Finding into death of Ross Malcolm Campbell

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2013 005996

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 ofthe Coroners Act 2008 (Vic) I, John Olle, Coroner having investigated the death of ROSS MALCOLM CAMPBELL without holding an inquest: find that the identity of the deceased was ROSS MALCOLM CAMPBELL born on 22 March 1973 and the death occurred sometime between 27 December 2013 and 28 December 2013 at , Clifton Springs, Victoria 3222 from: 1(a) NECK COMPRESSION CONSEQUENT UPON HANGING Pursuant to section 67(1) of the Coroners Act 2008 (Vic) I make findings with respect to the following circumstances:

1. Ross Malcolm Campbell was born on 22 March 1973 and was 40 years old at the time of his death. He was self-employed and resided with his wife, Susan Campbell, in Clifton Springs.

2. A coronia! brief was provided by Victoria Police to this Court, comprising statements obtained from witnesses, treating clinicians and investigating officers. I have drawn on all of this material as to the factual matters in this finding. At my request, the Coroners Prevention Unit! reviewed the circumstances surrounding the death of Ross. I have used this information to assist my finding.

1 A specialist service for coroners created to strengthen their prevention role and provide them with expert assistance.

Hereafter referred to as 'CPU'. The role of the CPU is to assist coroners investigating deaths, particularly deaths which occur in a healthcare setting. The CPU is staffed by healthcare professionals, including practising physicians and nurses, who are independent of the health professionals and institutions under consideration. The CPU professionals draw on their medical, nursing and research experience to evaluate the clinical management and care

BACKGROUND AND CIRCUMSTANCES

3. Ross met Susan in 1997, and they married approximately 18 months after meeting. They remained married for 15 years, and lived together in Melbourne for the majority of their relationship with Susan's three sons from a previous relationship, Brent, Tristan and Jesse. Ross was estranged from the remainder of his family. Prior to his death, he experienced a relationship breakdown with Susan. He was previously employed as a prison officer at Melbourne Assessment Prison, but in December 2010 Ross and Susan moved to Clifton Springs and opened a Bottlemart bottle shop.2

4. Ross was a regular drinker, and Susan recalled that he would often be drunk and would drink beer and bourbon every night. After Ross was made to attend a Men's Behavioural Course at Bethany in 2011, Ross was better for a while but he was still drinking alcohol regularly.3

5. Ross and Susan's relationship occurred in the context of family violence. In February 2011, an intervention order was put in place to protect Susan from Ross's abuse; Susan and Ross were estranged for approximately one month before Ross moved back in, and Ross was ordered to attend the Men's Behavioural Course. Ross's anger and abusive behaviour towards Susan escalated in the three months prior to his death. During this time, Susan would sleep downstairs, which exacerbated Ross's anger and she could hear him ranting, yelling and screaming at her from upstairs. Susan moved out of the family home on several occasions, however she always returned to Ross.4

6. On 24 December 2013, Ross and Susan went to their neighbour Karen Wilson's house for dinner where Ross expressed that he was upset that Susan had invited friends around to their house for dinner on Christmas Day.5 Later that night, Ross attended the family holiday house in Ocean Grove, where Tristan was staying with his girlfriend. Ross allegedly made threats towards Tristan and the police were called, however Ross left the house prior to police attending. 6 provided in particular cases by reviewing the brief of evidence, medical records, the autopsy report and any particular concerns which have been raised.

2 Coronia! brief, statement of Susan Campbell, dated 11 February 2014, 1.

3 Above n 2, 1-2.

4 Above n 2, 1-2.

5 Coronia! brief, statement of Karen Wilson, dated 23 April2014, 8.

6 Above n 2, 2.

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7. On 26 December 2013, Ross and Susan worked in the bottle shop together, and Ross allegedly told Susan that he was going to kill all of her children and her grandchild, and that she had ruined Christmas. Brent and Tristan decided that Susan should move out of the family home, and escorted her home to collect her belongings from the house. They took her to stay with them in Ocean Grove, and they informed Ross that they were taking Susan with them, and that she was not returning. Ross only nodded in response. 7

8. On 27 December 2013 at approximately 8:30a.m., Susan returned to the bottle shop to attend to business there. At approximately 11 :OOa.m., Ross entered the shop, and upon sighting Susan he left without incident. Shortly after, Susan left the shop with Brent to go to Melbourne. 8

9. At approximately 11 :OOa.m., Ross's neighbour Darren Wilson recalled seeing Ross leave the house and walk towards the bottle shop, returning approximately five minutes later.

Darren waved to Ross, but he did not return the gesture, walking straight to his front door and going inside. 9

10. Later that day, Susan requested Darren ask Ross to attend to an expected delivery at the bottle shop. Darren went to Ross's house on five occasions, where he tried knocking on the door and calling out to Ross with no response. Darren also attempted to call Ross on his telephone, but his calls went unanswered.10

11. On 28 December 2013, Darren and Karen attempted to elicit a response from Ross by banging on the front door of his house and calling out to him. They observed that his two dogs were locked inside the house and were unable to get out, the lights had not been turned on after dark, and the upstairs balcony door had been slightly open all night.11

12. Karen told Susan that they had attempted to check on Ross, but were unable to locate him. Susan found the circumstances to be unusual and became concerned that Ross may have harmed himself, so she contacted police requesting a welfare check 12 7 Above n2.

8 Above n2.

9 Coronia! brief, statement ofDarren Wilson, dated 23 April2014, 5.

10 Above n 7.

11 Above n 5, 9.

12 Above n 2, 3.

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13. At 10:36a.m. Victoria Police officers attended Ross's home and gained access to the house using a ladder to climb up to the first floor balcony where a sliding door was left open. Police officers could not find Ross upstairs, and went to the stairs to head downstairs when they found Ross on the lower portion of the stairs, slumped down the stair case and held up by a leather belt looped around his neck which was tied to the hand.

rail of the stairs. Ross was declared deceased at the scene, and police officers found a handwritten suicide note on the kitchen table.

POST-MORTEM INSPECTION AND REPORT

14. A post-mortem inspection and report was undertaken by Dr Paul Bedford, Specialist Pathologist at the Victorian Institute of Forensic Medicine. Dr Bedford reported findings consistent with the clinical history.

15. Toxicological analysis of blood detected the presence of ethanol (~0.1 Og/1 OOmL).

16. Dr Bedford reported that the cause of death is neck compression consequent upon hanging .

.F URTHER INVESTIGATION Presence ofK nown or Emerging Risk Factors Substance Abuse

17. There is an established linlc between alcohol consumption and violence, and alcohol consumption and suicide. Evidence suggests that alcohol is a significant risk factor to non-fatal family violence and suicide. 13

18. Ross regularly consumed alcohol, drinlcing beer and bourbon most nights. Susan stated that it was common for Ross to be so drunlc that he would sleep upstairs because he could not walk down the stairs.14 Ross abstained from alcohol for a few months in 2010 and reduced his spirit consumption for a period of time in 2011, however at the time of his death he continued to abuse alcohol.

13 Botsis, Plutchik & Kotler et al., (1995). Parental Loss and Family Violence as Correlates of Suicide and Violence Risk. Suicide and Life-Threatening Behaviour, 25, 253-260; Barrett AE & Turner RJ (2005).Family Structure and Mental Health: The Mediating Effects of Socioeconomic Status, Family Process and Social Stress. Journal ofH ealth and Social Behaviour, 46, 156-169; Wade, TJ & Pevalin DJ (2004). Marital Transitions and Mental Health. Journal of Health and Social behaviour, 45, 155-170; Hassan R (1996) Social Factors in suicide in Australia. Trends and Issues in Crime and Criminal Justice, 52, 1-6; Parliament of Australia (20 10). The Hidden Toll: Suicide in Australia. Canberra: Commonwealth of Australia.

14 Above n 2, 1.

History of Family Violence

19. Increased suicide risk is a known adverse outcome associated with family violence.

Family violence is a recognised stressor in suicides of victims and perpetrators.15 Common precipitating stressors shared between the two include substance abuse, mental illness, family breakdown and a response to the loss of control connect family violence and suicide. 16

20. The relationship between Ross and Susan was marked by verbal and physical abuse perpetrated by Ross. The emotional abuse included calling Susan names and criticising her housekeeping and cooking. Susan stated that the abuse was constant throughout the relationshipY Karen recalled that arguments could be heard a few times a night, and on one occasion following an argument Susan displayed a black eye, blood on her face and pain in her ribs. On this occasion, Susan refused to call the police, and stayed the night with Karen.18

21. On 27 February 2011, an incident occurred where Ross was physically violent toward Susan. Police were involved, and a Family Violence Intervention Order (FVIO) was subsequently taken out with Ross listed as the respondent and Susan as the protected party. After this incident, Ross and Susan continued to work at the bottle shop together, however after one month of living separately Ross moved back in with Susan and was required to attend a Men's Behavioural Change Program (MBCP) once a week for three months.19 . The evidence suggests that Ross continued to perpetrate family violence against Susan proximate to his death.

15 Botsis AJ, Plutchik R, Kotler M & Van Praag HM (1995). Parental Loss and Family Violence as Correlates of Suicide and Violence Risk. Suicide and Life Threatening Behaviour, 25, 253-260; Barrett, AE & Turner RJ (2005).

Family Structure and Mental Health: The Mediating Effects of Socioeconomic Status, Family Process and Social Stress.

Journal of Health and Social Behaviour, 46, 156-169.

16 Hassan R (1996) Social Factors in suicide in Australia. Trends and Issues in Crime and Criminal Justice, 52, 1-6.

Matstekaasa A (2006). Is Marriage/Cohabilitation Beneficial for Young People? Some evidence of psychological distress among Norwegian college students. Journal of Community and Applied Social Psychology, 16, 149-165; Polk (1994) When men kill: scenarios of masculine violence. Cambridge: Cambridge University Press; Parliament of Australia (2010). The Hidden Toll: Suicide in Australia. Canberra: Commonwealth of Australia; Wade TJ & Pevalin DJ (2004). Marital Transitions and Mental Health. Journal ofH ealth and Social behaviour, 45, 155-17.

17 Above n 2, 1.

18 Above n 5, 8.

19 Above n 2, 1.

Relationship Breakdown

22. There is evidence to show a linlc between relationship breakdown and suicide. Evidence suggests that males are more vulnerable during separation, particularly where interpersonal conflict is involved. 20

23. Susan moved out of the family home on several occasions during her relationship with Ross, however she always returned. Ross was last seen alive on 27 December 2013, the day after Susan left him to stay with her children. The evidence suggests that Ross's decision to take his life may have been influenced by the relationship breakdown with Susan.

Mental Health

24. There is documented evidence to suggest that people who suffer from a mental illness are at risk of suicide.21 Approximately one year prior to the fatal incident, Ross's general practitioner (GP) discussed a possible diagnosis of depression, anxiety and bipolar.

Further, psychologist Dr Adolf Depper determined that Ross suffered from a possible diagnosis of bipolar disorder. Despite these potential diagnoses, Ross failed to attend treatment from his GP or psychologist on more than two occasions, which made it difficult to determine a definite diagnosis.

25. It appears that Ross struggled to cope with mental health issues, which manifested in anger. However, he had threatened suicide in the past22 and he was hesitant to seek medical assistance as he did not want to be labelled. 23 20 Wyder M, Ward P & De Leo D. (2008). Separation as a Suicide Risk Factor. Journal ofA ffective Disorders, 116, 1-6; Wyder M, Ward P & De Leo D. (2008). Separation as a Suicide Risk Factor. Journal ofA ffective Disorders, 116, 1-6; Mastekaasa A. (2006). Is Marriage/Cohabilitation Beneficial for Young People? Some evidence on psychological distress among Norwegian college students. Journal of Community and Applied Social Psychology 16, 149-165; Wade TJ & Pevalin DJ (2004). Marital Transitions and Mental Health. Journal ofH ealth and Social behaviour, 45, 155-170; Cantor CH & Slater PJ (1995). Marital Breakdown, Parenthood and Suicide. Journal ofF amily Studies, 1, 91-102.

21 Australian Government Department of Health (2014) "Statistics on suicide in Australia" Fact Sheet 3. Canberra: Australian Government.

22 Above n 11.

23 Above n 2, 3.

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Legal Services

26. On 27 February 2011, police were involved in a family violence incident between Ross and Susan. On this occasion, they arrived home at approximately 9:00p.m. after working in the bottle shop, and they consumed alcohol together and became intoxicated. An argument developed between them and Ross was verbally abusive and punched Susan in the head and face on at least three occasions causing lacerations to her left eye and nose.

Susan went to bed with Ross, waiting for him to fall asleep before calling the police.

Police attended and located Susan in a distressed state and Ross asleep in bed with a baseball bat lying beside him. Ross was unable to explain the pool of blood beside him on the bed. Susan did not wish to press charges against Ross, however police applied for a FVIO and referred Ross to seek assistance from a MBCP.

2 7. On 1 March 2011, an interim FVI0 was taken out against Ross, and he moved out of the family home. A condition of the interim FVIO prohibited Ross from going or remaining within 100 metres of the family home. On 5 April 2011, a final FVIO was granted at Geelong Magistrates' Court, and expired as of midnight on 4 October 2011. The final FVIO varied the interim FVIO and removed the condition prohibiting Ross from going or remaining within 100 metres of the family home. Enquiries made by police revealed that a FVIO had previously been granted prior to this event, but expired at court.

Men's Behavioural Change Program

28. Ross contacted the MBCP at Bethany Community Support on 2 March 2011 after a referral by police. He was assess for program suitability on 3 March 2011. During the assessment interview, Ross described a pattern of psychological and physical family violence occurring on a frequent basis. He stated that he would usually use verbal abuse and progress to physical violence when Susan would attempt to defend herself. He stated that he was inclined to use violence whilst affected by alcohol, and indicated that his abuse of alcohol had recently escalated. Ross stated that he could not recall the incident that occurred on 26 February 2011, and that similar incidents had occurred in the past where Susan had not informed police.

29. Dr Tatjana Djokic, Team Leader at Bethany Community Support, noted that other information detailed in the assessment indicated that Ross did not identify any enduring health or mental health issues, was not taking any prescribed medication, and was not accessing mental health services at the time .. However, he disclosed fleeting suicidal

ideation in response to the family violence incident of 26 February 2011, but denied any intent or plan.

30. Ross attended the MBCP from 31 March 2011 to 4 August 2011. The program was for men seeking to address issues associated with abusive, controlling behaviour and family violence, and utilised a psycho-educational approach including exploration of the nature and effects of violence, cognitive effects of behavioural change, managing emotions, dealing with conflict, choice and change. Ross attended all requirements of the program and that occurred over 18 weeks for a total of 30 hours.

31. Ross identified that triggers for his violent behaviour included frustration with himself about feeling inadequate and that he was not as smart as Susan.24 Following completion of the course, his behaviour improved and he ceased bringing alcohol spirits home. He continued to consume beer, however his self-imposed ban on spirit consumption was short lived. 25

32. Ross's responses on the exit interview and personal evaluation suggested that he had gained insight into the need to take responsibility for his use of violence, and to implement relevant self-management strategies as required. Ross also indicated a 'noticeable change for the better' in his use of family violence. Ross declined the offer of any follow up appointments or referrals to counselling at the conclusion of his participation in the MBCP. The evidence suggests that the MBCP had a positive effect on reducing Ross's violent behaviour, however, his violent behaviour recommenced and escalated in the months leading up to his death.

Health Services

33. Proximate to his death, Ross sought treatment from his GP at Drysdale Bulk Billing Medical Centre on two occasions, 21 December 2012 and 16 January 2013. Medical records indicate that on the 21 December 2012 presentation, Ross appeared anxious and depressed. He was suffering from mood changes since childhood, and his GP Dr Gunathilake noted that Ross sometimes felt low with anxiety symptoms and tended to easily feel grumpy and irritable. He reported consuming eight to ten standard drinks per day, seven days a week, and he did not report suicidal thoughts or previous suicide 24 Intake Interview and Assessment, Bethany Community Support Men's Behavioural Change Course.

25 Above n 2, 2.

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attempts.26 Ross was provided with psycho-education and possible diagnoses of depression, anxiety and bipolar were discussed. Dr Gunathilake completed a GP Mental Health Care Plan and in addition advised Ross to attend Bellarine Community Health Care. Ross did not seek subsequent treatment with Bellarine Community Health Care.

34. On 16 January 2013, Ross attended his GP for review. At this appointment, he sought treatment for mood swings. Dr Gunathilake referred Ross to a psychiatrist, Dr Joe Black, however Ross did not seek treatment from Dr Black.

35. Ross attended two sessions for assessment with psychologist Dr Depper on 28 December 2012 and 11 January 2013. Dr Depper concluded that Ross suffered from a possible diagnosis of bipolar disorder. Ross was assessed using the Depression Anxiety Stress Scales (DASS21)27 which revealed a constant in total scores within the mild dysfunction , range. Dr Depper provided psycho-education in relation to Ross's dysfunction and cognitive behaviour therapy, augmented with mindfulness technique. Dr Depper referred Ross back to Dr Gunathilake for further psychiatric investigation, however Ross chose to discontinue therapy sessions with Dr Depper.28 Identification ofP otential Prevention Interventions MBCP Suicide Risk Assessment

36. Despite his reluctance to engage with health services, Ross completed a MBCP with Bethany Community Support in 2011. In his intake assessment, the clinician asked Ross "Have you ever thought about or tried to hurt yourself?" In response to this question, notes from the intake assessment state that "after recent incident, I wondered if it would be easier, but I wouldn't do anything", however there is no evidence indicating that there was any follow up regarding his suicidal ideation. There is no evidence to suggest Ross underwent a suicide risk assessment during his intake or exit interview with the MBCP.

37. Upon completion of the MBCP, Ross refused the offer of referral or follow up. As a result, it appears there was no follow up from Bethany Community Support to determine if Ross had returned to perpetrating family violence or consuming alcohol in excess, both of which had been identified as precursors to his perpetration of family violence.

26 Drysdale Bulk Billing Medical Centre Medical Records of Ross Campbell.

27 The Depression Anxiety Stress Scales (DASS) is a set of self-report scales used to measure 'negative emotional states of depression anxiety and stress.' The DASS21 is a short version of the basic questionnaire.

28 Above n 25.

COMMENTS

38. Although clinicians identified that Ross was suffering from undiagnosed mental illness, his lack of engagement made it difficult for health services to appropriately address his suicide risk. Ross's death highlights the difficulties of engaging male perpetrators of family violence with the appropriate mental health and support services to address the underlying causes of their violent behaviour and suicide risk.

39. Victoria Police recommended to the Royal Commission into Family Violence that conditions attached to a family violence intervention order need to be tailored to meet the individual circumstances. Conditions need to include measures such as drug and alcohol a treatment, and program completion must be monitored similar to community corrections order. I support Victoria Police's recommendation.

FINDING

40. I am satisfied, having considered all of the evidence before me, that no further investigation is required.

41. I find that Mr Campbell intentionally took his own life.

42. I find that Ross Malcolm Campbell died sometime between 27 December 2013 and 28 December 2013 and that the cause of his death is neck compression consequent upon hanging.

RECOMMENDATIONS Pursuant to section 72(2) of the Coroners Act 2008 (Vic), I make the following recommendations connected with this death:

1. That No to Violence provide an updated minimum standards for Men's Behavioural Change Programs to incorporate a requirement for suicide risk assessment upon eligibility and throughout Men's Behavioural Change Programs.

2. That the Victorian Governinent establish a state wide accreditation process for Men's Behavioural Change · Programs in order to ensure that all programs meet an updated minimum standards as published by No to Violence.

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I direct that a copy of this finding be provided to the following: The family of Ross Campbell; Interested parties; and Investigatig.g Member, Victoria Police.