Finding into death of Jahit Elliott Alieff

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2009/2103

FINDING INTO DEATH WITH INQUEST!

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

Inquest into the Death of: JAHIT ELLIOTT ALIEFF

Hearing Dates: 18 October 2010

Appearances: Ms Deborah Foy on behalf of Eastern Health

Police Coronial Support Unit: Senior Constable King Taylor - Assisting the Coroner Findings of: AUDREY JAMIESON, CORONER

Delivered on: 3 March 2015

Delivered at: Coroners Court of Victoria

65 Kavanagh Street

Southbank VIC 3006

1 The Finding does not purport to refer to all aspects of the evidence obtained in the course of the Investigation. The

material relied upon included statements and documents tendered in evidence together with the Transeript of proceedings and submissions of legal representatives/Counsel. The absence of reference to any particular aspect of the evidence, either obtained through a witness or tendered in evidence does not infer that it has not been considered.

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I, AUDREY JAMIESON, Coroner having investigated the death of JAHIT ELLIOTT ALIEFF AND having held an inquest in relation to this death on 18 October 2010

at the Coroner’s Coutt of Victoria sitting at MELBOURNE

find that the identity of the deceased was JAHIT ELLIOTT ALIEFF

born on 21 March 1982

and the death occurred on 22 April 2009

at Unit 2, 22 Roger Street, Doncaster East 3109

from: l(a) HANGING

in the following summary of circumstances:

1. On 18 October 2010, an inquest under section 52(1) of the Coroners Act 2008 (Vic) (the Act) was held into the death of Mr Jahit Elliott Alieff. Whilst the circumstances of Mr Alieff’s death do not warrant a mandatory inquest, I have determined that a discretionary inquest is warranted to assist me with making my statutory findings, in particular the

circumstances in which his death occurred.

2. Mr Alieff was an involuntary patient on a Community Treatment Order” (CTO) which was made on 1 December 2008, following his discharge from the psychiatric unit, Upton House.

On the morning of 21 April 2009, Mr Alieff left his home without telling anyone where he was going or taking any belongings. When he had not returned by nightfall, his mother reported him missing at the local police station. At approximately 1.20pm on 22 April 2009, a friend of Mr Alieffs, Mr Anthony Feehan, who was visiting at Mr Alieff’s home, found

? Section 12 Mental Health Act 1986 (Vic)

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him hanging froin a large pine tree in the front garden by a green coloured fabric dog lead.

Emergency services were immediately called. Police attended, no resuscitation attempts

were implemented as it was apparent Mr Alieff had been deceased for some time.

BACKGROUND AND CIRCUMSTANCES

3. Mr Alieff was born on 21 March 1982. He was 27 years old at the time of his death. He lived with his Grandmother, Ms Lorna Elliott, at Unit 2, 22 Roger Street, Doncaster East.

Ms Elliott raised him as his legal guardian from the age of six. His mother, Ms Julie Elliott, remained in regular contact throughout ‘his childhood. Since 2002, Ms Julie Elliott lived with Mr Alieff at Ms Elliott’s house. He was unemployed.

4, In March 2002, Mr Alieff was diagnosed with schizo-affective disorder. He was known to use illicit substances including alcohol, cannabis and heroin. At the time of his diagnosis he was expressing persecutory thoughts, manic symptoms and experienced auditory hallucinations of voices. Since 2002, he has been admitted to Upton House six times with symptoms of relapse of his mental illness due to non-compliance with medication and use of illicit substances, He has previously been treated on a CTO and has been managed by the Koonung Continuing Care Team (CCT) on a recurring basis since 2003. In late 2006, he was referred to the Mobile Support and Treatment Service (MSTS) to provide intense case management, improve therapeutic alliance and provide psycho-social rehabilitation.

Following a three month trial period he was referred back to Koonung CCT for case management as he was avoiding MSTS. By October 2007, his mental state had improved and he showed improvement in medication compliance. He was discharged from the CTO with case management continuing at Koonung CCT. Over the next few months his medication compliance became erratic and his clinic attendance irregular. In May 2008, as a voluntary patient, he chose not to continue with treatment. In October 2008, he experienced relapse symptoms of his schizo-affective disorder, becoming aggressive and argumentative at home. He was provided respite at Linwood House, however his aggression escalated and on 19 October 2008, he was admitted as an involuntary patient to Upton House. By December 2008, his mental state improved and he was discharged first to a Crisis and Assessment Treatment (CAT) team and then to Koonung CCT on 23 December 2008 for

case management under his CTO. The CTO was effective from 1 December 2008 to 1 June

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2009. On discharge he was prescribed Risperidone’ 4mg, Chlorpromazine* 100mg, Sodium

Valproate® 1g, Lithium SR° 450mg, Risperdal Consta’ 50mg.

SURROUNDING CIRCUMSTANCES:

In January 2009, Ms Elliott made the decision to sell her house and move to a retirement village. Therefore, Mr Alieff had to find new accommodation before May 2009. Ms Elliott reported that both Mr Alieff and Ms Julie Elliott were upset she had sold the house.®

Mr Alieff’s treating team at Koonung CCT consisted of Consultant Psychiatrist Dr Channarayapatna Prasama and Psychiatric Registrar Dr Gamini Undugodage. His initial case manager was Ms Seigrid Cook who transferred case management to Registered Psychiatric Nurse Imogen Zobel on 2 February 2009. For a short period of time after discharge from Upton House, Mr Alieff was visited daily by a CAT team who supervised

him taking his oral medications.

The Risperdal Consta prescribed to Mr Alieff was administered as depot medication’ fortnightly by Koonung CCT. It was practice that he would attend for his depot medication and his next fortnightly appointment would be scheduled while at the clinic. Appointments would consist of administering his depot medication and a review with his case manager, medical officer or psychiatrist. His attendance at scheduled appointments was poor; he would miss or cancel appointments that were intended for case review, mnedical review or psychiatric review and would often only attend for his depot medication. On a number of occasions his depot medication was administered a few days late because of missed appointments, however, he never missed a dosage and would therefore have clinic contact approximately every two weeks. When he failed to attend appointments, contact would be attempted. with him and his appointment would be rescheduled or in some instances he

would go to the clinic requesting his depot medication unannounced. Regular telephone

3 Risperidone is an atypical antipsychotic prescribed for schizophrenia and some behavioural disorders.

4 Chlorpromazine is an antipsychotic medication used for the treatment of schizophrenia.

Sodium Valproate is an anticonvulsant

$ Lithium SR is prescribed for treatment of acute episodes of mania and hypomania and for the prophylaxis of recurrent manic-depressive illness,

7 Risperdal Consta is long-acting risperidone administered by intra~muscular injection.

• Statement of Ms Lorna Elliot, dated 27 April 2009.

° Depot medication is given by injection, which releases the drug slowly over some weeks.

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contact was maintained with Ms Elliot and Ms Julie Elliot to discuss Mr Alieff’s welfare.

He failed to attend appointments for medical review on 2 January 2009'° and 16 January

2009,"!

8. On 19 January 2009, Ms Cook conducted a case management review with Mr Alieff. They discussed the sale of Ms Elliott’s home and his need to find alternative accommodation in the next three months. A public housing application was started and Mr Alieff said he had made appointments with housing services in Doncaster and Ringwood. It was noted he had self ceased all oral medication. Mr Alieff also reported he had lodged an appeal to the Mental Health Review Board and was awaiting a hearing date. The appeal hearing was later scheduled for 2 February 2009. Because of the appeal he would need to be reviewed with his Consultant Psychiatrist, so an appointment was scheduled for 28 January 2009. Mr Alieff cancelled this appointment. His appeal hearing was later adjourned because he wanted to seek legal representation. On 2 February 2009, he failed to attend his first case review with new case manager RPN Zobel. She contacted him that afternoon and on 3 February 2009 and 4 February 2009; each time he would agree to attend the next day. He did not attend until 6 February 2009, his depot medication was administered and he did not

see RPN Zobel. A medical review was eventually scheduled for 10 February 2009,

9. Dr Undugodage saw Mr Alieff on 10 February 2009. At the time of the psychiatric review Dr Undugodage reported Mr Alieff showed symptoms of schizo-affective disorder with negative features, such as lack of motivation and poverty of content of thought. He had no positive symptoms of his psychotic illness such as delusional thoughts or perceptual symptoms like auditory hallucinations.!? He stated having to leave Ms Elliott’s house was difficult for him. Dr Undugodage reported the insight Mr Alieff had into his illness was limited, as he was of the opinion that he had a substance induced problem and not a mental illness.!? Despite this, Mr Alieff did not see the need for involving drug and alcohol services in his treatment. Mr Alieff was informed that the treating team’s advice was to continue

depot medication fortnightly and continue his CTO.

10 Mr Alieff’s depot medication was administered on 5 January 2009.

"! Mr Alieff’s depot medication was administered on 19 January 2009.

” Statement of Dr Gamini Undugodage, dated 29 April 2009

" Tid,

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10. On 18 February 2009, Mr Alieff failed to attend his scheduled appointment with RPN Zobel. He was called and re-booked for his depot medication on 20 February 2009, which he attended. At this appointment he signed forms to withdraw his appeal to the MHRB."*- His next appointment was to consist of a review and was scheduled to coincide when his depot medication was required on 6 March 2009. At this appointment RPN Zobel assisted him to complete his public housing application forms. Mr Alieff failed to attend his next scheduled appointment for medical review and depot medication on 20 March 2009. RPN Zobel spoke with Ms Elliott who reported Mr Alieff had been sleeping a lot. He attended on 23 March 2009, for his depot medication and was booked for a medical review and depot medication on 6 April 2009. He did not attend this appointment, however was administered his depot medication the following day. An appointment was made for review with RPN Zobel on 20 April 2009. She reported discussing Mr Alieff’s housing situation. He told her that he had found somewhere to live which was temporary. RPN Zobel noted that his mental

state was unremarkable, with no suicidal or homicidal ideation,

me

.On 17 April 2009, Mr Alieff’s Uncle, Mr Michael Elliott, arrived at Ms Elliott’s house to help make final arrangements for the move. On 21 April 2009, Mr Elliot and Ms Julie Elliott had an argument. Ms Elliott reported that Mr Alieff was present for and listened to the argument and that he was upset with Ms Julie Elliott.'° Mr Alieff left the house through the back door and did not return. Mr Feehan visited shortly after Mr Alieff left. He stayed until approximately 3pm. That evening, concerned for Mr Alieff's welfare, Ms Julie Elliott reported him as missing at Doncaster Police Station. She informed RPN Zobel at

approximately 11.50am on 22 April 2009, who in turn informed Dr Prasanna.

12, On 22 April 2009 at approximately Ipm, Mr Feehan returned looking for Mr Alieff. He sat in the carport with Mr Elliot and Ms Julie Elliot. At approximately 1.20pm, he saw what ‘looked like a pair of jeans hanging in a tree’ in the front corner of the garden.!” He investigated and found Mr Alieff hanging from the tree by a green coloured fabric dog lead.

Emergency Services were called immediately. Mr Feehan did not attempt to perform

4 The MHRB appeal date was scheduled for 16 February 2009 and the withdrawal of appeal was signed on 20 February 2009.

1S Exhibit 1 ~ Statement of RPN Imogen Zobel, dated 20 May 2009.

'6 Statement of Ms Lorna Elliott, dated 27 April 2009.

'7 Statement of Mr Anthony Feehan, dated 24 April 2009.

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cardiopulmonary resuscitation as it was apparent Mr Alieff had been deceased for some

time.

INVESTIGATION Identity

13. The identity of Jahit Elliott Alieff was without dispute and required no additional

investigation.

The medical investigation

14, On 27 July 2009, Dr Melissa Baker, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM), performed an external examination of the body of Mr Alieff and reviewed a post mortem CT scan and the Form 83 Victorian Police Report of Death.

Anatomical findings included a ligature mark around his neck with possible track marks on his left arm. Toxicological analysis of blood retrieved post mortem showed the presence of risperidone (14ng/mL) and hydroxyrisperidone'® (44ng/mL). Cannabinoids'!? were detected presumptively in urine retrieved post mortem. Dr Baker ascribed the cause of Mr Alieff’s

death to hanging.

INQUEST

Jurisdiction

15. At the time of Mr Alieff’s death, the Coroners Act 1985 (the Old Act) applied.

16, The Coroners Act 2008 (Vic) (the New Act) commenced operation on 1 November 2009.

Schedule 1, section 7 of the new Act states "Subject to clause 10, if the hearing of an inquest has begun under the old Act and the inquest is not completed before the commencement day, the old Act continues to apply on and from the commencement day to the inquest’. Clause 10 does not apply to these circumstances.

17.In the preamble to the new Act, the role of the coronial system in Victoria is stated to involve the independent investigation of deaths for finding the causes of those deaths and to

contribute to the reduction of the number of preventable deaths and the promotion of public

8 Hydroxyrisperidone is an active metabolite of Risperidone.

° Cannabis (marijuana) contains the main active psycho-active ingredients Delta 9-tetrahydrocannabinol and 11-OHDelta 9-tetrahydrocannabinol. These are collectively known as cannabinoids.

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health and safety and the administration of justice. Reference to preventable deaths and public health and safety are referred to in other sections of the new Act.”?

oo

. Section 67 of the New Act sets out the statutory role of the Coroner in that a Coroner must find, if possible, the identity of the deceased, the cause of death and, in some cases, the circumstances in which the death occurred. The ‘cause of death’ generally relates to the medical cause of death and the ‘circumstances’ relates to the context in which the death occurred,

19, A coroner may also comment on any matter connected with the death, including matters relating to public health and safety and the administration of justice.”’ A coroner may also report to the Attorney-General and may make recommendations to any Minister, public statutory authority or entity, on any matter connected with a death, which the coroner has investigated including recommendations relating to public health and safety or the administration of justice.”

Issues to be explored at inquest

e Mr Alieff’s supervision on his CTO including his;

o failure to engage with his case manager; o failure to attend appointments; o failure to attend MHRB appeal hearing.

e Whether there was an adequate assessment of Mr Alieff’s mental state while on the CTO;

o case management reviews and medical reviews.

Evidence at Inquest

20. Viva voce evidence was obtained from the following witnesses at the Inquest: e Imogen Zobel, Registered Psychiatric Nurse e Dr Channarayapatna Prasanna, Consultant Psychiatrist, Eastern Health

21. RPN Zobel gave evidence that she had previously had contact with Mr Alieff at Koonung CCT prior to becoming his case manager. She had administered his depot medication on a

number of occasions and described having a rapport with Mr Alieff, saying he had requested

20 See for example, sections 67(3) & 72(1) & (2) 2! Section 67(3) 2 Section 72(1) & (2)

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her as his subsequent case manager.”* She stated she had a very thorough handover of his file from Ms Cook. Regarding Mr Alieff’s housing situation she stated they discussed options for him including boarding houses and public housing.” He told her on 20 April 2009, that he had found temporary accommodation, but RPN Zobel said she did not know where this was, other than “a boarding house.””* This was information she would to need to have but said “we hadn’t got to that point in our conversation””® She also stated Mr Alieff

appeared to be more relaxed about it than she had expected.”

22, RPN Zobel stated that when someone lodges an appeal to the MHRB a medical review must be conducted and a report sent to the MHRB before the appeal hearing. It is routine for anyone on a CTO to be seen once a month by the psychiatric registrar and once every three months by the psychiatrist, Mr Alieff cancelled his appointment for the medical review and failed to attend on many other occasions. She stated that because Mr Alieff wasn’t attending scheduled appointments with her, when she did see him she had to assess him “fairly

8 Regarding the failure to engage and missed

informally’ due to time constraints,” appointments she stated “he was disorganised and erratic...but I never had the sense that he was hostile or resistant.””? She also stated that the patchiness of his engagement made her feel “a little bit off centre” with her engagement with him, stating if she had been more assettive, it might have interrupted their engagement.” He was engaging just enough for RPN Zobel “not to act.?! While he missed appointments he was “willing, cooperative and pleasant” and not the kind of clinical presentation she would expect with someone breaching their CTO? She would have been prompted to act if he was exhibiting symptoms like

deterioration in his self care, if he was hostile, irritable, hearing voices or expressing

3 Transcript of evidence, p3.

4 Transcript of evidence, p14.

°5 Transcript of evidence, p4.

6 Transcript of evidence, ps.

2 Transcript of evidence, p4.

By, ranscript of evidence, p6.

» Transcript of evidence, p16.

» Ibid.

3! Transcript of evidence, p8.

» Transcript of evidence, p9.

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delusional ideas, hopelessness or anger.’ Mr Alieff did not exhibit any of these

symptoms."

23, On.20 March 2009, when Mr Alieff did not attend for his medical review or depot injection, RPN Zobel spoke with Ms Elliott who reported he had been sleeping a lot. RPN Zobel stated she wondered if this change was related to substance use. Mr Alieff did not see his drug and alcohol abuse as a problem and had in the past declined referral to drug and alcohol support services. These treatment services are voluntary and it must be the patients’ decision

to attend.

24, Dr Prasanna gave evidence that he commenced working part time at Koonung CCT on 15 January 2009, and was the monitoring psychiatrist supervising Mr Alieff while he was on the CTO, He did not personally have direct contact with Mr Alieff. He stated each patient has a psychiatrist, junior medical officer and a case manager allocated to them. General practice is that the case manager and junior medical officer will review the patients quite frequently and the consultant psychiatrist reviews the patient every three months.> Clinical reviews were also conducted in clinical review meetings, where a case would be presented and the treatment plan discussed. Dr Prasanna was part of a clinical review team which conducted reviews on Thursday’s, whereas RPN Zobel was part of a team which conducted clinical reviews on Tuesday’s. This meant RPN Zobel would present Mr Alieff’s case to another consultant psychiatrist and not Dr Prasanna.° He gave evidence that in 2010, this issue of cross team arrangements was rectified, with the consultant psychiatrist, junior

medical officer and case manager all on the same team.*’

25. Dr Prasanna stated that a consistent pattern of aggression had developed when Mr Alieff was unwell, showing-he was symptomatic.*® Aggressive behaviour had prompted his family to contact mental health services resulting in his hospitalisation in October 2008 at Upton

House. Dr Prasanna was of the belief that Mr Alieff was adequately managed at Koonung

3 Transcript of evidence, p22.

• Transcript of evidence, plo.

55 Transcript of evidence, p28.

6 Transcript of evidence, p29.

7 Transcript of evidence, p30.

8 Transcript of evidence, p3i.

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27,

CCT, as was the CTO.” He was adhering to his treatment plan and they ensured he got his depot medication. He did not present as aggressive or demonstrate behavioural disturbance which would have indicated he was symptomatic. While he was coming to the clinic late, he did not refuse treatment, he participated in the process and presented as polite.*° Dr Prasanna stated the missed appointments or coming in late prompted the case manager to be in regular contact with Mr Alieffs family and this was something that may not have happened had he

attended on time.

Dr Prasanna stated there is often an issue working with young people whose care is managed under the Mental Health Act (Vic) 1986 by a CTO." Treating teams try to take the least restrictive option and not encroach too much on personal space. They try to engage and not force the patient. He stated the engagement process is long and that it takes time to establish a rapport and then they build on that rapport.*? They don’t want to push too hard in the beginning and jeopardise relations later on. Dr Prasanna stated the belief he formed from reading Mr Alieff’s notes was that he was “probably minimising a lot...he was not very forthcoming,” but that he was “coping relatively well.”“? He did not exhibit agitation or

aggression in the months after his discharge which are indictors of his mental state.

Dr Prasanna gave evidence that if Mr Alieff presented as agitated, aggressive or displayed features of not coping, this would have prompted the treating team to review him more frequently and add another layer of supervision.** He would have involved CAT team to home visit and treat him and they would have supervised him taking his oral medication,*® Regarding Mr Alieffs decision to stop taking oral medication, Dr Prasanna stated while he would prefer patients to take all prescribed medication, he was not concerned because the depot medication he was receiving was equally efficacious as the oral medications.“ There

were occasions when Mr Alieff received his depot medication late; Dr Prasanna stated the

® Transcript of evidence, pp30-31.

“9 Transcript of evidence, p32.

"Ibid.

” Transcript of evidence, p33.

8 Ibid.

“ Transcript of evidence, p34.

• Ibid.

6 Transcript of evidence, p37.

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29,

medication would have been at a stable level, so this was not a concern.” He said it was not unusual for patients to be a few days late for depot medication and their response: would differ depending on the patient, “ For Mr Alieff, Dr Prasanna said they were in touch with his family and did not receive any adverse reports, meaning they were willing to give him more leeway to come in on his own rather than use force.” Dr Prasanna was of the belief that by the end of April, Mr Alieff had started to take some form of ownership which was an

encouraging sign.*°

Dr Prasanna stated he would have preferred to review Mr Alieff, but said he was confident in his treating team. They did not have concerns regarding his treatment and worked in a manner that was the least restrictive option.*’ He stated Mr Alieff responded well to medication, evident in his turn around from being hospitalised for six weeks to presenting

very well to RPN Zobel and Dr Undugodage at appointments.**

Dr Prasatma gave evidence that some of the factors that may have contributed to Mr Alieff taking his own life included the stress he was facing from his housing situation, family relations and use of illicit substances. Dr Prasanna explained that someone diagnosed with schizo-affective disorder can fluctuate from a manic presentation to a depressive state, In October 2008, when hospitalised, he displayed manic features. Dr Prasanna stated he may have been going into a depressive state; however was of the opinion that this would have been noticed by his family and RPN Zobel. Another diagnostic possibility was that he may have gone into a post psychotic depressive phase, however again he noted that no depressive

features were revealed at his assessment on 20 April 2009.4

FINDINGS

CTO’s allow for the treatment of people who would otherwise be involuntary inpatients in the least restrictive environment in the least intrusive manner possible, however a person on

a CTO is still subject to involuntary treatment and is required to be monitored. Between 23

• Ibid.

48 4

® Thid.

50 7

Sly

» Thid.

fee)

5:

£

Transcript of evidence, p38.

Transcript of evidence, p39.

Transcript of evidence, p43.

Transcript of evidence, p44.

Transcript of evidence, pp44-45.

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December 2008 and 22 April 2009, Mr Alieff had only one medical review and missed many appointments intended for case management review. The monitoring psychiatrist, specified in Mr Alieff’s treatment plan, had no direct contact with him, Nevertheless, Mr Alieff did receive his depot medication regularly and responded well to it. He was reviewed by RPN Zobel on 20 April 2009, and I acknowledge that he did not exhibit symptoms of

relapse. I also acknowledge that he did not have a history of self-harm or suicidal ideation.

. I find that the lack of regular assessment and Mr Alieff’s reduced engagement hindered the development of an ongoing relationship with his treating team and inhibited their ability to identify a relapse or decline in his mental state in the weeks leading up to his death. The level of monitoring tolerated by his treating team is difficult to reconcile with the provisions

of the Mental Health Act 1986 (Vic).

. The level of actual monitoring of Mr Alieff by Koonung CCT was less than ideal. However,

I make no adverse conimient in relation to the overall care he received.

. Laccept and adopt the medical cause of death as identified by Dr Melissa Baker and find that Mr Jahit Elliott Alieff died from hanging in circumstances where I am satisfied that Mr Alieff intended to take his own life.

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a

Pursuant to section 73(1) of the Coroners Act 2008, I order that the findings be published on the

internet in the absence of any objection to the same.

I direct that a copy of this finding be provided to the following: e Ms Julie Elliott e Dr Mark Oakley Browne, Chief Psychiatrist, Office of the Chief Psychiatrist e Associate Professor Paul Katz, Eastern Health e° Ms Susannah Whitty, Eastern Health

e Senior Constable Daniel Sonderhof

Signature:

AUDREY JAMIESON CORONER

Date: 3 Match 2015...—--~

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