Finding into death of Brian David Everingham

IN THE CORONERS COURT Court Reference: COR 2016 5860

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: Brian David Everingham Date of birth: 16 December 1964 Date of death: 11 December 2016 Cause of death: I(a) Cardiac arrhythmia in the setting of

methylamphetamine use

Place of death: 34 Lidgett Street, Bacchus Marsh, Victoria

INTRODUCTION

1. Brian David Everingham was a 51-year-old man who lived in Pentland Hill at the time of

his death.

2. Mr Everingham was found deceased at 34 Lidgett Street in Bacchus Marsh on 11 December 2016.

THE PURPOSE OF A CORONIAL INVESTIGATION

3. Mr Everingham’s death was reported to the Coroner as it appeared to be unexpected and so

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

4. The role of a coroner 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, the forensic pathologist who examined Mr

Everingham, treating clinicians and investigating officers.

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

jurisdiction facts must be established on the balance of probabilitics.!

IDENTITY

7. On 11 December 2016, Michael Dowd visually identified his friend Brian David Everingham, born 16 December 1964.

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

CIRCUMSTANCES IN WHICH THE DEATH OCCURRED

9. On 10 November 2016 Mr Everingham and Michael Dowd went to Steven Merceica’s house at 34 Lidgett Street in Bacchus Marsh to play guitar and have a few drinks.? Mr Dowd went

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.

to bed at around midnight.’ According to Mr Merceica at approximately 1.00am or 2.00am on 11 November 2016, he and Mr Everingham injected methamphetamine (ice) into their

arms.

According to Mr Merceica:

‘I noticed Brian lying face down in front of the front door. I laughed thinking he had fallen asleep so I dragged him into the lounge room onto a mattress and put a doona over him and

went to bed on the couch.”*

Mr Merceica states that he woke at approximately 7.00am and went into the loungeroom where he had to step over Mr Everingham a number of times. He states that at approximately 9.00am or 9.30am he became concerned because Mr Everingham was in exactly the same position he had left him in. He sought assistance from Mr Dowd whe found Mr Everingham unresponsive, lying face down on the lounge room floor and saw that he was deceased.> Mr Merceica contacted emergency services who attended and confirmed Mr

Everingham’s death.®

CAUSE OF DEATH

On 15 December 2016, Dr Paul Bedford, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an examination upon Mr Bedford’s body and provided a written report, dated 3 January 2017. In that report, Dr Bedford concluded that a reasonable cause of death was ‘J(a)Cardiac arrhythmia in the setting of methylamphetamine

use’.

Toxicological analysis identified the presence of methylamphetamine and amphetamine.

The presence of methylamphetamine indicates the use of methamphetamine, also known as ‘ice’, Amphetamines stimulate the central nervous system causing persons to become hyperactive and more aroused. Blood pressure and heart rate are also increased. This stimulation lasts as long as the drug is present in a person’s body, with larger effects more

intense soon after administration.

2 Statement of Michael Dowd dated 11 December 2016, Coronial Brief; Statement of Steven Mercieca dated 11 December 2016, Coronial Brief.

3 Statement of Steven Mercieca dated 11 December 2016, Coronial Bricf.

• Statement of Steven-Mercieca dated 11 December 2016, Coronial Brief.

5 Statement of Steven Mercieca dated 11 December 2016, Coronial Brief; Statement of Michael Dowd dated 11 December 2016.

§ Statement of Michael Dowd dated 11 December 2016, Coronial Brief; Statement of Detective Senior ConstableAnthony Euvrard dated 11 April 2018, Coronial Brief.

15. Life threatening reactions to mcthamphetamine can occur. These include agitation, fever, aggression and violence, and can rapidly lead to very high body temperatures, with elevated heart rate and blood pressures. Death from methamphetamine misuse is uncommon following acute use, although long term damage to the heart can lead to increased morbidity and mortality. Irregular heart rate (arrhythmia) is possible at high concentrations particularly

on exertion or in times of stress.

16. Dr Bedford commented that ‘the post mortem examination has shown a mildly enlarged heart with minimal coronary artery disease’. He noted that the toxicology analysis found ‘elevated level of methylamphetamine (ice) which predisposes the heart to an abnormal

potentially fatal heart rhythm’.

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

Intent

18. There is no indication that Mr Everingham intended to end his life. I find that Mr Everingham’s death was the accidental result of drug use.

COMMENTS PURSUANT TO SECTION 67(3) OF THE ACT

19. A recent study, ‘Rates, characteristics and circumstances of methamphetamine-related death in Australia: a national 7-year study’, assessed the trends and mortality rates of

methamphetamine-related death in Australia.’

20. The study found that methamphetamine-related death rates doubled in Australia from 2009 to 2015. Whilst toxicity was the most frequent cause, natural disease, suicide and accident

comprised more than half of deaths.®

21. Death due primarily to natural disease in conjunction with methamphetamine toxicity was attributed in a fifth of cases. The most frequent natural disease was cardiac and/or

cardiovascular disease. ?

22. During my four years serving as a Victorian Coroner, I have become concerned by the growing number of deaths | investigate which occur in a context of methamphetamine use.

These include both deaths where methamphetamine use is a direct causal factor, such as in

7 Shane Darke, Sharlene Kaye and John Duflon, ‘Rates, characteristics and circumstances of methamphetamine-related death in Australia: a national 7-year study’ (201) 112(12) Addiction 2191

8 Ibid.

9 Ibid.

Mr Everingham’s case, (for example methamphetamine-involved overdoses, ‘and motor vehicle collisions involving methamphetamine-affected drivers), and deaths where usc of the drug is a relevant stressor affecting the mental and physical health of the deceased as well as their relationships with partners and family and friends.

23. Further to this point, I note that my anecdotal observations regarding methamphetamine involvement in Victorian deaths are reflected in a range of evidence showing that the burden

of methamphetamine-related mortality has increased substantially over the past decade:

A 2014 Coroners Prevention Unit data summary prepared for the Parliament of Vicioria’s Law Reform, Drugs and Crime Prevention Committee, showed that between 2009 and 2013 the annual frequency of deaths reported to the Coroners Court of Victoria where methamphetamine was detected more than doubled, from 66 deaths in

2009 to 166 deaths in 2013.'°

A subsequent national study found that the rate of methamphetamine-related deaths

across Australia doubled during the period 2009-2015 (referred to above).!!

Victorian Coronial data shows that between 2009 and 2016, the annual frequency of overdose deaths involving methamphetamine rose from 23 to 119. There was a subsequent decline to 93 deaths in 2017, however despite this decline methamphetamine was still the third most frequent contributing drug (after diazepam and heroin) in 2017.'?

I directed the Coroners Prevention Unit to examine methamphetamine involvement in suicide deaths. The Coroners Prevention Unit reported back to me that during the period from 2009 to 2015 (for which complete annual data on toxicology results in suicides is available via the Victorian Suicide Register), the annual frequency of suicide deaths where methamphetamine was detected increased from seven to 42.

24. The increase in methamphetamine-related deaths - and harms more broadly - has been accompanied by an increase in community efforts to understand and address them. Key

developments have included:

10 The Coroners Prevention Unit data summary was provided as a submission to the Law Reform, Drugs and Crime Prevention Committee’s methamphetamine inquiry, and appended to the Committee’s final report in this inquiry. See Law Reform, Drugs and Crime Prevention Committee, Inquiry into the Supply and Use of Methamphetamines, particularly ‘Ice’, in Vietoria - Final Report, Melbourne: Parliament of Victoria, September 2014, volume 2 of 2, pp.787-799.

' Darke S, Kaye 8, Duflou J, “Rates, characteristics and circumstances of methamphetamine-related death in Australia: a national 7-year study”, Addiction, 2017, doi: 10.111 1/add.13897.

2 Jamieson A, Finding without inquest into the death of Samuel Jack Morrison, Court Reference COR 2016 2730, Southbank: Coroners Court of Victoria, 6 August 2018.

The Law Reform, Drugs and Crime Prevention Committee commenced its Inquiry into the Supply and Use of Methamphetamines, particularly ‘Tce’, in Victoria in 2013, and delivered its Final Report in September 2014. The Final Report contained 54

recommendations.

These recommendations were considered by the Victorian Government’s Ice Action Taskforce, which developed an Ice Action Plan (released on 5 March 2015) to

coordinate the response to methamphetamine-related harms.

The Ice Action Plan in turn informed the development of the Victorian Drug Rehabilitation Plan, launched in October 2017. This maintained the importance of addressing methamphetamine-related harms, while also expanding the focus to

encompass other illegal drugs as well as misuse of pharmaceutical drugs.

In parallel with these Victorian initiatives, the Australian Government also took steps to address methamphetamine harms, announcing its National Ice Action Taskforce in April 2015 and National Ice Action Strategy in December 2015. The National Strategy included funding for programs over a four-year period.

25. Given this significant activity at both a state and federal level; my sincere hope is that over time I will see a decrease in methamphetamine use among the deaths I investigate. The decline between 2016 and 2017 in methamphetamine involvement in Victorian overdose deaths was a positive sign, though it is still far too early to conclude that this was a ‘turning point’ as opposed to an anomaly or temporary decline. In considering this issue, I also have regard to an informative and thought-provoking commentary in the Medical Journal of Australia last year, in which drug harm experts Matthew Frei and Alex Wodak discussed the governments’ approach to methamphetamine and argued that progress in harm reduction may be ineffective without a greater reorientation of drug policy from law enforcement to a health and social perspective.°

26. I have directed the Coroners Prevention Unit to continue monitoring methamphetamine involvement among deaths reported to the Coroners Court of Victoria, so we can gain further insight into whether current state and federal initiatives are having an impact on the drug’s harms.

27. Ihave directed a copy of this finding be sent to the Secretary of the Department of Health and Human Services to distribute to the team responsible for the implementation and

evaluation of Victoria’s Ice Action Plan.

5 Frei M, Wodak A, “Beyond ice: rethinking Australia’s approach to illicit drugs”, Medical Journal of Australia, 2017, doi: 10.5694/mja16.00108.

FINDINGS AND CONCLUSION

28, Having investigated the death, without holding an inquest, I find pursuant to section 67(1) of the Coroners Act 2008 that Brian David Everingham, born 16 December 1964, died on 11 December 2016 at Bacchus Marsh, Victoria, from I(a) Cardiac arrhythmia in the setting of

methylamphetamine use in the circumstances described above.

29. Pursuant to section 73(1A) of the Coroners Act 2008 I direct this finding be published on

the internet in accordance with the rules.

30. I direct that a copy of this finding be provided to the following: Mr Jacob Everingham, senior next of kin.

Secretary, Department of Health and Human Services.

Detective Senior Constable Tony Euvrard, Victoria Police, Coroner’s Investigator.

Signature:

Lee gl 1

CAITLIN ENGLISH CORONER Date: 23 November 2018