Finding into death of Pratik Dugar

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: 2012 / 4249

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, AUDREY JAMIESON, Coroner having investigated the death of PRATIK DUGAR

without holding an inquest:

find that the identity of the deceased was PRATIK DUGAR born on 31 July 1985

and the death occurred on 8 October 2012

at Railway line at Flora Road, Clayton 3168

from:

1 (a) MULTIPLE INJURIES SUSTAINED WHEN STRUCK BY A TRAIN

Pursuant to section 67(2) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Mr Pratik Dugat was 27 years of age at the time of his death. He lived at 55 Keylana Drive,

Keysborough 3174 with his parents and brother Saurabh. He was an accountant and worked

in his father’s accounting business in Clayton,

2. Mr Dugar had a medical history of anxiety disorder with depression. He had been consulting his General Practitioner Dr Andrew Mau of Clayton Road Doctors since 2003.

He had presented on a number of occasions with persisting anxiety associated with abdominal pains which was subsequently diagnosed as a lactose intolerance. He was commenced on the antidepressant medication, Sertraline in 2005. On 9 May 2012, Mr Dugar advised Dr Mau that he had been self-medicating his anxiety with cannabis and he expressed the desire to cease his antidepressant medication which he subsequently did on 24 July 2012. Mr Dugar informed Dr Mau that his life stresses included the sudden death of his brother in India from a heart attack, his parent's disapproval of his use of cannabis and

alcohol, and ambivalent feclings of working in the family business. Mr Dugar last saw Dr

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Mau on 14 August 2012 where Dr Mau counselled Mr Dugar against his use of cannabis

and provided him with a referral to Dr Jack Warhaft, an addiction medicine specialist.

On 25 September 2012, Mr Dugar presented to the Emergency Department at Frankston Hospital with suicidal ideation. He reported having taken an overdose on doxylamine. At the time of his presentation, he had attended with his brother and sister and reported recent loses including the death of a friend and interest in a female who had subsequently commenced a relationship with a friend of his, He also reported that he had been noncompliant with his prescription medication Sertraline for the last two weeks, He also reported using cannabis but that he also ceased this approximately two weeks ago. He was assessed as being a low risk of suicide and was discharged for Crisis Assessment Treatment Team (CATT) follow up. He was last seen by the Dandenong CAT team on 7 October 2012, with the visiting clinician documenting that there was no identifiable suicide ideation

plan or intent. Overall, Mr Dugar was assessed as being low risk of suicide.

On Monday 8 October 2012, at approximately 12.34pm, the 12.05pm Cranbourne to Flinders Street train was travelling between Clayton and Huntingdale stations when Mr Dugar was seen by the train driver to run into the path of his train at the Flora Road pedestrian crossing. Mr Dugar was struck by the train. He received fatal injuries and died

at the scene.

Investigation

Dr Sarah Parsons, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an external examination on the body of Mr Dugar and reviewed a post mortem CT scan. Dr Parsons attributed Mr Dugar’s injuries to multiple injuries sustained when struck by a train. Toxicological analysis identified that the metabolite of Risperidone, Hydroxyrisperidone at a sub-therapeutic level. Diazepam and its metabolite were also

identified.

The police investigation did not identify any suspicious circumstances or the involvement of

any third parties. No specific expression of intention has been identified.

The investigation undertaken by Metro Trains Melbourne concluded that it was highly probable that Mr Dugar was aware of the approaching train and decided to enter the track area. The investigator, Mr Alan Scott also recommended that consideration be given to making this particular crossing active through the provision of pedestrian gates and audible

tones that operate for the passage of trains.

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8. Having considered all the available evidence, I am satisfied there are no suspicious

circumstances and that no further investigation is required.

Finding The evidence supports the conclusion that Mr Dugar did not accidentally find himself in the path of an oncoming train. Although the pedestrian crossing has been identified as having scope for

improvement, it was sufficient to have prevented Mr Dugar from entering onto the railway tracks in

the manner in which he was witnessed to by the train driver.

In all the circumstances, I am satisfied that Pratik Dugar intentionally took his own life by placing

himself in the path of an oncoming train.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s)

connected with the death:

I accept and support the recommendation identified by Mr Alan Scott, Investigator for Metro Trains. Melbourne, and recommend that consideration be given to making the pedestrian railway crossing at Flora Road, Clayton active through the provision of

pedestrian gates and audible tones.

Pursuant to section 73 of the Coroners Act 2008, I order that this Finding be published on the internet.

I direct that a copy of this finding be provided to the following: Mr Shreyas Dugar Senior Constable Bradley Johnson, Investigating Member Mr Alan Scott, Investigator, Metro Trains Melbourne Mr Michael Averkiou, Department of Transport The Chief Psychiatrist

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Signature:

yo

AUDREY JAMIESON Date: 3 February 2014

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