Finding into death of Kasim Colic

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2015 000567

FINDING INTO DEATH WITH INQUEST

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

Inquest into the death of: KASIM COLIC Delivered on: 5 November 2015

Delivered at: Coroners Court of Victoria 65 Kavanagh Street, Southbank

Hearing dates: ; 5 November 2015 Findings of: JUDGE IAN L GRAY, STATE CORONER Counsel assisting the Coroner: Ms Erica Capuzza, State Coroner’s Solicitor.

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I, JUDGE IAN L GRAY, State Coroner, having investigated the death of KASIM COLIC

AND

having held an inquest in relation to this death on 5 November 2015

at Melbourne

find that the identity of the deceased was KASIM COLIC

born on 5 February 1935

and the death occurred on 29 December 2014

at Centar Sarajevo, Bosnia Herzegovina

from:

(a) UNASCERTAINED

in the following circumstances:

Background

1,

Mr Colic was a 79-year-old man who was born in Bosnia Herzegovina and was educated

until primary school.

During World War II conflict (which occurred during his childhood) he experienced trauma resulting in a facial injury, loss of vision in one eye and amputation of one finger. Mr Colic worked in various labouring and bookkeeping jobs. He was again exposed to violence during the former Yugoslav War and stated that he was not directly involved in war conflict

but witnessed significant traumatic events.

In about 1998, Mr Colic and his wife, Ms Rasija Colic, migrated to Australia. They had two

adult sons who lived in Bosnia Herzegovina and an adult daughter who lived in Melbourne.

After their arrival in Australia, Mr and Ms Colic purchased a home in Glenroy with assistance from their daughter and her husband. Mr Colic was apparently not informed or did not understand that their names were listed on the property title, and was adamant that he did not consent to the arrangement. In 2010, Mr Colic learned that his daughter and sonin-law were part-owners of his home and was outraged, believing that they had deceived

him,

Mr Colic’s medical history included significant ongoing cerebrovascular and cardiovascular disease and related risk factors including diabetes, high blood pressure and raised cholesterol. His mobility was affected by a stroke that occurred in May 2011, particularly with respect to his balance.and gait. He had had several falls and had become increasingly frail. Mr Colic had an established diagnosis of vascular dementia complicated by behavioural and psychological symptoms of dementia and psychosis. He also had a history of major depressive disorder during his adulthood in Bosnia Uerzegovina and suffered from

ongoing problems of post-traumatic stress disorder.

The property issue was a source of ongoing conflict between Mr Colic and his daughter, On 19 September 2010, Mr Colic attended his daughter and son-in-law’s home and attacked them with an axe. They received lacerations and bruising. Mr Colic denied ever attempting

to harm his son-in-law and daughter.

Mr Colic was charged with several offences in relation to the incident and was found not guilty because of mental impairment. On 28 November 2011, the Honourable Justice Curtain ordered that he be liable to a non-custodial supervision order pursuant to section 26(2) of the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 for a nominal

term of 12 years and 5 months.

Circumstances surrounding the death

Mr Colic was under the supervision of the authorised psychiatrist of the Victorian Institute of Forensic Mental Health (Forensicare) and received treatment from the North Western Mental Health North West Aged Person’s Assessment and Treatment Team (the treating team). One of the conditions of the non-custodial supervision order was that Mr Colic was not to leave the State of Victoria without the written permission of the authorised psychiatrist of Forensicare. Mr Colic had experienced a considerable deterioration in his

physical health and cognitive capacity.

A previous leave application had been granted for Mr Colic to travel to Bosnia Herzegovina with his wife to visit his sons from 9 May to 5 August 2012. Mr Colic attended his general

practitioner (GP) in Bosnia Herzegovina during this time.

Mr Colic again applied for leave to travel to Bosnia Herzegovina with his family from 11 February 2014 for a period of three months, until 11 May 2014. This leave was approved by the authorised psychiatrist of Forensicare and the necessary arrangements were made for Mr

Colic to be reviewed by the same GP every three weeks whilst overseas. It was intended

that he would stay with his son and that his son would escort him to‘and from Australia. His mental state had been assessed as stable in October 2013 (having been his most recent Quarterly Report) and, in the context of his stable mental state, his leave was approved. It was also noted that Mr Colic was increasingly frail and that due to his advancing age and declining health, it would become difficult for him to travel overseas to his homeland and

see his family in the future.

11. During his leave, Mr Colic’s Quarterly Report was completed in March 2014 with information provided by his Bosnian GP. The report documented a deterioration in Mr Colic’s physical health and noted that reports were received less frequently than the agreed three-weekly period. After attempts to obtain reports and contact Mr Colic, a report dated 8 May 2014 was provided by a presumed locum service. It stated that Mr Colic was not

capable of travelling short or long distances and that cach trip was considered high risk.

12. Follow up contact after Mr Colic’s failure to return from leave revealed that his phone in Australia had been disconnected. A visit to his home in Australia revealed that the home was a rental property and was occupied by tenants. Mr Colic’s son in Bosnia Herzegovina reported that his father’s return to Australia was uncertain due to his poor health. Mr Colic’s

son was aware of the non-custodial supervision order conditions.

13. Mr Colic’s failure to return from leave was reported by the Department of Health (as it then was) to the Supreme Court on 24 June 2014. The Department stated to the Court that:

[i]n view of Mr Colic’s age, history of compliance with his non-custodial supervision

order, ill health and the fact thai prior to travelling overseas Mr Colic had been

assessed as posing a low risk to himself and others, the Secretary to the Department

will not be making an application to the Court under section 30A(1) of the Crimes

(Mental Impairment and Unfitness to be Tried) Act 1997 for a warrant to arrest Mr Colic at this time.’

14, Mr Colic’s treating team in Australia continued to liaise with his family in Bosnia Herzegovina, and repeated requests were made for information about his treatment. Several

documents were forwarded by Mr Colic’s son which indicated as follows:

e cerebral CT scan report describing the presence of a large lesion in each of the left and right hemispheres of the cerebellum and abnormalities consistent with atrophy of the

cerebral hemispheres and with vascular disease

e neurologist report describing incontinence, and spastic paresis affecting all four limbs

' Letter from Forensicarc to Supreme Court of Victoria dated 27 January 2015.

e further report from the neurologist directing that there be procedure for regulation of

palliative care « urology report diagnosing adenoma prostate

e a third neurological report (from a different neurologist) noting supraventricular tachycardia and a diagnosis of further cerebrovascular compromise due to embolic events

• lumbar spine CT scan documenting spinal disc disease.”

On 12 January 2015, Mr Colic’s treating team received an email from Mr Colic’s son. The

email stated that Mr Colic had died on 29 December 2014.

Coronial investigation and inquest

Apart from a jurisdictional nexus with the State of Victoria, reportable deaths are, generally, deaths that appeared to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from an accident or injury. However, some deaths are reportable irrespective of the nature of the death, based on the status of the person immediately before

death.

As well as Mr Colic’s death being due to unknown causes, it was reportable as he was a person under the control, care or custody of the Secretary to the Secretary to the Department of Health and Human Services (DHHS) at the time of his death.? This is one of the ways in which the Coroners Act 2008 (Vic) recognises that people in the control, care or custody of the State are vulnerable, and affords them the protection of the independent scrutiny and

accountability of a coronial investigation.

Another protection is the requirement for mandatory inquests. While there is a discretionary power to hold an inquest in relation to any death a coroner is investigating,’ this was a mandatory or statutorily prescribed inquest as Mr Colic was, immediately before death, a

person placed in custody or care.°

? Letter from Forensicare to Supreme Court of Victoria dated 27 January 2015.

3 See section 3 for the definition of a “person placed in custody or care” and section 4(2)(c) of the definition of

“reportable death”,

4 Section 52(1) provides that a coroner may hold an inquest into any death that the coroner is investigating.

5 Section 52(2) and the definition of “person placed in custody or care” in section 3, in particular paragraph (d) thereof — “a person under the control, care or custody of the Secretary to the Department of Human Services.

ai.

This finding draws on the totality of the material the product of the coronial investigation of Mr Colic’s death, contained in the coronial file and compiled by the Coroner’s Investigator Senior Constable Paul Collins. All this material will remain on the coronial file. In writing this finding, I do not purport to summarise all evidence, but refer to it only in such detail as

appears warranted by its forensic significance and the interests of narrative clarity.

Forensicare reported Mr Colic’s death to the Coroner by letter dated 27 January 2015, as he ordinarily resided in Victoria and was subject to a non-custodial supervision order at the

time of his death.

In order to seek to obtain confirmation of Mr Colic’s death and the cause of his death, I made further enquiries with Forensicare, the Australian Federal Police (AFP) and with Mr

Colic’s former Victoria Legal Aid lawyer.

Both the AFP and Forensicare were able to provide copies of Mr Colic’s death certificate to the Court. The certificate issued by the Birth Register for the area of Centar Sarajevo was translated. into English and. states that Mr Kasim Colic, born on 5 February 1935 and formerly residing at Rusida Prgude 3, Sarajevo, Centar, died on 29 December 2014 at 3.30pm at Centar Sarajevo and his funeral was held at Lepenica, Rogatica, Bosnia

Herzegovina. The certificate does not include the cause of Mr Colic’s death. -

The AFP was also asked to obtain medical records for Mr Colic that might reveal further evidence regarding the cause of his death, The AFP has made attempts but was unsuccessful, and advised the Court that it is unlikely that they will be able to obtain such information due to ongoing terrorism concerns in Bosnia Herzegovina and associated disruption.

To date, no further information has been received regarding a possible cause for Mr Colic’s death. It appears that Mr Colic had no family in Australia who attended his funeral or who had seen him since July 2014, and the Court was advised by the Coroner’s Investigator, SC Collins, that Mr Colic’s wife and sons in Bosnia Herzegovina have no plans to return to

Australia.

Conclusion

25,

Based on the available evidence before me and notwithstanding full investigation, the precise cause of Mr Colic’s death is unable to be established to the requisite coronial standard. Given the particular gcographical limitations in this matter, the Court is unable to

pursue any further investigation into the death. It appears, based on the substantial evidence

of Mr Colic’s deteriorating health from his Forensicare file and subsequent correspondence from Forensicare, that his death appears to have been from natural causes. However, in the

absence of further evidence, I am unable to find that cause of death specifically.

26. There is scope under section 77 of the Coroners Act to consider reopening the coronial investigation should compelling new facts and circumstances become known in the future,

and if it is appropriate to do so.

27. Accordingly, I find that: a. the identity of the deceased is Kasim Colic; and

b. Mr Colic died from unascertained causes, on 29 December 2014, at Centar Sarajevo,

Bosnia Herzegovina, in the circumstances described above.

I convey my sincere condolences to Mr Colic’s family and friends for his death.

I direct that a copy of this finding be provided to the following: Ms Rasija Colic, Senior Next of Kin c/o Mr Mirsad Colic Ms Melissa Iskov, Corporate Lawyer, Victorian Institute of Forensic Mental Health

SC Paul Collins, Police Coronial Support Unit.

Signature:

JUDGEIANLGRAY = /

STATE CORON.

Date: Sys i