Finding into death of HJE

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2014 000882

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: Paresa Antoniadis Spanos, Coroner Deceased: HJE!

Date of birth: 22 December 1980 Date of death: 14 February 2014 Cause of death: Hanging Place of death: Blackburn

| In this finding, the deceased’s name and anything likely to identify her or her family has been redacted at the request of the Senior Next of Kin so that the Finding and Comments can be published on the Court’s website, in accordance with general practice in this jurisdiction where there was been no inquest.

I, PARESA ANTONIADIS SPANOS, Coroner,

having investigated the death of HJE without holding an inquest:

find that the identity of the deceased was HJE born on 22 December 1980 and that the death occurred on 14 February 2014

at a residential address, Blackburn, Victoria 3130

from:

I(a) HANGING

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

1. HJE was a 33-year old unemployed woman who lived alone in Blackburn. She had separated

from her partner, BA, two days before her death and is survived by her parents and a sister.

2. HJE was diagnosed with Anxiety and Depression in her early 20s, though she had been prescribed an antidepressant as a teenager when encountering difficulties coping with a major illness her father had at that time. She had chronically poor sleep, experienced nightmares and increased her alcohol consumption to problematic levels at time of stress or relationship crisis.

She had consulted two psychiatrists and a psychologist prior to consulting psychiatrist Dr Robert Mestrovic for the first time in December 2009.

3. Dr Mestrovic confirmed HJE’s diagnosis, noting underlying personality difficulties that primarily manifested at times of relationship stress and rejection. He also noted her previous medication overdoses in March 2006, December 2007 and June 2008 which were linked to

personal relationship crises.

4. Throughout 2010, HJE consulted Dr Mestrovic at least monthly for psychological therapy and her medications were rationalised. Her mental state improved and stabilised, she was working full time, engaging in recreational activities and had moderated her alcohol use. As a consequence, HJE only needed to consult Dr Mestrovic once in 2011 and, though her sleep

remained suboptimal, she had consolidated gains made the previous year.

5. | When next reviewed in April 2012 HJE’s mental state was stable. She had moved in with a new partner — BA, a single father of two young children who lived with him part of the time — and was enrolled in an accountancy course online. She had changed jobs but was dissatisfied

with her new role and workplace.

6. By August/September 2012, HJE was relapsing into depression under the weight of study, new family responsibilities and work dissatisfaction. She took sick leave from work and increasingly withdrew to bed. She engaged in deliberate self-harm and experienced fleeting

suicidal thoughts, eventually requiring a five-week open ward admission to The Melbourne

Clinic [TMC] under Dr Mestrovic’s care commencing in November 2012. The psychiatrist saw HJE intensively throughout the admission, adjusted her medications and recommended that she and BA engage in coupleS counselling following discharge. He also arranged for a

new general practitioner to assist her with a WorkCover claim.

Over the course of 2013, there were innumerable crises in HJE’s relationship with BA, with evictions, verbal arguments and even minor physical altercations. Each time, within a matter of hours or a few days, the relationship resumed and HJE was confronted with the confusion

associated with talk of marriage and parenthood.

HJE’s mother, HA, believed that BA was controlling — for instance, only allowing HJE to use his spare car when he was happy with the relationship and evicting her at will — and that her daughter’s mental health had deteriorated since the relationship started. HA recalled an occasion in March 2013 when HJE was staying with her parents and her husband found HJE

in her bedroom self-harming by lacerating her arms.

Dr Mestrovic managed HJE’s frequent relationship crises with additional medication adjustments and increased session frequency, with individual therapy focussing on helping her to manage her confusion and determine where ‘she finished and [BA’s] personality came in’?

The psychiatrist saw HJE and BA together on a few crisis occasions and reiterated his

recommendation that they commence therapy as a couple.

The psychiatrist also referred HJE to intensive or specialised treatment programs as required.

For instance, in April 2013, she commenced TMC’s Anxiety Management Program, completing nine of 14 sessions in which she reportedly engaged well and through which she developed some anxiety management techniques. After completing the program in August

2013, HJE was placed on the waiting list for the Depression Management Program.

During September 2013, HJE presented as increasingly angry, irritable and reactive. Her sister informed Dr Mestrovic that HJE was posting aggressive and offensive messages on social media — alienating friends in the process — and that the family was concerned about her.

Considering the behaviour to be a possible side effect of a recent change of HJE’s

antidepressant from venlafaxine to reboxetine, Dr Mestrovic reduced her reboxetine dose.

On 21 September 2013, the police were called after HJE allegedly lunged at BA with a knife and was acutely suicidal, having reportedly sent BA a text message indicating that she

intended to commit suicide. She was ultimately transferred by ambulance to The Alfred

2 Statement of Dr Robert Mestrovic.

Hospital for psychiatric assessment and, from there, was admitted to the Intensive Psychiatric

Care Program of TMC due to her emotional dysregulation.

On admission to TMC, HJE was assessed as at moderate risk of suicide and high risk of aggression. She was considered to be experiencing an Adjustment Disorder due to her deteriorating relationship with BA. During the admission she was prescribed lithium, quetiapine and diazepam, and her antidepressant was ceased due to concerns it was causing

her anger.

On 27 September 2013, BA attended a session between HJE and the inpatient treating psychiatrist, Dr John Sheedy. BA expressed his willingness for HJE to return home and live with him, and HJE asked to be discharged that day. She presented as positive and bright and

at low risk of harm and was discharged.

HJE did not remain at BA’s home for long. She continued to be agitated and aggressive and prone to outbursts of verbal abuse and anger. BA was concerned about the effect such behaviour would have on his children and so.asked HJE’s parents to accommodate her. She stayed with them for about a fortnight before moving into a rental property in Blackburn by herself.

Dr Mestrovic supported HJE’s move to live independently, particularly as it had occurred by choice and not as a result of “eviction”. By November 2013, HJE and BA had commenced couple counselling with Dr Zygmund Kaminsky, the psychiatrist recommended by Dr Mestrovic a year earlier. He also referred HJE to Dialectical Behaviour Therapy [DBT] at TMC, noting on the referral that she was at low risk of suicide and self-harm but posed a

moderate risk of aggression and harm to others.

On 22 January 2014, HJE attended an appointment at TMC for a DBT assessment. She reported difficulties consistent with Borderline Personality Disorder and was assessed as suitable for the DBT program. At that time, she was considered at moderate risk of aggression or of harming others, though particularly BA, and at low risk of self-harm or suicide. Through DBT it was anticipated that HJE would learn to manage her mood fluctuations and impulsivity, which was reportedly exacerbated by alcohol use. HJE was placed on the waiting list to commence a DBT pre-commitment program and was due for a

further assessment in April 2014.

Throughout January and February 2014, HJE attended weekly sessions with Dr Mestrovic.

The themes of these sessions were her ongoing difficult interactions with BA, including verbal

and physical fights, and her ongoing confusion about the relationship. However, HJE he did

vANe

23,

not disclose any suicidal thoughts. There was a crisis in the couple’s relationship in late January which prompted Dr Mestrovic to contact Dr Kaminsky and, as at the time of HJE’s last face-to-face contact with her psychiatrist on 12 February 2014, she had not spoken to BA

for about a week.

On the evening of 12 February 2014, BA went to HJE’s house and ended his relationship with her because he could no longer cope with her hostility. Initially he offered to allow her to use his spare car for another week but after seeing that HJE had posted a derogatory comment about him on Facebook, he returned to her home to retrieve the car keys. They argued and, when the disagreement escalated to physical violence, HJE telephoned the police. Attending police failed identify any evidence of injuries and did not have any concerns for the safety of either party. BA claimed his car keys and left, however, the pair continued to exchange antagonistic and derogatory text messages for a few more hours before ceasing

communication altogether.

On 13 February 2014, HJE left a message for Dr Mestrovic in which she described what had happened the previous night. She asked for an earlier appointment than that scheduled and a script for diazepam. Dr Mestrovic reported texting two messages to HJE: one offering an

earlier appointment on 17 February 2017 and arranging a script for diazepam, and a later one

providing support and reassurance.

HIE informed her parents that she and BA had broken up. That evening, HA took her daughter out to dinner at one of HJE’s favourite restaurants. They returned to HJE’s home around 7.30pm, where HA watered the garden and played with the dog while her daughter completed some income protection paperwork. They had a lovely time together. Later that night, HA told her husband who was interstate that HJE seemed happy and was ‘pretty good considering the break up’ 3 HA had not been concerned that her daughter was at risk of

suicide.

On 14 February 2014, HA tried to contact HJE by telephone and text message from about 1.30pm onwards but received no response. After work, HA went to her daughter’s home and when she received no response from her daughter and could not gain entry to the property, she

contacted police and asked them to conduct a welfare check.

At about 8.00pm, Leading Senior Constable Christopher Robinson of Nunawading Police attended HJE’s address and gained entry to the property through the unlocked back door.

3 Statement of HA.

24,

2h.

Upon entering the dining room he observed a woman, later identified as HJE," hanging by the neck from an electrical cord attached to a hook fixed to a wall near ceiling height and an

overturned chair on the floor nearby. HJE had apparently been deceased for some time.

LSC Robinson commenced a coronial investigation and later compiled the brief of evidence on which this finding is largely based. During a search of HJE’s home, a number of handwritten notes in which HJE explained her actions were seized along with a mobile phone which, once interrogated, revealed an internet search history relating to suicidal means and the

text messages between HJE and BA in the immediate aftermath of their break-up.

Senior forensic pathologist, Dr Michael Burke of the Victorian Institute of Forensic Medicine, reviewed the circumstances of the death as reported by police to the coroner, post-mortem computer assisted tomography [PMCT] scans of the whole body and performed an external examination. Among Dr Burke’s anatomical findings were an abraded injury around HJE’s neck consistent in dimension with the electrical cord found in association with her body, and

the absence of other injuries and any natural disease.

Routine post-mortem toxicology detected alcohol at a level of 0.22 g/100mL and quetiapine,

diazepam and temazepam, consistent with therapeutic use.

Dr Burke advised that it was reasonable to attribute HJE’s death to hanging without the need

for an autopsy.

At my request, the Coroners Prevention Unit [CPU] reviewed the available materials, including HJE’s medical records, and provided advice about the adequacy of her mental

health management proximate to death. The CPU advised:

4. Over the course of treatment, Dr Mestrovic utilised psychological therapies to manage mood and relationship difficulties and pharmacotherapies to address

depression, anxiety and insomnia.

b. Dr Mestrovic referred HJE to more intensive or specialist treatment programs as required. These interventions included inpatient admissions at the TMC and referrals to its Anxiety Management Depression Management Program and DBT

programs. He also referred her to another clinician for relationship counselling.

4 HJE was formally identified by her mother.

5 The Coroners Prevention Unity [CPU] was established in 2008 to strengthen the prevention role of the Coroner. CPU assists the Coroner to formulate prevention recommendations and comments, and monitors and evaluates their effectiveness once published. It is staffed by skilled investigators and practising physicians and nurses who are independent of the health professionals or institutions relevant to a particular investigation. They assist the Coroner’s investigation of deaths occurring in a healthcare setting by evaluating the clinical management and care provided and identifying areas of improvement so that similar deaths may be avoided in the future.

Over the years, HJE was prescribed a range of antidepressants (escitalopram, venlafaxine, duloxetine and reboxetine), a mood stabiliser (lithium), a benzodiazepine (diazepam) and an atypical antipsychotic (quetiapine).

. Although it was thought that reboxetine may have negatively influenced HJE’s mood and behaviours, she ceased this medication while an inpatient at TMC in September

2013. Post-discharge, she continued to exhibit aggressive behaviours and affective

instability without the influence of medication, suggesting that it was not the cause.

Medical records indicate that HJE wished to trial a period without antidepressant medication and at the time of her death, she was prescribed mood stabilising and calming medications but no antidepressant. Given her presenting symptoms of

mood instability and aggression, this course seems appropriate.

The primary stressor proximate to HJE’s death was her tumultuous relationship with BA. Prior to that relationship, she had experienced a period of stability where she required minimal mental health treatment and intervention. Unfortunately, regular arguments and break-ups clearly had a detrimental effect on her mental state. As HJE’s depressive symptoms appeared to be a reactive response in the context of psychosocial stressors, referring her to relationship counselling and DBT was appropriate. Efforts at relationship counselling were not able to avert a further break-up on 12 February 2014, which appears to have been a major trigger for HJE’s

suicide.

_ HJE attended weekly face-to-face sessions with Dr Mestrovic throughout January and February 2014, the last appointment being on 12 February 2014 which focused on difficult interactions with BA and confusion about the relationship. There was no

mention of suicidality.

_ Dr Mestrovic did not see HJE following her relationship breakdown on the evening

of 12 February 2014 but communicated with her by text.

On 13 February 2013, HJE presented as future-focussed and help-seeking, requesting an appointment with Dr Mestrovic and completing paperwork for income protection

with her mother who considered her to be in a positive mood that evening.

It is not clear what occurred on 14 February 2014 to prompt HJE’s suicide.

However, contributing factors may include that is was Valentine’s Day, she did not receive any communication from BA, and that she had consumed alcohol and

benzodiazepines, and was likely intoxicated, at the time of her death.

k. It appears that HJE was using alcohol as a maladaptive coping strategy to manage her depressed mood in response to the relationship break-up. Unfortunately, consuming alcohol can further exacerbate symptoms of depression and crosssectional research has found that it is associated with increased rates of suicidal ideation, attempt and suicide. In this context, HJE would likely have experienced depressed mood, poor judgment and impaired decision-making together with a

heightened risk of impulsivity.

The CPU concluded that the clinical management and care provided by Dr Metrovic and TMC

was reasonable and appropriate.

I find that HJE, late of a known residential address in Blackburn (omitted due to its tendancy to identify the deceased), died there on 14 February 2014 and that the cause of her death was hanging. Given the lethality of the means she chose and the notes apparently left by her at the scene, I am satisfied that HJE intended to take her own life.

The available evidence does not support a finding that there was any want of clinical management or care on the part of her Dr Mestrovic or The Melbourne Clinic, that caused or contributed to HJE’s death. Rather, the evidence demonstrates that there was nothing overt in HJE’s interactions with her psychiatrist, nor with her mother, following her break-up with BA

to indicate that she was at increased risk of suicide.

COMMENTS

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

the death:

1. HJE’s death highlights how technology is changing the way health practitioners communicate with their patients, as email and text messages are now common and expected forms of communication. However, email and text message communications inhibit the health practitioner’s ability to conduct a thorough mental state and risk assessment as visual

and verbal cues are unavailable.

2. The challenge for individual health practitioners is to determine for themselves how and

when to use these forms of communication ethically, the patient’s safety being paramount.

3. Ata minimum, patients should be informed that private practitioners are not able to provide

a crisis service and may not receive text messages, voicemails or emails until the next

working day and, as a minimum, patients should be provided with contact details of

appropriate 24-hour crisis services.

I direct that a copy of this finding be provided to the following: HJE’s family Dr Mestrovic The Melbourne Clinic Office of the Chief Psychiatrist

LSC C. Robinson, Nunawading Police

Signature:

Pawo»

PARESA ANTONIADIS SPANOS CORONER Date: 30 March 2017