At approximately 9.30pm he stated that he was going down the street to ‘get a can’. Ms Baker understood this to mean a can of premixed alcohol. He left the premises in a red Ford laser and returned some 20 minutes later stating he needed his wallet to pay for the petrol he had purchased.

Ms Baker states that he then left the house again saying that he was going to get his ‘cans’.

He did not mention the petrol again and left. Ms Baker states that he was not angry and

appeared calm. Ms Baker later ascertained that when he had returned Mr Scott had changed

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li.

motor cars and had left the premises in her Maroon Ford Festiva registration UUD579. Ms

Baker attempted to contact Mr Scott by phone during the course of the evening to no result,

Video footage and store receipts reveal that Mr Scott attended at the 7-Eleven Convenience store at 9.36pm on 20 July 2011 and purchased 17 litres of unleaded petrol and two four

metre rolls of black cloth tape.

At 1.05am on 21 July 2011 a police patrol observed a fire in a motor vehicle at the Rosebud Foreshore Camping Ground, Police state that the vehicle a Ford Festiva Hatch registered number UUD 579 was well alight when they arrived at the scene. Victoria Police fire examiners report that the interior of the vehicle including the cloth seats and plastic mouldings and fittings had been totally consumed by fire revealing the steel structures

beneath, The engine, radiator and wheel rims appeared partially melted.

The severely burnt remains of Mr Scott were located in the vehicle, His identity was confirmed by scientific means, including DNA analysis. An examination was undertaken by

Forensic Pathologist Dr Linda Iles and Dr Iles reported:

“Tn the reclined passenger seat heavily charred human remains are present....

Melted plastic or similar material is present over the neck and chest area and the pelvic area. Portions of copper wire are adherent to the trunk.... Post mortem examination demonstrates the presence of soot within small and large airways and a very high carboxyhaemoglobin concentration (88%).

This carboxyhamoglobin concentration is recognised to be fatal and thus the cause of death has been given above. This indicates that the deceased was alive and breathing whilst a fire was smouldering or exhaust gasses were being produced, but given the state of the deceased’s remains 1 am unable to comment on the deceased’s conscious state whilst he was inhaling carbon monoxide rich ait. There is no post mortem evidence of injury to the deceased’s remains prior to them being extensively burnt, however examination is markedly limited by the extensive thermal injury to the

deceased remains”’.

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16,

Toxicological analysis identified carboxyhaemoglobin concentration of 88%, cyanide (a bi

product of combustion of some types of plastic, methadone at ~ 0.6mg/L. and diazepam.

Dr Iles stated that in her opinion the cause of death was 1(a) Effects of Fire,

The pathologist did not identify any evidence of occult injury such that I might conclude any

other person was involved in the death.

The scene and the motor vehicle were examined by Victoria Police Forensic Scientist Ms Rachel Ann Noble. Ms Noble reported that the cabin had sustained most of the fire damage and that all of the combustible material inside the passenger compartment had been consumed including the seats, roof lining, trim and dashboard. She reported that it appeared that the windows of the vehicle had been closed at the time of the fire. The severely burnt body of a deceased adult male was located in the drivers seat. The seat was reclined at the time of her examination, An extensive examination of the vehicle was undertaken at the

Victoria Police Forensic Science Centre.

. The forensic scientist reported that whilst no flammable liquid was detected on samples this

may have been either because no liquid was present or because any flammable liquid had

burnt or evaporated to below detectable level.

lam satisfied that the latter is the case. The intensity of the fire resulted in severe damage to the vehicle thus limiting the capacity to identify the fuel or items used to ignite the fire

within the cabin.

The forensic scientist also reported that the pattern and extent of the damage were consistent with the fire starting inside the passenger compartment by the ignition of available materials.

She stated:

“Due to the severity of the fire damage it was not possible to determine what ignited first. There were no containers of a type used to store or transport flammable liquid identified amongst the debris inside the vehicle or in the area surrounding the vehicle. The use of flammable to initiate the fire cannot be excluded and given the

level of burning observed is most likely. There was no obvious source of accidental

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20,

21,

24,

ignition identified among the debris and in the circumstances, the probable source of

ignition is a match or cigarette lighter.

Examination of the vehicle was also undertaken by Victoria Police

The evidence is that Mr Scott had purchased items including the black fabric tape which may have been utilised in igniting the fire. An empty plastic packaging for the tape and an empty spool of cable wire was located in the boot of the vehicle he had originally used on the evening of 20 July 2011. Also located in this car were remnants of white powder

subsequently analysed as being deodorant type powder from an aerosol propellant canister.

It is reasonable to conclude that the fire originated within the passenger cabin of the Ford Festiva motor vehicle, that it was ignited with flammable liquid and that the fire was lit by Mr Scott. The evidence. establishes that Mt Scott drove his motor vehicle to the Rosebud Foreshore camping ground and it appears that he has ignited petrol or other inflammable items within the cabin of the motor vehicle. The exact mechanism of ignition and flammable

substance used is not able to be determined due to the intensity of the fire within the cabin,

No note was located at Mr Scott’s home. Some time after Mr Scott’s death a report was made by an associate of Mr Scott that there were suspicious circumstances in relation to his

death and that a person identified to police may have been involved in the death. The

-allegation was investigated by police. They found no evidence of any involvement of any

other person in the setting or igniting of the fire or in the death of Mr Scott.

Police report that there were no suspicious circumstances. There is no evidence to suggest that any other person caused or contributed to the fire or was involved in the death of Mr

Scott.

I am satisfied having regard to the evidence of Mr Scott’s recent suicidal ideation and his advice to his sister on 16 July, 2011 of the mechanism he would choose to end his own life, the mechanism which ultimately resulted in his death, that it reasonable to conclude that Mr

Scott took his own life.

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26, Having considered the available evidence I find that Mr Mark Scott intentionally took his own life on 21 July 2011 and that his death was due to the effects of fire.

27.1 direct that a copy of these findings be provided to the Family of Mr Mark Scoit, the

Interested Parties and to the Investigating Police Officer.

Signature:

KM. W. PARKINSON CORONER 16 January 2013

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