Finding into death of Leigh Ronald Bellingham

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2008 2734

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: LEIGH RONALD BELLINGHAM

Delivered On: 5 June 2013

Delivered At: Level 11, 222 Exhibition Street Melbourne 3000

Hearing Dates: 4 March 2010

Findings of: JANE HENDTLASS, CORONER

Police Coronial Support Unit Leading Senior Constable King Taylor assisting the’ Coroner

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I, JANE HENDTLASS, Coroner having investigated the death of LEIGH BELLINGHAM

AND having held an inquest in relation to this death on 4 March 2010

at MELBOURNE

find that the identity of the deceased was LEIGH RONALD BELLINGHAM born on 13 July 1970

and the death occurred between 26 June 2008 and 27 June 2008

at Room 33, Club Laverton, 15 Aviation Road, Laverton 3028

from:

1(a) TOXIC EFFECTS OF HEROIN IN COMBINATION WITH MIRTAZAPINE AND

SERTRALINE

in the following circumstances:

1. Leigh Ronald Bellingham was 37 years old when he died. He lived with his parents, John and Sandra Bellingham, and his sister, Nicole Bellingham, at 11 Shirley Crescent in Woori

Yallock.

2. Mr Bellingham’s medical history included hepatitis C, depression, alcohol and heroin abuse,

social phobia and attempted suicide. His general practitioner was also Dr Kirwan.

3. Dr Kirwan prescribed mirtazepine, Nexium (esomeprazole), sertraline, and Xanax

(alprazolam). He told the Court that Mr Bellingham was always a suicide risk:

“He'd often mention, when I'd ask him he'd always say, "One day I'll do it". He was

determined for a number of years to do it.”

4. In 2007, Mr Bellingham was admitted to Marocondah Hospital Psychiatry Unit three times following suicide attempts, the third as an involuntary patient. His involuntary status was

withdrawn when he accepted voluntary treatment.

5. After each admission, Dr Kirwan was concerned about Mr Bellingham, He expressed this

concern this way:

“... he was a worry for me, you know, he was a suicide risk once he left hospital every time.

But you can't keep him locked up for ever either...

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Leigh told me at one stage that he told them - as a lie to get out, he didn't want to stay in

hospital a lot of the time, he told me that he denied suicidal ideas so they'd let him out.”

In November 2007, Mr Bellingham separated from his wife and children, He was particularly affected by this change in his circumstances because he had no access to the children. In Dr

Kirwan's opinion:

“Things got worse after his ...his relationship broke up ... he didn't have access to his children. Lle was in his own way a good father, He loved spending time with his children and I'd say that was the final thing - another thing that he saw as his failure in his life that he couldn't even be a good dad even though he wanted to be, so he got very depressed after

that.” Further, Dr Kirwan observed:

“He said life was miserable for him and he had certain reasons for it. He couldn't see any way out of it. Towards the end certainly his brain was affected. After a couple of overdoses he wasn't the same person and his memory was poor. His speech was poor, slurred, he had some trouble particularly communicating. Towards the end his comprehension was probably

reduced.”

On 4 January 2008, Mr Bellingham presented to Dr Kirwan with poor memory and headaches.

Dr Kirwan considered he remained a suicide risk and referred him back to the Crisis

Assessment and Treatment Team. He also doubled his alprazolam.

On 19 February 2008, Mrs Bellingham found Mr Bellingham with a knife in his hand and evidence of overdose on sertraline, alprazolam and mirtazapine. Mr Bellingham presented to

Angliss Hospital Emergency Department in an ambulance.

On 21 February 2008, Mr Bellingham was transferred for neuropsychological assessment and admission to Maroondah Hospital Inpatient Mental Health programme. He was diagnosed with major depressive disorder, borderline personality traits and iron deficiency anaemia. His

consultant psychiatrist was Dr Amitava Sarkar.

On 27 February 2008, Mr Bellingham was discharged home for support from Dr Kirwan and

referral to a psychologist.

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On 5 March 2008, Mr Bellingham returned to see Dr Kirwan following his hospital admission. Dr Kirwan ceased his alprazolam and sertraline and prescribed mirtazepine 30mg nocte and diazepam 10mg three times a day. On 12 March, he returned to Dr Kirwan to establish his Mental Health Care plan and continued Nexium (Esomeprazole), diazepam and

sertraline,

Further, on 15 March 2008, Mr Bellingham was admitted to Box Hill Hospital with rectal

bleeding. On 24 March, he was discharged with no diagnosis and no active blecding.

On 7 May 2008, Mr Bellingham last consulted Dr Kirwan. He was highly anxious and he was concerned that his mother was doing better than he was, However, Dr Kirwan had seen him

in a worse condition previously:

“No, he wasn't much different than when - he was still very stressed but as I said, he wasn't as bad as the time when I knew he was going to do it. He had his bag packed in 2007. He had medication ready to take and I knew he was going to do it then and I stopped him from leaving

the surgery. He wasn't anything like that.” gery VIRINg

In Dr Kirwan’s opinion, alprazolam is probably slightly better for panic attacks and severe

anxiety. His mother last consulted Dr Kirwan the same day.

On 7 May 2008, Dr Kirwan ceased his diazepam and prescribed 50x2mg tablets of alprazolam with one repeat. James Kwok Pharmacy dispensed 50 tablets of sertraline to Mr Bellingham

on the same day.

On 7 May 2008, James Kwok Pharmacy also dispensed 100 tablets of alprazolam and 30

tablets of sertraline to Mrs Bellingham.

However, Dr Kirwan had no reason to suspect that Mr Bellingham and his mother were

colluding and planning to commit suicide:

“I was quite prepared to admit that they might - both of them might commit suicide. It's

surprising they did it together which means that it's planned and they were both compliant.

‘That was a difficult thing for them to do.”

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28,

On 2 June 2008, James Kwok Pharmacy dispensed 50 tablets of alprazolam prescribed by Dr Kirwan on 4 January 2008 and 30 tablets of mirtazepine prescribed by Dr Kirwan on 5 March 2008 to Mr Bellingham.

On 2 June 2008, James Kwok Pharmacy also dispensed a further 100 tablets of alprazolam prescribed on 7 May 2008 and 30 tablets of sertraline prescribed on 18 February 2008 and 30 tablets of mirtazepine prescribed on 12 March 2008 to Mrs Bellingham.

On 19 June 2008, James Kwok Pharmacy dispensed a further 50 tablets of alprazolam prescribed by Dr Kirwan on 4 January 2008, 30 tablets of mirtazepine prescribed by Dr Kirwan on 5 March 2008 and 60 tablets of sertraline prescribed by Dr Kirwan on 8 April 2008 to Mr Bellingham.

On 25 June 2008, Mrs Bellingham was particularly depressed and crying. Leigh Bellingham told his sister that he was taking Mrs Bellingham away for a few days as she needed a break.

He later asked his sister to feed the dog.

On 26 June 2008, Seville Village Pharmacy dispensed 100 tablets of alprazolam and 30 tablets of sertraline prescribed on 7 May 2008 and 30 tablets of mirtazepine prescribed on 12 March 2008 to Mrs Bellingham.

At about 8.30pm on 26 June 2008, Sandra and Leigh Bellingham booked into Room 33 of the

Club Laverton motel in Laverton.

At 11.05am on 27 June 2008, Richard Schembri found Mr Bellingham and Mrs Bellingham

both unresponsive in the hotel room. They were unable to be revived.

Police found medication packets for Xanax (alprazolam), Axit (mirtazapine), Mirtazon (mirtazapine) and Zoloft (sertraline) in the room as well as two used syringes and six empty

cans of scotch and coke.

Leigh Bellingham was identified by fingerprint matching against Victoria Police fingerprint

tecords

The forensic pathologist who performed the autopsy formed. the opinion that the cause of death was toxic effect of heroin in combination with mirtazepine and sertraline. He had also

sustained blunt force trauma to the head and face. Toxicological analysis detected heroin and

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codeine metabolites in blood and urine where therapeutic levels range up to 0.1g/L and

therapeutic levels of mirtazepine and sertraline.

29, Accordingly, | find that Leigh Bellingham died from the toxic effect of heroin in combination with mirtazepine and sertraline. I am unable to say whether he intended to dic or how he

sustained the non-fatal injuries to his head and face.

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

Mr John Bellingham

Ms Nicole Bellingham

Detective Senior Constable Christopher Field, Altona North Crime Investigation Unit

Interested Parties

Signature:

[Ae

DR JANE HENDTLASS CORONER Date: 5 June 2013

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