Finding into death of WJ

- IN THE CORONERS COURT OF VICTORIA

AT MELBOURNE Court Reference: COR 2014 000169

FINDING INTO DEATH WITHOUT INQUEST

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

I, PARESA ANTONIADIS SPANOS, Coroner,

having investigated the death of WJ

without holding an inquest:

find that the identity of the deceased was WJ

born on 23 March 1988

and that the death occurred between 9 and 10 J; anuary 2014 at Blackman Hotel, 452 St Kilda Road, Melbourne, Victoria

from: I(a) PENTOBARBITONE TOXICITY

Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. WJ was a 25-year old single man who lived with his parents in Arthur’s Seat. He completed a bachelor’s degree in design in 2013! after which he was employed part-time by the Royal Melbourne Institute of Technology. He also worked intermittently as a disc jockey and as an escort? Due to his work schedule and social life, WJ would often stay with friends or in hotels in Melbourne rather than return to the family home. ,

2. In December 2013, WJ’s parents became concerned that their son may be depressed because he was

isolating himself in the family’s caravan at Shoreham, spending long periods in bed and behaving

uncharacteristically. Both encouraged him to discuss his concerns with them, and the deceased’s

mother suggested that he seek counselling and managed to persuade him to resume living with them.

WJ denied he was depressed, did not persist with psychological counselling and appears to have given

his parents little indication that he was contemplating taking his own life.

' According to the deceased’s mother, WJ did not complete a Bachelor of Design but was awarded the degree posthumously.

? According to the deceased’s mother, WJ was working as a DJ ona casual basis when he died, this was his only job at the time of his death, and he had lied to his family and friends about working at RMIT and as an escort.

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ll.

On 14 December 2013, WJ ordered Nembutal (pentobarbitone) on the Internet, paid for it via an

untraceable Western Union transaction and arranged for its delivery.

On the afternoon of 9 January 2014, WJ told his father that he was going into the city to meet up with his cousin and that he would not be home that evening. Just before 9pm he arrived at the Blackman Hotel in Melbourne alone and without luggage and paid for a room for the night. He entered the room at 9.08pm and did not leave. Although he did not meet with his cousin as planned, he communicated with her via text message. In these messages, WJ disclosed that he was applying for jobs because living at home was ‘no longer an option ... since Mum found out I’m an escort’. WJ’s cousin

reportedly had no concerns for his wellbeing.

On 10 January 2014, Blackman Hotel housekeeping staff attended WJ’s room prior to and after the

11am check out time and found him apparently asleep and so did not disturb him. As he was a rewards

member at the hotel, the Duty Manager authorised a late check out.

At approximately 7.40pm, the Duty Manager entered WJ’s room and observed him in bed, unresponsive and apparently deceased. Emergency services were called and, upon arrival, paramedics

were unable to revive WJ.

Victoria Police commenced a coronial investigation. Upon a search of WJ’s hotel room, police located and seized a plastic bag containing traces of a white powder and an opened envelope addressed to WJ from an address in China in the bin. No note was found at the scene, however, the deceased’s father subsequently found electronic and handwritten documents written by WJ suggesting that he was depressed and wanted his suffering to stop. In the course of their investigation, police located emails between WJ and another individual and details of a funds transfer sent by him to a second individual

through which the purchase of pentobarbitone and its importation were arranged.

Forensic Pathologist, Dr Heinrich Bouwer, from the Victorian Institute of Forensic Medicine reviewed the circumstances of WJ’s death as reported by police to the coroner, performed an autopsy and reviewed the results of toxicological analyses of post-mortem blood samples and the white powder located at the scene. Having done so, Dr Bouwer attributed WJ’s death to pentobarbitone toxicity.

The white powder seized by police tested positive for pentobarbitone.

Although approved for use as a veterinary drug in euthanasia, pentobarbitone is not authorised for

human use in Australia by the Therapeutic Goods Administration.

Pentobarbitone is a prohibited import pursuant to the Commonwealth Customs (Prohibited Imports) Regulations 1956 and, as such, it is illegal to bring the drug into Australia in petson or by mail, unless the importer is licenced and has written permission to, import via the Office of Chemical Safety and

Environment.

At my request, the particulars of the evidence related to WJ’s pentobarbitone transaction were

provided to the Australian Customs and Border Protection Service [ACBPS] and the Australian

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Federal Police for further investigation. I was advised that none of the names or addresses used in the transaction (or any permutations of the same) and no record of any importations originating from the address in China appeared in ACBPS information holdings. The supplier’s details have been added to the ACBPS database to aid detection of any future importations by the same person/entity.

12. Given the compelling evidence that an importation did in fact occur, it is likely that the pentobarbitone

received by WJ was misdescribed or concealed and so not identified when imported by mail. I was advised by law enforcement that no further avenues for investigation of this importation exist given that all names and addresses, other than those used by WJ, were false and that the account to which

funds were transferred is untraceable.

13. I find that WJ died of pentobarbitone toxicity, some time between 9 and 10 J: anuary at the Blackman

Hotel in Melbourne after having ingested pentobarbitone with the intention of taking his own life.

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

1. In light of issues raised by the deceased’s family in correspondence with the Court dated 21 May 2014, and at my request, the Coroners Prevention Unit? [CPU] provided advice about the incidence of suicide by pentobarbitone toxicity in Victoria, the frequency with which contact with “suicide

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organisations” occurred prior to those deaths and issues and opportunities for prevention of such

deaths.

2. The CPU analysed the Victorian overdose deaths register to identify all suicides investigated by Victorian coroners between 2000 and 2014, where pentobarbitone overdose was a causal or contributory factor. Each suicide was analysed to determine whether the circumstances of death were consistent with being a “rational suicide”,> and also whether there was any evidence the

deceased obtained suicide information from suicide organisations or another similar source.

3 The Coroners Prevention Unit (CPU) is a specialist service comprising a team of investigators and health clinicians.

The CPU assists coroners fulfil their prevention role and contribute to a reduction in preventable deaths.

‘ The term “suicide organisations” is intended to encapsulate a range of organisations that provide information often intended for elderly individuals and/or those suffering serious/terminal illness and/or cognitive decline who wish to end . their lives. Some “suicide organisations” provide detailed instructions about suicide methods (primarily non-violent and painless methods), including how to source and.use drugs such as pentobarbitone. The phrase “suicide organisations” was used for convenience by the CPU in advice provided to me and I use it for the same reason.

Although “rational suicide” is a contested term (due to debates about what comprises ‘rationality’) it was adopted by the CPU for the purposes of this research as a means of distinguishing between pentobarbitone suicides by the intended audience of “suicide organisations” (older people and people suffering serious physical illness who are not mentally ill and who wish to end their lives in a dignified manner at a time of their choosing) and those committed by other individuals not falling within the generally understood concept of ‘euthanasia’. The definition of “rational suicide” used by the CPU is “suicide seen by others as an understandable reaction to life circumstances; be associated with unendurable suffering (usually of a physical nature); be in accord with a reasonable appraisal of future outcomes in terms of a cost-benefit analysis; have some connection with a reduced life expectancy; and be uncontaminated by

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3. The CPU identified 53 pentobarbitone overdoses between 1 January 2000 and 31 December 2014,

52 of which met the inclusion criteria for pentobarbitone suicide. These 52 deaths included:

a. 30 coroner-determined suicides;

b. 14 deaths still under coronial investigation where the circumstances and cause of death were consistent with suicide; and

c. eight deaths where the coroner completed the investigation and did not explicitly determine the deceased’s intent, however the circumstances and cause of death were consistent with suicide.

4. The overall annual frequency of Victorian pentobarbitone suicides between 2000 and 2014 indicates that deaths occurred intermittently until 2009 when they appear to become more regular and frequent.© The annual frequency of pentobarbitone suicides in Victoria has increased greatly in

recent years

‘5. A slight majority of suicides (n = 27, 51.9%) occurred in circumstances consistent with rational suicide.’ However in the years 2013 and 2014, 15 of 23 pentobarbitone suicides (65.2%) occurred in

circumstances inconsistent with rational suicide.®

6. In the majority of pentobarbitone suicides occurring in circumstances consistent with rational suicide, there was evidence the deceased had accessed information produced by a suicide

organisation (21 of 27 deaths, 77.7%).

7. Conversely, for deaths that occurred in circumstances inconsistent with rational suicide, the CPU was unable to identify evidence of suicide organisation material being accessed in most deaths (20 of 25 deaths, 80.0%). One explanation is that information from suicide organisations is generally not reaching people outside their target audience. However, an alternative explanation is that younger

mentally ill people are accessing information about pentobarbitone from suicide organisations

psychological dysfunction”, after Hewitt, J, “Schizophrenia, mental capacity, and rational suicide,” Theoretical Medicine and Bioethics, vol 31, 2010, p.72 and Pilpel A, Amsel, L, “What is Wrong with Rational Suicide”, Philosophia, vol 39, 2011, p.112. :

§ CPU noted that the annual frequency of Victorian pentobarbitone suicides in 2012 was recorded as one and was likely to be inaccurate (given that 11 such deaths had occurred in 2011 and eight and 15 respectively in 2013 and 2014). CPU considered the likely to explanation to be that after VIFM ceased routine testing for pentobarbitone in April 2010, there ° was some change in the practice of optional pentobarbitone screening during 2012 and possibly 2013, which led to a decrease in pentobarbitone detection. :

7 Circumstances identified as consistent with rational suicide included that the deceased was: terminally ill, had a serious physical illness that permanently and significantly reduced quality of life; elderly and in physical decline, and feared the actual or impending loss of independence, mobility etc; elderly and expressed a wish to die at a time and ina manner of his or her choosing.

§ Circumstances identified as inconsistent with rational suicide included that the deceased did not suffer any terminal or debilitating illness or was diagnosed with a mental illness. Where deaths did not fit readily into one or other category, CPU exercised judgment as to which category better fit the death.

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online, rather than through direct contact with the organisations, and this access is not always

identified and documented by investigating police.

8. Alternatively, or in addition, the CPU notes that information about pentobarbitone is now widely and freely available on the internet, and suicide organisations are now only one means through which a

person can learn about this suicide method.

9. The majority of the recent suicides have occurred in circumstances where the deceased was not an elderly person or seriously ill and planning a dignified end to life (‘rational suicide’), but rather was

mentally ill and/or suffering from depression.

10. The CPU has struggled to identify any opportunities for preventing pentobarbitone suicide in Victoria through further restricting access either to pentobarbitone or restricting access to

information about its use in suicide:

a. Pentobarbitone regulation is appropriate. It is banned for human use in Australia, cannot legally be imported, and only veterinarians are allowed access to it. Possibly veterinarian access could be tightened further, however the data available to the CPU suggests most suicides involved pentobarbitone imported from overseas rather than sourced locally from

veterinarian supplies.?

b. Suicide organisations’ publications advocating specific suicide methods Gncluding pentobarbitone use) are banned in Australia but there is no practical way to prevent

Australians from viewing and accessing them via the internet.!°

ce. The Australian Customs and Border Protection Service is well aware that people attempt to import pentobarbitone illegally into Australia to assist in suicide, and has released a public “information sheet regarding this practice.'' There is probably no recommendation a Victorian coroner could make that would realistically assist the Australian Customs and

Border Protection Service further in the task of detecting illegal imports.

11. A contextual consideration in prevention is that any intervention targeting ‘non-rational’ pentobarbitone suicide has the potential to draw the attention of suicide organisation that campaign for the right to a dignified death. Coroners have traditionally avoided engaging with campaigners in

this area because the debate around the dignified end to life is primarily a matter for the executive

° Among the 52 pentobarbitone suicides, the CPU identified seven where the deceased was a veterinarian and probably accessed the pentobarbitone through work. In most cases where the pentobarbitone source could be confirmed, it was imported by post from overseas; however in the majority of deaths (27, 51.9%) the CPU could not establish the source from the available material. :

10 In Coroner Michelle Hodgson’s comments for the death of Sally McGladdery (20074986), she noted that any recommendation addressing publication of information on suicide would be impossible to implement, given “the sheer volume of material that is available to someone who is seeking that information”.

1! See Australian Customs and Border Protection Service, "Importing barbiturates pentobarbital / Nembutal", March 2011.

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and legislative arms of government, involving as it does conflicting legal, ethical and clinical

considerations that are very difficult to negotiate through the coronial lens of death prevention.

I direct that a copy of this finding be provided to the following: The deceased’s family S/C A. Van Maanen (#36340), c/o O.I.C. South Melbourne Police Station Australian Customs and Border Protection Service Australian Federal Police Suicide Prevention Australia Secretary, Department of Health and Human Services

Parliament of Victoria, Inquiry into End of Life Choices

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~ Signature:

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PARESA ANTONIADIS SPANOS CORONER Date: 21 September 2015

Cc: Manager, Coroners Prevention Unit

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