Finding into death of Jade Lesley Dorogi

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR-2009 / 2330

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: JADE LESLEY DOROGIT

Delivered On: 20 December 2013 Delivered At: Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne 3000 Hearing Dates: 2" August 2013 Findings of: JOHN OLLE, CORONER Representation: Mr N. Dunstan, on behalf of the family

Mr J. Hanncbery, on behalf of Daniel Mobbs

Police Coronial Support Unit Sergeant D. Dimsey

lol?

J, JOHN OLLE, Coroner having investigated the death of JADE LESLEY DOROGI

AND having held an inquest in relation to this death on.2 August 2013

at Melbourne .

find that the identity of the deceased was JADE LESLEY DOROGI

born on 6 November 1983

and the death occurred on 6 May 2009

at Western Hospital, 148-160 Gordon Street, Footscray 3011

from: 1 (a) CEREBRAL HYPOXIA AND MULTISYSTEM ORGAN FAILURE 1(b) HEROIN (MORPHINE) TOXICITY

in the following circumstances:

1. Jade Dorogi was aged 25 years at the time of his death, He lived at 8 Moreton Court, Hoppers Crossing.

2. The coronial brief is comprehensive and has fully addressed the tragic circumstances of Jade’s death.’

Coronial background

3. In March 2013, I was assigned carriage of this investigation’, A Direction Hearing was held

on 24 May, 2013 to identify the scope of the inquest. Both the family and Mr Mobbs were

represented. Following submissions, J indicated the inquest would focus on the manner in

which Jade ingested heroin on the night of his death.

At inquest

4. The inquest was conducted on 2 August 2013. Despite the devastating loss suffered by

Jade’s family, J'take this opportunity to commend their dignity throughout the proceeding.

5. Further, I acknowledge the role of my assistant, Sgt Dimsey and members of Counsel, Mr

‘Hannebery for Mr Danicl Mobbs and Mr Dunstan on behalf of the family.

"A copy of the coronial brief will remain in the court file

2 Due to the impending retirement of the investigating coroner

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Background

6. Jade lived with his parents and worked as a plasterer. Sadly, drug addiction was the scourge

of his life. He had displayed sporting prowess and had excellent work prospects. He was

well respected by immediate family, extended family, friends, work colleagues and team

mates.

Circumstances

7. Jade and his cousin Daniel Mobbs were close friends. Regrettably, illicit drugs were their

common interest and their days spent feeding their addiction.

8. Jade used a variety of illicit drugs but not heroin. Dwayne Russell was a friend of Daniel

and J ade. In his statement, Dwayne stated Jade wanted to try heroin:

“He would always ask Daniel to get him some to try, when they would get ice and heroin Jade always would want Mobbsy to give him some, but he wouldn’t. He didn’t want Jade to end up the same way as his two brothers, who had died from

F 3 heroin overdose.”

9. Despite losing two brothers to heroin overdose, Daniel was a heroin user. :

Chronology of events

.10. In respect to the events of 4 May, 2009 I am satisfied of the following:

Jade collected Daniel

Prior to the night, Jade was not a heroin user

Danicl obtained heroin from 4 Laverton Street

Daniel and Jadc ingested heroin in Jade’s motor vehicle

Jade overdosed and was observed slumped over the steering whcel Daniel stated that he had “killed his cousin”

The car was driven from Laverton Street and subsequently pulled over to the side of

a frecway

Jade was semi conscious on the side of the road

Statement Dwayne Russell inquest bricf page 31

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A passer by observed Daniel significantly drug affected and appeared oblivious to

his surroundings The ambulance service was called and found Daniel performing CPR on Jade

On 7" May Daniel attended the home of Jade’s and removed new and used syringes

from the car and disposed of them

Jade had previously injured the thumb of his left hand and could only have injected

the needle into his right arm with difficulty

Daniel is unable to recall the events of 4 May 2009, in particular the manner in

which Jade ingested heroin.

11. Iam unable to find:

Whether Daniel assisted Jade inject heroin

Whether Daniel’s comments outside the premises that he had “filled his cousin’ referred to obtaining the heroin which caused the overdose, encouraging Jade to use heroin, assisting Jade to inject the heroin, failing to immediately seek ambulance

attendance or some other reason.

The means by which the vehicle travelled from Laverton St to the side of the

freeway.

The reason Daniel disposed of the syringes in the 7 May

Evidence of Daniel Mobbs

12. At inquest I granted a 8. 57 certificate.

13. . Daniel could not recall the evening’s events. Daniel was aware that Jade had not previously

used heroin and was acutely aware of the high risk of overdose for heroin naive persons. He

acknowledged occasions heroin users would assist each other to inject heroin, though

denied personally doing so.

14. Daniel was highly critical of his failure to perform CPR and/or call for ambulance

assistance, He is adamant were he not significantly drug affected, he would have done so.

Further, he would have ensured Jade only used a small amount of heroin. He gave

compelling evidence that despite having no recollection of the evening’s events, in

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particular Jade’s injection of heroin, an appropriate response would have saved Jade’s life.

He explained the appropriate response:

“T would have rang an ambulance and started CPR, make sure he was getting oxygen

into his lungs I would have done.

Question: And is that something you’ve thought about for some time?

Answer: I think about it nearly every day. I think about it nearly every day, you

know.

Question: And your families haven’t had any contact since? What’s liappened there?

Answer: No, we don’t4

In my. view, the evidence docs not allow a finding that Daniel understood the gravity of Jade’s condition and further, it remains a matter of speculation whether the tragic consequences of Jade’s heroin overdose could have been averted in any event. Daniel

apologised to Jade’s family for his failure, describing himself as an idiot.

Mrs Darogi does not accept that Jade would have voluntarily used heroin, Further, in view of his injured thumb, she does not believe it was physically possible for Jade to inject into

his right wrist.

On the evidence, I am unable to determine either issue.

-- Daniel was well aware of the lethal potential of heroin in a heroin naive person. Further, his

brothers had died of heroin overdose and he would never encourage a heroin naive person to

use. Daniel was addicted to heroin, which he freely acknowledged had ruined his life.

There is no evidentiary basis to find Daniel encouraged Jade to use heroin. On the evidence of Daniel, and the statement of Dwayne, Daniel had always steadfastly resisted Jade’s wish

to use heroin.

I offer my sincere condolences to the family of Jade. I acknowledge the determined efforts of Mrs Dorogi to seck clarity to understand the tragic circumstances in which Jade

overdosed, Sadly, on the evidence, I cannot provide the clarity she seeks.

• Pages 25 and 26 inquest transcript

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Post Mortem Medical Examination

21. ‘On the 13 May 2009, Dr Malcolm Dodd Senior Forensic Pathologist at the Victorian

Institute of Forensic Medicine performed an autopsy on the body of Jade Lesley Dorogi.

22. Dr Dodd found the cause of death to be cerebral hypoxia and multisystem organ failure and

heroin (morphine) toxicity.

23. Dr Dodd commented:

Finding

“The cause of death in this case would appear to be one of cerebral hypoxia and

multisystem organ failure following on from the administration of heroin.

The summary of circumstances report indicates that the deceased was transferred to

hospital after being found in a motor vehicle.

The initial impression was that of a possible drug overdose.

The post mortcm cxamination showed, externally, the suggestion of needle track

marks in thé right antecubital fossa.

The internal examination showed nonspecific changes.

Histological examination showed hypoxic changes within brain, kidney and liver in

tandem with scattercd areas of acute bronchopneumonia.

Toxicological analysis of ante mortem blood samples disclosed the presence of

morphine in plasma and urine, Alcohol was not detected.

Methamphetamine and amphetamines were both detected in blood samples obtained

at 0603 hours on the 5th of May 2009.

This sample represents the earliest blood collection presumably at the time of

immediate medical intervention.”

| find the cause of death of Jade Dorogi to be cerebral hypoxia and multisystem organ failure and

heroin (morphine) toxicity.

• Dr Dodds post mortei report

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I direct that a copy of this finding be provided to the following: : The Family of Jade Dorogi Detective Senior Constable Corey Page, Investigating Member of Victoria Police

Signature:

/

JOHN OLLE/ CORONER er/2043

Date: 20 Deée

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