Finding into death of Charlie Zarkadis

IN THE CORONERS COURT Court Reference: COR 2016 5236

OF VICTORIA

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

Findings of: Caitlin English, Coroner Deceased: Charlie Zarkadis Date of birth: 4 March 1962 Date of death: 4 November 2016 Cause of death: I(a) Heroin overdose

Place of death: 4 Bendigo Street, Collingwood, Victoria

BACKGROUND

1. Charlie Zarkadis was a 54-year-old man who lived in Port Melbourne at the time of his death.

2. On3 November 2016 he travelled to Collingwood and purchased heroin. He proceeded to

4 Bendigo Street at some point and the next morning was found there deceased.

THE PURPOSE OF A CORONIAL INVESTIGATION

3. Mr Zarkadis’ death was reported to the Coroner as it appeared to be unexpected or unnatural

and so fell within the definition of a reportable death in the Coroners Act 2008.

4. The role of acoroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine

criminal or civil liability.

5. The Coroner’s Investigator prepared a coronial brief in this matter. The brief includes statements from witnesses including family members and the forensic pathologist who

examined Mr Zarkadis.

6. I have based this finding on the evidence contained in the coronial brief. In the coronial

jurisdiction facts must be established to the standard of proof of the balance of probabilities. !

IDENTIFICATION OF THE DECEASED

7. On 8 November 2016, Sam Zarkades visually identified Mr Zarkadis’ body as being that of his brother Charlie Zarkadis, born 4 March 1962.

8. Identity is not in dispute and requires no further investigation.

CIRCUMSTANCES IN WHICH THE DEATH OCCURRED

9. Mr Zarkadis had a long history of substance abuse and mental health issues. He was diagnosed with schizophrenia in 1998 and since then had ten admissions to public psychiatric hospitals

in Victoria.”

' This is subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

? Discharge Summary dated 23 September 2016, Alfred Health Medical Records.

Mr Zarkadis first met Kosta Metallidis around 1985, and the two re-connected around 2008.

Mr Metallidis notes that at this time Mr Zarkadis told him ‘he had been using Heroin but only occasionally’. Mr Zarkadis ‘would have a shot (inject [heroin]) when he was having problems

in his life. ... I think he was only using it every 2 or 3 months’ 3

Mr Zarkadis had regularly used cannabis throughout his life. In the time leading up to September 2016, he had begun smoking synthetic cannabis.4

Mr Zarkadis was a voluntary patient of the St Kilda Road Clinic Community Care Team, but would not attend the Clinic for treatment and so received home visits. On 13 September 2016 mental health practitioners visiting Mr Zarkadis determined that due to deterioration in his

mental state he should be admitted to Alfred Hospital as an inpatient.

He remained in hospital until 23 September 2016 when he was discharged into the care of his mother. The plan was to follow up with community treatment and to continue treatment with

depot injections of the antipsychotic zuclopenthixol at an increased dose.°

Events proximate to death

Mr Metallidis recalls the following:

‘On Thursday the 3" of November 2016 Charlie called me up and asked me to come down to his house because he needed to see me, he told me he would pay for petrol to drive down. I

left my place and drove to Charlie’s mother’s house in Port Melbourne.”!

Sam Zarkades was told by his mother that at this time ‘Charlie asked her for $250 and told her that they were going out for a nice dinner. She reluctantly gave him $250 and they then

went out.’®

Mr Metallidis recalls that, later that afternoon, Mr Zarkadis asked him to drive to a location in Vere Street, Collingwood, where Mr Zarkadis could purchase marijuana and heroin.

Mr Metallidis did so and states Mr Zarkadis went inside the location for ‘about ten minutes’?

After they left, Mr Metallidis noted that Mr Zarkadis ‘wasn’t looking well, he was yawning a

lot and seemed very tired’ and that Mr Zarkadis began to smoke marijuana in the car.

Statement of Kosta Metallidis dated 15 February 2017, Coronial Brief.

Discharge Summary dated 23 September 2016, Alfred Health Medical Records.

Discharge Summary dated 23 September 2016, Alfred Health Medical Records.

Ibid.

Statement of Kosta Metallidis dated 15 February 2017, Coronial Brief.

Statement of Sam Zarkades dated 7 February 2017, Coronial Brief.

Statement of Kosta Metallidis dated 15 February 2017, Coronial Brief.

Mr Metallidis began to drive back toward Mr Zarkadis’ mother’s house in Port Melbourne,

but he states Mr Zarkadis asked him to drive him back to Collingwood.!°

According to Mr Metallidis, at this time Mr Zarkadis asked him ‘to call his mother and tell

her that he was going to stay at my house. I called Charlie’s mother and told her that he was

‘staying at my house and that he is sleeping’ "!

Mr Zarkadis’ mother later told Sam Zarkades that she had received a call from Mr Metallidis

at around 9.30pm informing her that Mr Zarkadis was not coming home and was asleep.’

Mr Metallidis then drove back to Collingwood and dropped Mr Zarkadis off ‘around Johnston street and Campbell street’, at which time Mr Zarkadis told him that ‘he was going to see some friends’. Mr Metallidis noted that Mr Zarkadis seemed very unsteady. Mr Metallidis did

not see Mr Zarkadis again, and believes he dropped him off at ‘9pm at the latest’.'

4 Bendigo Street, Collingwood

As of 3-4 November 2016, the house at 4 Bendigo Street, Collingwood was owned by the Victorian Government after being purchased as part of the East West Link project. Senior

Constable Kylie Bevan of Victoria Police described the house as follows:

‘[It] is now used as a squat house by numerous different people coming and going. The house is unkept and in [squalor], with food scraps, general mess, syringes and other drug

paraphernalia scattered throughout.’

On 3 November 2016, Dalston Westly-James-Hayes, who had been living at 4 Bendigo Street for ‘about two months,’ left the house at around 4.00pm. At that time ‘there wasn’t anyone in the house or the kitchen’ however when he returned at around 9.00pm, he states: ‘As J passed the kitchen I noticed the bloke [Mr Zarkadis] lying on a mattress in the kitchen. ... He was lying on his stomach with his arms near his head. It looked like he was sleeping’. Mr Westly-

James-Hayes saw Mr Zarkadis again at around 10.30pm and again thought he was sleeping. 18

© Ibid.

" Ybid.

" Statement of Sam Zarkades dated 7 February 2017, Coronial Brief.

13 Statement of Kosta Metallidis dated 15 February 2017, Coronial Brief.

4 Police Summary of Circumstances, Coronial Brief.

15 Statement of Dalston Westly-James-Hayes (undated), Coronial Brief.

23,

Mr Westly-James-Hayes’ father, Mr Dalston Hayes (senior), came to 4 Bendigo Street on 3 November 2016 to pick up some belongings and saw Mr Zarkadis as well, but ‘thought he

was sleeping, so [he] left him alone’ .®

At approximately 1.00am on 4 November 2016 Frank Hayes went to 4 Bendigo Street and saw Mr Zarkadis lying on a mattress. He states that he ‘looked like he was sleeping. He was

moving around as you do trying to get comfortable’. Frank Hayes left the house shortly after. "7

Dalston Hayes returned at around 10.00am on 4 November 2016, saw Mr Zarkadis still apparently asleep and decided to check on his well-being. He thought that Mr Zarkadis was breathing, but when he touched him he found that Mr Zarkadis’ skin was cold. He states that

he remembered ‘seeing a needle, maybe I or 2’ around Mr Zarkadis.'®

Dalston Hayes returned to his home at 16 Bendigo Street and informed his partner Alysson Stallion of Mr Zarkadis’ presence in the house. Ms Stallion went to 4 Bendigo Street and

observed that Mr Zarkadis was deceased. She contacted emergency services.’

Dalston Hayes, Frank Hayes, Mr Westly-James-Hayes and Ms Stallion all state Mr Zarkadis

was not known to them.

CAUSE OF DEATH

Sis

On 9 November 2016, Dr Paul Bedford, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an examination upon Mr Zarkadis’ body and provided a written report, dated 7 December 2016. In that report, Dr Bedford concluded that

a reasonable cause of death was ‘/(a) Heroin overdose’.

Toxicological analysis of the post mortem samples taken from Mr Zarkadis identified the presence of morphine, codeine and 6-monacetylmorphine (a heroin-specific metabolite) as well as the antipsychotic zuclopenthixol and a metabolite of delta-9-tetrahydrocannabinol, an

active component of cannabis.

The presence of 6-monoacetylmorphine indicates use of heroin.

I accept Dr Bedford’s opinion as to cause of death.

16 Statement of Dalston Hayes dated 4 November 2016, Coronial Brief.

7 Statement of Frank Hayes (undated), Coronial Brief.

'8 Statement of Dalston Hayes dated 4 November 2016, Coronial Brief.

!9 Statement of Alysson Stallion dated 4 November 2016, Coronial Brief.

Intent

Br

The toxicology report indicates a number of ways in which death can follow an injection of heroin. Death as a result of overdose of heroin is as a result of the pharmacological properties of the drug. The usual mechanism here is depression of that part of the brain controlling respiration by the high levels of morphine. This effect may be compounded if other drugs or

alcohol are present.

There is no indication that Mr Zarkadis intended to end his own life.

COMMENTS PURSUANT TO SECTION 67(3) OF THE ACT

34,

Bpe

Mr Zarkadis travelled from Port Melbourne to Collingwood in order to source drugs. Although he died in a house, it was a house used by people who were temporarily squatting and it appears no-one knew him or were aware he had used drugs. Residents and former residents saw him ‘sleeping’ when they attended to re-claim some possessions. They noticed he

appeared deceased when they returned the following day to retrieve more property.

Mr Zarkadis’ overdose occurred in the suburb of Collingwood which forms part of the City of Yarra. In her finding following an inquest into the death of Ms A, delivered on 20 February 2017,”° Coroner Jacqui Hawkins addressed the high rate of heroin-related deaths in the City

of Yarra.

In that finding Her Honour made several recommendations about measures that should be taken to prevent such deaths in the future, including taking steps to establish a safe injecting facility trial. This recommendation has been supported in a number of coronial findings

published since.?!

On 7 September 2017 the Victorian Parliament’s Legal and Social Issues Committee tabled the final of its Inquiry into the Drugs, Poisons and Controlled Substances Amendment (Pilot Medically Supervised Injecting Centre) Bill 2017. This report included several findings that recognised the drug harm reduction potential of supervised injecting facilities (see particularly

findings 6, 8, 9, 10 and 11).

20 Published on the Coroners Court of Victoria Website under Case Number 241816.

2! See Coroner Audrey Jamieson’s Finding without Inquest into the Death of David Leslie Chapman dated 8 May 2017 (Case Number 272216), Coroner Gregory McNamara’s Finding without Inquest into the Death of SO dated 7 July 2017 (Case Number 373516) and Coroner Jacqui Hawkins’ Finding without Inquest into the death of Skye Suzanne Turner dated 16 October 2017 (Case Number 115217).

38. The Victorian Government has since introduced legislation for a medically supervised injecting room to be trialled for two years at the North Richmond Community Health Centre.”

This trial is expected to begin by June 2018.73

39. Mr Zarkadis’ death highlights the continuing need for measures to minimise the harm caused by drugs in Victoria and provides further evidence supporting the importance of introducing

medically supervised injecting facilities to prevent similar deaths in the future.

FINDINGS AND CONCLUSION

40. Having investigated the death, without holding an inquest, I find pursuant to section 67(1) of the Coroners Act 2008 that Charlie Zarkadis, born 4 March 1962, died on 4 November 2016

at Collingwood, Victoria, from I(a) Heroin overdose in the circumstances described above.

41. Iconvey my condolences to Mr Zarkadis’ family.

' 42. Pursuant to section 73(1A) of the Coroners Act 2008, I order that this Finding be published

on the Internet.

43. [direct that a copy of this finding be provided to the following:

Mrs Zoe Zarkadis, senior next of kin.

Alfred Psychiatry, Alfred Health.

The Honourable Martin Foley MP, Minister for Mental Health.

Ms Kym Peake, Secretary, Department of Health and Human Services Victoria.

North Richmond Community Health.

Senior Constable Kylie Bevan, Victoria Police, Coroner’s Investigator.

Signature:

CAITLIN ENGLISH CORONER Date: 15 December 2017

2 Drugs, Poisons and Controlled Substances Amendment (Medically Supervised Injecting Centre) Bill 2017 (Vic).

health.vic, ‘Medically supervised injecting room — Frequently asked questions’.