Finding into death of Beverley Broadbent

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 1671

FINDING INTO DEATH WITHOUT INQUEST

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

I, CAITLIN ENGLISH, Coroner having investigated the death of Beverley Broadbent

without holding an inquest:

find that the identity of the deceased was Beverley Broadbent born on 27 November 1929, and the death occurred on 11 February 2013

at Oak Grange Retirement Village, 695 Hawthorn Road, Brighton East, Victoria

from:

l(a) PENTOBARBITONE TOXICITY

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

Ihave had the carriage of this investigation following the retirement of Coroner Spooner in February 2014.

Introduction

Beverley Broadbent was 83 years of age at the time of her death. Ms Broadbent resided at the Oak Grange Retirement Village in Brighton East. Ms Broadbent’s mother died when she was 6 and she was raised by her father and had no siblings. Ms Broadbent never married

and had no children.

On. 12 February 2013, Ms Margaret McCorry, a nurse who worked at Oak Grange, found Ms Broadbent in bed, deceased. Ms McCorry notified Dr Karen Lewis, a doctor who took the Tuesday morning clinic at Oak Grange. As Dr Lewis had only met Ms Broadbent once

previously, she telephoned Ms Broadbent’s regular GP, Dr Nick Carr.

Dr Carr completed the medical certificate cause of death as 1a) Acute Myocardial Infarction

2. Breast cancer.

On 2 April 2013, The Age newspaper published two articles containing details of an interview with Ms Broadbent headed ‘Rational suicide Why Beverley Broadbent chose to

die.” The articles detailed Ms Broadbent’s intention to take her own life at some time in the

future.

Ms Broadbent’s death on 11 February 2013 was not reported to the coroner.

Coronial investigation

As The Age article suggested that Ms Broadbent’s death was the result of suicide, the State Coroner initiated an investigation on 19 April 2013 to determine whether Ms Broadbent's

death was reportable.

Section 14(1) of the Coroners Act 2008 (Vic) gives a coroner authority to investigate a death that is or may be reportable. Section 4(1) creates a jurisdictional nexus with Victoria. A

reportable death is defined in s 4(2) as:

(a) a death that appears to have been unexpected, unnatural or violent or to have

resulted, directly or indirectly, from an accident or injury; or

(b) a death that occurs (i) during a medical procedure; or (ii) following a medical procedure where the death is or may be causally related to the medical procedure — and a registered medical practitioner would not, immediately before the procedure

was undertaken, have reasonably expected the death.

The investigation involved establishing Ms Broadbent’s cause of death.

It was noted in The Age article that Ms Broadbent had intended to donate her body after death to the University of Melbourne. The Coroner’s Court contacted the University’s Anatomy Department and verified that the Department had received Ms Broadbent’s body on 18 February 2013 and taken blood samples for routine viral testing. As the results were positive for hepatitis, the University had not used her body and she was cremated on 18 April 2013. However, Ms Broadbent’s blood samples were still held by the Victorian Infectious Diseases Reference Laboratory (VIDRL). A sample was retrieved and sent to the

Victorian Institute of Forensic Medicine for testing.

' The Age ‘Rational suicide Why Beverley Broadbent chose to die’, Julia Medew, 2 April 2013, 1.

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13,

A toxicological analysis detected Pentobarbitone (trade names Nembutal, Barbopent and Carbrital) at 84 mg/L. The toxicology report indicated that post mortem blood concentrations of pentobarbitone in deaths attributed to the toxicity of pentobarbitone, range

from 10 mg/L. This suggests Ms Broadbent had lethal levels of pentobarbitone.

In light of this finding, Ms Broadbent’s cause of death could be reasonably formulated as pentobarbitone toxicity, As her cause of death is ‘unnatural,’ it is a reportable death pursuant

to s 4 (2)(a) Coroners Act 2008.

Following this, an investigation was also conducted into the circumstances of Ms Broadbent’s death, which included obtaining statements from Doctors Carr and Lewis, Ms

McCorry and the Manager of Oak Grange Retirement Village.

Medical history

14,

16,

Ms Broadbent had a past medical history of hypertension, hyperlipidaemia, a total hip replacement in 2007 and breast cancer diagnosed in 2012. She decided to take no action

regarding her breast cancer. Dr Carr had been her treating GP since 2003.

In the interview with The Age, Ms Broadbent detailed a declining quality of life in her old.

age, including arthritis, peripheral neuropathy, regular ophthalmic migraines and nightly

cramps for which she took panadol osteo.

She described the ageing process as ‘robbing her of her physical and mental fitness.”

End of life planning

17,

As indicated, statements were obtained to ascertain the circumstances surrounding Ms

Broadbent’s death.

Mr Roy Witherington, Manager of Oak Grange Retirement Village stated Ms Broadbent had arranged for a friend to care for her dog for several days. On 12 February 2013, Ms Broadbent’s friend returned the dog, but was concerned as Ms Broadbent had not answered her doorbell. It was then that Mr Witherington contacted nurse Ms McCorry to attend the

unit with him, in case medical assistance was required.

‘Ms McCorry found Ms Broadbent in bed, deceased.

Mr Witherington asked Ms McCorry to seck the assistance of Dr Lewis.

? The Age ‘Rational suicide Why Beverley Broadbent chose to die’, Julia Medew, 2 April 2013, 1.

21. Mr Witherington stated he had no knowledge that Ms Broadbent intended to take her own life.”

22. Dr Lewis was at Oak Grange for her Tuesday morning medical clinic.

23. Dr Lewis attended Ms Broadbent’s unit. Ms Broadbent was deceased in bed, holding a half eaten chocolate frog. There were Mylanta tablets on the bed side table. She stated she had no knowledge of Ms Broadbent’s intention to end her own life and did not see any evidence of this, such as tablets or bottles of medication, in Ms Broadbent’s room.‘ She then contacted

Dr Carr,

24, Dr Carr provided a statement. Dr Carr stated he was aware of Ms Broadbent’s long standing intention to end her own life and that he and Ms Broadbent had several discussions, commencing in 2003, regarding this intention. In 2003, Ms Broadbent stated to Dr Carr she wanted no fuss or autopsy and had asked Dr Carr what he would write on her death certificate. He stated it should be possible for him to certify that she died of a heart attack.

Although Dr Carr stated this was never discussed again, it remained a tacit agreement

between them.

25. In 2005, Ms Broadbent asked Dr Carr for a prescription for barbiturates to take when she decided to end her life. Dr Carr stated:

T told her I had no expertise in this area, and that I could not advise her about what dose

might be fatal.”

26. He provided her with a prescription for 30 mg phenobarbitone®, dated 22 September 2005.

27. A search of the Medicare Australia Pharmaceutical Benefit Scheme (PBS) showed

phenobarbitone was dispensed once to Ms Broadbent in 2005.

28. Ms Broadbent had contacted Exit International and had met Dr Rodney Syme several times

when preparing for her death.

3 Statement for the coroner by Roy Witherington, dated 4 June 2013

• Statement for the coroner by Dr Karen Lewis, dated 18 May 2013

• Statement for the coroner by Dr Nick Carr, dated 23 July 2013

§ Phenobarbitone is a barbiturate prescribed for seizures and treating sleep disorders. 11 works by slowing activity in the brain,

The last discussion between Dr Carr and Ms Broadbent was on 13 January 2013. Ms Broadbent confided to Dr Carr that she had some pentobarbitone (Nembutal) which she had

purchased over the internet and that she intended to take her own life soon.

A friend, a nurse named Amanda, later revealed in The Age that she had been present when

Ms Broadbent died however was only present to provide comfort. It was reported:

‘Amanda said Ms Broadbent drank a lethal dose of Nembutal — the barbiturate ethanasia advocates call the ‘peaceful pill’ — about 7.30pm on February 11, She died serenely in her

bed about 30 minutes later.””

The Age article indicates Ms Broadbent specifically chose Monday 11 February 2013 as the date of her death: she knew her neighbours would be distracted at a monthly dinner and she would be undisturbed. Further, she knew the local doctor would be present at Oak Grange

on Tuesday morning attending the weekly clinic.

Medical certificate cause of death

With respect to the medical certificate cause of death, Dr Carr stated that he certified the cause of death as 1a) Acute Myocardial Infarction and 2) Breast cancer, in keeping with Ms

Broadbent’s wishes for no fuss and no autopsy.

Dr Carr did this despite being aware that Ms Broadbent had almost certainly taken her own

life.

Dr Carr stated that he had certified death from myocardial infarction despite knowing the

death was probably reportable, but decided to honour Ms Broadbent’s wishes.

Dr Carr stated:

‘As she was 83 years of age, and found peacefully dead in bed, an acute myocardial infarction was a reasonable medical possibility for her cause of death. I was, however, aware she had almost certainly fulfilled her desire to end her life at the time and in the manner of her own choosing, and that as such her death was reportable. It was my personal decision to accede to Ms Broadbent’s preference and issue a death certificate in accordance

with our previous discussion and her stated wishes. *

7 The Age ‘Suicide a calm and beautiful ending, says witness’, Julia Medew, 19 November 2013.

8 Statement by Dr Nick Carr, dated 23 July 2013.

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36, Dr Carr stated:

Trom early in her time as my patient she had made it clear what her wishes would be towards the end of her life, and sought my views and if necessary my assistance. I advised her that I had no strong personal views one way or the other about voluntary euthanasia, and that my main concern was respect for her autonomy and her right to manage her life,

and death, the way she chose,”

37. Dr Carr stated he was surprised Ms Broadbent had gone to the media knowing she wanted “no fuss.’ In retrospect, he felt he should have reconsidered what he put on the death

certificate:

‘Knowing that she had approached the media, I should perhaps have reconsidered what to pui on the death certificate. However, I had a choice between doing what was technically correct, and doing what was the particular wish of a woman whom I had known and respected for 15 years. I chose the latter, as I felt it would dishonour Ms Broadbent and our professional: relationship to do otherwise...I will always remember this extraordinary woman who was clear about what she wanted, and had the courage to see it through her

own way. 710 Post mortem report

38. A report was prepared by Forensic Pathologist Dr David Ranson at the Victorian Institute of Forensic Medicine after consideration of the toxicology analysis and the circumstances of Ms Broadbent’s death''. Dr Ranson noted that an autopsy could have confirmed or refuted the causes of death stated on Ms Broadbent’s death certificate, and/or identified other natural disease processes or other pathologies that could have caused or contributed to her death at that time. He also acknowledged it was also possible that such a post mortem examination would not reveal any anatomical/pathological information that would assist in

| se | atriving at a cause of death. | |

39, Dr Ranson stated that in his opinion, the level of pentobarbitone identified would be

expected to cause the death of Ms Broadbent.

• Statement by Dr Nick Carr dated 23 July 2013 © Ibid. |

" Document detailing the nature and results of the medical investigation into the death of Beverley Broadbent by Dr David Ranson, Victorian Institute of Forensic Medicine, dated 27 August 2015,

40. I have had regard to Ms Broadbent’s medical records, as well as her medical history, the toxicology results and the circumstances of her death. I accept Dr Ranson’s opinion as to the

cause of death.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected with the death:

1. A known effective intervention in suicide prevention is to reducc access to the means of

suicide.

2. The drug used by Ms Broadbent to take her life was pentobarbitone, which is currently banned for human use in Australia. Current restrictions make it a criminal offence to import.

The Australian Customs and Border Protection Service has produced a public information

sheet warning about restrictions on its importation and the applicable criminal penalties.

3. The article in The Age indicates Ms Broadbent was in contact with Dr Rodney Syme and Exit International prior to her death. As Ms Broadbent’s death was not reported to the coroner, there was no early investigation which may have revealed how she accessed the pentobarbitone or what materials she had referenced to assist planning her death. Dr Carr indicated that she told him she had acquired the pentobarbitone over the internet. As this matter was reported to the coroner some time after Ms Broadbent’s death, it was not

possible to further pursue this part of the investigation.

4, 1 refer to the recommendations in the Coroners case of I“ikri Memedovski” regarding reportable deaths and the legal obligations on medical practitioners to report deaths that arc

reportable to the coroner.

COR 2009 5807. ‘This finding is available on the Coroners Court of Victoria website.

Finding I find that Beverley Broadbent died from pentobarbitone toxicity in circumstances where she ‘

intended to end her own life.

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

Ms Katie Simmonds Mr Roy Witherington, Village Manger, Oak Grange Avant Lawyers

Australian Health Practitioners Regulation Authority

Signature:

ZEtttey rr ‘

CAITLIN ENGLISH CORONER

Date: 3 September 2015