Finding into death of Shaun Luke Beagley

TIN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2014 001172

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 (Vic) .

I, John Olle, Coroner having investigated the death of SHAUN LUKE BEAGLEY without holding-an inquest: find that the identity of the deceased was SHAUN LUKE BEAGLEY born on 15 October 1980 and the death occurred sometime between 1 March 2014 and 2 March 2014 at 230 Milners Road, Lang Lang East, Victoria 3894 from: l(a) MIXED DRUG TOXICITY Pursuant to Section 67(1) of the Coroners Act 2008 (Vic), I make these findings with respect to

the following circumstances:

1. Shaun Luke Beagley was aged 33 years at the time of his death. Ie resided alone in Lang Lang East. He is survived by his parents Edward (Don) and Loretta, his brother Simon, and his daughters Eloise and Eden, with whom he maintained close and loving

relationships.

2. A coronial brief was provided by Victoria Police to this Court, comprising statements obtained from family, 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 mental health medical management and care of

Shaun. [ have also used this information to assist my finding.

' 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

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BACKGROUND AND CIRCUMSTANCES

3. Shaun had a history of continued illicit drug use, despite multiple attempts at drug rehabilitation during his life. Following the birth Eden with his former partner Helen, he ceased taking drugs but turned to alcohol. He was diagnosed with Hepatitis C, and following cessation of drug use he suffered from cellulitis, depression, poor circulation

and weight gain.”

4. As a result of difficulties in their relationship, including the escalation of Shaun’s drinking, Helen and Shaun separated on 13 October 2013. Shaun struggled with the separation, missing the children and the family home atmosphere. When it became apparent that Helen was not returning home, Shaun became self-absorbed and depressed,

refusing to respond to phone calls and messages, and missing work regularly.?

5. Between 6 December 2013 and 13 December 2013, Shaun was admitted as a voluntary patient to the Casey Hospital Inpatient Psychiatric Unit after attempting suicide by consuming 20 temazepam tablets with 1.5 litres of bourbon. On the night of 6 December 2013, Shaun had been drinking heavily and called Don, telling him he had done something stupid and taken an overdose of tablets. Don called Shaun’s employer who lived nearby and asked him to go check on him, and Don called 000.4 Treating clinicians at Casey Hospital commenced Shaun on sertraline 100mg as treatment for depression, and naltrexone 50mg to assist with alcohol cravings. Shaun’s mood improved, and he

was discharged on 13 December 2013.°

6. On 18 January 2014, Shaun was readmitted to Cascy Hospital following a suicide attempt by carbon monoxide poisoning in the context of continued alcohol use. He had ceased medications, and recommenced using intravenous heroin and amphetamines. After a week on the ward, Shaun agreed going to the Acute Prevention and Recovery Care

service (A-PARCS) would be a much better discharge destination than going straight

the clinical management and care provided in particular cases by reviewing the brief of evidence, medical records, the autopsy report and any particular concerns which have been raised.

? Coronial brief, statement of Helen Beange, dated 7 August 2014, 34.

3 Coronial bricf, statement of Edward Donald Beagley, undated, 41.

• Above n 3.

5 Coronial brief, statement of Dr Martin Preston, dated 16 March 2014, 20.

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home. Shaun continued to have low mood and affect at the end of his third week in APARCS, and he was considered at risk of repeat relapse. He was moved to the Enhanced

PARCS (E-PARCS), where patients receive support during a 1 to 6 month stay.°

On 1 March 2014, Shaun asked to take overnight leave from E-PARCS. He told Registered Psychiatric Nurse (RPN) Karen Pollock he was meeting with two females interested in moving in with him to assist with his living costs. RPN Pollock asked Shaun if he had any thoughts or intent to self-harm, and he said no. Shaun was approved for overnight leave, and supplied a 2 day Webster pack of medication. Shaun advised he

would be back on 3 March 2014 at approximately 11:30a.m.’

On 2 March 2014 at 8:30a.m., Helen discovered Shaun had sent her a text message at 7:05a.m. which left her concerned for his welfare. Helen called Don, who tried to contact Shaun without success. Don contacted the E-PARCS and left a message, believing that Shaun was still there. At approximately 1:15p.m., RPN Pollock spoke with Don, who was surprised to learn that Shaun was on overnight leave to Lang Lang. A short while later, Don received a further call from the facility, advising they had not been able to get a response from Shaun. Don was asked if he could attend Shaun’s address, but it was eventually decided that the matter be referred to police as a request for a welfare check.

Police officers attended, but the premises was secured and it appeared that no onc was

present.®

Casey PARC facility staff called Don to advise that the police were unable to locate Shaun. Don drove to Lang Lang, arriving sometime after 7p.m. Don unlocked the kitchen door and entered the home, and could hear television noises coming from the main bedroom. Don found Shaun deceased, lying on the bed. Next to Shaun were some family photos, an empty medication blister pack, and a used syringe. Don found a

handwritten note from Shaun, apologising for the selfishness of his actions.”

5 Above n5, 7 Coronial brief, statement of Karen Pollock, dated 22 March 2014, 25-26.

8 Coronial brief, statement of Sergeant Kevin Iles, dated 15 July 2014, 27.

° Above n 3, 46.

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POST MORTEM EXAMINATION AND REPORT

A post-mortem examination and report was undertaken by Dr Joanna Glengarry, Forensic Pathology Fellow at the Victorian Institute of Forensic Medicine. Dr Glengarry reported .

the left antecubital fossa showed discolouration of the skin and microscopic evidence of

scatring and a reaction to foreign material in the skin

Toxicological analysis of blood and urine samples detected the presence of heroin metabolite 6-monoacetylmorphine’ in urine (~0.2mg/L), morphine!’ in blood (~0.1mg/L) and urine (>0.5mg/L), codeine in blood (~0.06mg/L) and urine (0.1mg/L), methylamphetamine in blood (~0.lmg/L) and presumptively detected in urine (°2.5mg/L), amphetamine in urine (~0.7mg/L), diazepam’? in blood (-0.2mg/L) and urine (~0.lmg/L) and its metabolite nordiazepam in blood (~0.4mg/I.) and urine (~0.1mg/L), oxazepam in urine (~0.8mg/L), temazepam in urine (~0.4mg/L), mirtazapine in blood (~0.1mg/L) and detected in urine, and zopiclone in blood (~0.lmg/L) and detected in urine. Senior Toxicologist Voula Staikos reported the results are consistent with the recent use of heroin in conjunction with methylamphetamine, diazepam,

mirtazapine, and zopiclone.

Dr Glengarry reported that the cause of death is mixed drug toxicity.

FURTHER INVESTIGATION

The CPU were requested to review the appropriateness of the decision by Casey PARC staff to permit Shaun to take overnight leave, and whether a family member should have

been notified of Shaun’s leave.

19 Within minutes of injection into a person, heroin is converted to morphine via the intermediate compound 6monoacctylmorphine (6-MAM). Morphine is the principal form detected in blood.

1! Mozphine is a narcotic analgesic used to treat moderate to severe pain. It is also a metabolite of codeine, Morphine is available as morphine tablets or injection, morphine infusions in hospital, or it may derive from the use of heroin. ,

"2 Diazepam is a sedative/hypnotic drug of the benzodiazepines class. The expected therapeutic blood concentrations of Diazepam and its active metabolite Nordiazepam have been reported to range up to 0.7 to 1.5mg/L and 0.3 to 0.5mg/L, respectively.

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17,

While in A-PARCS and E-PARCS staff regularly asked Shaun about any suicidal thoughts or feelings, which he either denied or more often stated he had no intent or plan but did have fleeting suicidal ideation. At these times, staff spoke with and distracted Shaun, the impact of which cannot be undcrestimated. Shaun had a resilience plan, but

he did not have a history of being able to divert himself or self-soothe his distress.

Shaun had previous overnight weekend leave to stay at his parents’ home for a family event. Shaun had been on both escorted and unescorted day leave since his admission to

A-PARCS, and this continued during his stay in E-PARCS.

_RPN Pollock reported being confident in giving permission for Shaun’s overnight leave,

as he had an assessment completed by the medical officer and consultant psychiatrist a few days prior. A medical revicw is an assumed level of care, but does not remove the responsibility for assessment of risk and mental state to be specific to the time it is being

completed.

The decision to allow Shaun to take leave was made by RPN Pollock after she had assesscd him. This appears reasonable, although the quality and content of the documented mental state examination is suboptimal. Shaun was a voluntary resident. He was not reporting active suicidal ideation or plan, and presented as keen to take leave.

However, Shaun had reported fleeting suicidal thought in the past 48 hours and his withdrawn behaviours since arriving at E-PARCS had not changed. The leave approved

by RPN Pollock was Shaun’s first overnight leave without escort.

PARCS had a signed consumer consent form allowing staff to speak to Don, Loretta, and Simon. His family was willing to engage with staff without issue and-had been asked to speak to Shaun’s boss about his work and sick leave.!? There is no evidence that staff at Casey PARCS made any attempt to encourage Shaun to contact his family or to ask if they could do so. There is no evidence that Casey PARCS staff considered making a telephone call at any time to check how Shaun was coping with weekend leave on his

own.

After the initial phone call from Don to E-PARC on the morning of 2 March 2014, there

does not appear to have been an effort to monitor the telephone which, given RPN

3 Monash Health digital medical records of Shaun Beagley, 87.

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Pollock had requested a welfare check by Victoria Police, it would be reasonable to expect. PARCS is not a crisis centre, but there were several hours between when

messages were left and staff returned calls in a service which is staffed 24 hours a day.

A statement from Susan Thomton, Occupational Therapist and senior clinician at EPARCS states that A-PARCS and E-PARCS are voluntary programs, are unlocked, and residents are free to go out on leave at any time. This is not quite accurate given residents are instructed to tell staff if they are going out, and staff will make assessment

of the risk and leave may be refused or cancelled.

There was no policy, procedure or guideline regarding leave at PARCS until April 2015, when Monash Health PARCS developed a Leave Procedure which is now endorsed by the organisation. The Leave Procedure features pre-planning of leave, and a mecting with a clinician pre-leave for assessment including a risk assessment and mental state examination documented in the clinical records. Residents are informed of their responsibilities regarding leave, and are expected to be responsible for recording their leave on the communal whiteboard with details of destination and return details. Where staff believe a resident should not go on leave, Ms Thornton indicates in her statement that family members are contacted by staff about leave according to the individual needs and situation of the resident.’ The PARCS Leave procedure is contemporary and should

increase the safety of residents at PARCS.

COMMENT

22,

The system for monitoring of telephone calls into E-PARC remains unchanged, and continues to rely on the motivation of staff to check the message bank. A mobile or cordless telephone would provide a feasible technological solution that is inexpensive and would give the nominated staff member immediate access to incoming calls during a

shift. This would provide stakeholders trying to contact staff with a timely response.

'4 Statement of Susan Thornton, dated 15 May 2015, 2.

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FINDING

23. I am satisfied, having considered all of the evidence before me, that no further

investigation is required. I am satisfied that there are no suspicious circumstances.

24, I find that Shaun intentionally took his own life.

25. I find that Shaun Luke Beagley died on 2 March 2014, and that the cause of his death is mixed drug toxicity.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008 (Vic), I make the following

recommendation connected with this death:

1. That the Monash Health PARCS Leave Procedure be amended to include a requirement that in the first overnight or leave event in circumstances where the resident will be alonc, PARCS staff encourage the resident to notify family and/or friend/s of the leave, or staff gain consent to notify family and/or friend/s of the leave, or if this fails PARCS staff make telephone contact with the resident while they are on leave for the purpose

of support and as an indicator of the resident’s safety.

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

The family of Shaun Beagley; Investigating Member, Nese and

Interested parties.

Si gnature:

John Olle Coroner 13 May 2016