Deceased
Jovan Kozarov
Demographics
62y, male
Coroner
Coroner Caitlin English
Date of death
2015-02-06
Finding date
2019-08-15
Cause of death
Incised wound to the neck
AI-generated summary
A 62-year-old man died from an incised neck wound inflicted by his son during a psychotic relapse. The son, with a 15-year history of schizophrenia managed in the community, was experiencing worsening psychotic symptoms in the days before the incident. The treating psychiatrist saw the patient on 5 February 2015, increased antipsychotic and mood-stabiliser medications, and arranged weekly reviews with the sister present. The coroner found the psychiatrist's actions appropriate given the lack of prior violence or clear risk indicators. However, the coroner noted that further exploration of family violence risk and impact, including engaging the parents more extensively in treatment planning and providing family psychoeducation, may have better supported the family's safety. The coroner endorsed recommendations for family-violence-sensitive mental health practice and improved carer support and education in schizophrenia management.
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IN THE CORONERS COURT Court Reference: COR 2015 0614
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, ACTING STATE CORONER
Deceased: MR JOVAN KOZAROV
Date of birth: 9 October 1952
Date of death: 6 February 2015
Cause of death: I(a) Incised wound to the neck.
Place of death: 18 Janet Crescent, Bundoora, Victoria
Background
The purpose of a coronial investigation
Matters in relation to which a finding must, if possible, be made
Identity of the deceased, pursuant to section 67(1)(a) of the Act
Medical cause of death, pursuant to section 67(1)(b) of the Act
Circumstances in which the death occurred, pursuant to section 67(1)(c)
of the Act
Comments pursuant to section 67(3) of the Act
Findings and conclusion
Jovan Kozarov (Mr Kozarov) was a 62-year-old man who lived in Bundoora, Victoria at the time of his death. Mr Kozarov was born in Macedonia and married his wife of 44 years, Paraska Kozarov (Mrs Kozarov), in that country.! Mr Kozarov moved to Australia in 1973 and Mrs Kozarov joined him here in 1974. The couple had two children, a son, Roger
Kozarov (Roger), and a daughter, Bilyana Sapazovski (Bilyana).”
At the time of his death, Mr Kozarov was semi-retired and remained active by doing maintenance and gardening jobs for the aged. He enjoyed the outdoors and was well liked
within the community.?
Roger was aged 38 years old when he killed Mr Kozarov. He lived at home with Mr and Mrs Kozarov for most of his life.* After completing Year 12, Roger did some labouring work at factories that Mr and Mrs Kozarov had previously worked at and was working for a
publication company packing DVDs in the two years prior to the fatal incident.
Roger was reported to have been engaged in illicit drug use, including Cannabis and Heroin between the periods of approximately 1995 until 2000.° In the early part of 2000, Roger’s behaviour against his sister Bilyana became increasingly aggressive and he would regularly approach Bilyana for money. When she refused, Roger would threaten to harm her. Bilyana applied for a Family Violence Intervention Order (FVIO) against Roger during this period in early 2000, however, he persisted in his behaviour and was ultimately arrested for breaching
the Order.®
Roger was sentenced to three months imprisonment as a result of breaching the FVIO and was held at the Melbourne Assessment Prison for three months between 23 May 2000 and 27 June 2000. During this time he attempted to self-harm. Roger was then transferred to the
Thomas Embling Hospital and upon his release from custody, was referred to and diagnosed
| Coronial Brief, Statement of Paraska Kozarov dated 6 February 2015, 71
with schizophrenia at the Early Psychosis Prevention and Intervention Centre (now known as
Orygen Youth Health).’
Roger’s therapeutic regime in the 13-14 years prior to Mr Kozarov’s death and after diagnosis, consisted of medication managed through monthly appointments with a treating
private psychiatrist.
Roger’s illness was relatively stable during this time and he resumed living with Mr and Mrs
Kozarov in the family home. Dr Nicholas Owens of Forensicare observed in his assessment:
‘[Roger] appears to have been very dependent on his family for most of his basic needs, although in recent years he had been working... in an unskilled job...[F]rom his own and others’ description, it would appear he has never been free of psychotic symptoms, which have waxed and waned even while maintaining compliance with treatment and abstaining
from psychoactive substance use. 8
In the weeks prior to Mr Kozarov’s death, the available evidence suggests that Roger was experiencing a recurrence of more severe schizophrenic symptoms.’ During this time, Roger
was uncooperative, not eating and appeared to be sleep deprived.!°
Mr Kozarov’s death constituted a ‘reportable death’ under the Coroners Act 2008 (Vic) (the Act), as the death occurred in Victoria and was violent, unexpected and not from natural
causes. !!
The jurisdiction of the Coroners Court of Victoria is inquisitorial.!7 The Act provides for a system whereby reportable deaths are independently investigated to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which the death
occurred.!3
7 Forensicare Psychiatric Report of Dr Nicholas Owens dated 23 November 2015, 8
8 Forensicare Psychiatric Report of Dr Nicholas Owens dated 23 November 2015, 12.
9 Coronial Brief, Statement of Paraska Kozarov dated 6 February 2015, 74; Coronial Brief, Statement of Bilyana Spazovski dated 6 February 2015, 93
'0 Tbid
'! Section 4 Coroners Act 2008 2 Section 89(4) Coroners Act 2008
3 See
Preamble and s 67, Coroners Act 2008
It is not the role of the coroner to lay or apportion blame, but to establish the facts.'4 It is not the coroner’s role to determine criminal or civil liability arising from the death under
investigation,! or to determine disciplinary matters.
The expression “cause of death” refers to the medical cause of death, incorporating where
possible, the mode or mechanism of death.
For coronial purposes, the phrase “circumstances in which death occurred,’ refers to the context or background and surrounding circumstances of the death. Rather than being a consideration of all circumstances which might form part of a narrative culminating in the death, it is confined to those circumstances which are sufficiently proximate and causally
relevant to the death.
The broader purpose of coronial investigations is to contribute to a reduction in the number of preventable deaths, both through the observations made in the investigation findings and by the making of recommendations by coroners. This is generally referred to as the Court’s
“prevention” role.
Coroners are also empowered:
(a) to report to the Attorney-General on a death;'7
(b) to comment on any matter connected with the death they have investigated, including
matters of public health or safety and the administration of justice ;!8 and
(c) to make recommendations to any Minister or public statutory authority on any matter connected with the death, including public health or safety or the administration of
justice.!? These powers are the vehicles by which the prevention role may be advanced.
All coronial findings must be made based on proof of relevant facts on the balance of probabilities.” In determining these matters, I am guided by the principles enunciated in
Briginshaw v Briginshaw.’! The effect of this and similar authorities is that coroners should
'4 Keown v Khan (1999) 1 VR 69.
5 Section 69 (1)
'6 Section 67(1)(c)
17 Section 72(1)
18 Section 67(3)
19 Section 72(2)
20 Re State Coroner; ex parte Minister for Health (2009) 261 ALR 152
not make adverse findings against, or comments about individuals, unless the evidence
provides a comfortable level of satisfaction that they caused or contributed to the death.
In conducting this investigation, I have made a thorough forensic examination of the evidence including reading and considering the witness statements and other documents in the coronial
brief.
Identity of the Deceased, pursuant to section 67(1)(a) of the Act
On 6 February 2015, Mrs Paraska Kozarov visually identified the deceased, to be Mr Jovan Kozarov, born 9 October 1952.
Identity is not in dispute in this matter and requires no further investigation.
Medical cause of death, pursuant to section 67(1)(b) of the Act
On 7 February 2015, Dr Linda Iles, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an autopsy upon the deceased’s body. Dr Iles provided a written report, dated 23 April 2015, which concluded that Mr Kozarov died from an incised
wound to the neck
Dr Iles commented that deaths in such cases occur as a result of blood loss but also may be contributed to by the effects of cerebral air embolism as a result of air entering vascular
structures of the neck.
After having viewed an image of the single edged knife provided by the crime scene investigator, Dr Iles stated that the fatal wound could have been inflicted by this or other
similar sharp-edged weapon.
Toxicological analysis of post mortem specimens taken from the deceased identified the
presence of a small amount of paracetamol in his blood.
Natural disease was present in the form of liver steatosis”? and mild concentric left ventricular hypertrophy.”? Notwithstanding this, natural disease did not contribute to Mr Kozarov’s death. ,
22 Otherwise known as Fatty Liver Disease.
23 This is mild enlargement and thickening of the heart’s main pumping chamber.
I accept the cause of death proposed by Dr Iles.
Circumstances in which the death occurred, pursuant to section 67(1)(c) of the Act
21s
In the days leading up to Mr Kozarov’s death, both Mr and Mrs Kozarov noticed Roger’s health deteriorating and his schizophrenic symptoms worsen. Roger became quiet and was hardly speaking. He was also becoming less co-operative, with deteriorating eating and sleeping habits: all signs Mr and Mrs Kozarov recognised as symptomatic of Roger’s
schizophrenia.”
Mr and Mrs Kozarov became increasingly concerned about Roger’s presentation. On 2 February 2015, Mrs Kozarov asked Bilyana to call Roger home from work on the pretence that Mrs Kozarov was unwell, as she was concerned about Roger being at work in his
condition.?°
On the same day, Mrs Kozarov asked Bilyana to make Roger an appointment with his treating psychiatrist to review his medication, and an appointment was made for 5 February 2015. In the intervening period, Mrs Kozarov told Roger to stay home from work. Mr Kozarov told Mrs Kozarov he had noticed Roger’s leg twitching which they recognised as a sign that Roger was deteriorating.?° Roger barely left the house during this period, and Mrs Kozarov stated
that she became so nervous about his worsening condition that she struggled to eat?”
Following Roger’s appointment with the psychiatrist on 5 February 2015, his dosage of both mood stabilisers and antipsychotic medications were increased. Roger was also booked in for
subsequent weekly reviews to attend with his sister until his condition stabilised.”
During the appointment on 5 February 2015, Roger’s treating psychiatrist noted Bilyana’s concerns regarding the recent distinct change in Roger’s behaviour as well as his own observations of Roger’s affect. In these notes, the treating psychiatrist observed Roger to be irritable and show signs of paranoia. Roger’s psychiatrist concluded, however, that there was
‘no convincing evidence of any delusions or hallucinations or disorganised thought, speech
24 Coronial Brief, Statement of Paraska Kozarov dated 6 February 2015, 74-78; Coronial Brief, Statement of Bilyana Spazovski dated 6 February 2015, 93-94
25 Coronial Brief, Statement of Paraska Kozarov dated 6 February 2015, 75
26 Thid, 76
2 Thid, 77
28 Ibid; Coronial Brief, Statement of Yogananda Ballekere dated 30 April 2015, 70
32:
33,
or behaviour’,? and considered Roger’s presentation to be ‘most likely indicative of a
Prodrome of a Psychotic Relapse’.*°
Despite the review undertaken of Roger’s medication on 5 February 2015, that afternoon, Roger told Mrs Kozarov that the chemist was unable to fill the script until the following day.
Mrs Kozarov watched Roger take his medication as normal that night.
The following morning, on 6 February 2015 at approximately 9.00am, Mrs Kozarov urged Roger to take his tablets, however he said he wanted to eat his breakfast first. When Mrs Kozarov left the garage, she saw that Roger’s medication was still in a cup in the garage
kitchen.*!
After making the beds inside, Mrs Kozarov showered and while in the bathroom she heard one of the cars being driven out of the driveway. She speculated that it was Mr Kozarov
going to work, and quickly dressed to see what Roger was doing in the garage.>
Approximately four or five minutes after she had heard the car leave, Mrs Kozarov walked out towards the garage and saw blood on the concrete. Mrs Kozarov then entered the garage and found Mr Kozarov on his back with his arms out to his side. Mrs Kozarov saw a
significant amount of blood around Mr Kozarov’s head and throat.
Mrs Kozarov tried to contact her daughter Bilyana and was unsuccessful. She then tried to contact Bilyana’s husband, who told Mrs Kozarov to contact emergency services.*?
Emergency services attended at approximately 9.17am and pronounced Mr Kozarov dead at
the scene.*4
On 31 March 2016 Roger was found not guilty of murder on the grounds of mental impairment and was placed on a Custodial Supervision Order for a period of twenty-five
years.
Family Violence
29 Coronial Brief, Statement of Yogananda Ballekere dated 30 April 2015, 69
3° Tbid 70
31 Coronial Brief, Statement of Paraska Kozarov dated 6 February 2015, 80
32 Tbid, 81-2
33 Coronial Brief, Statement of Paraska Kozarov dated 6 February 2015, 82; Coronial Brief, Statement of Robert Sapazovski dated 6 February 2015, 98
34 Coronial Brief, Statement of Constable Scott Goldfinch dated 15 February 2015, 123
be a place of trust, safety and protection.
Kozarov’s neck and causing his death constituted ‘family violence.’*°
opportunities in this case.
Family Violence and Mental Illness
the identified increase are still being explored.*?
“Our understanding is that people experiencing mental illness pose no higher risk of perpetrating family violence than the rest of the community unless they are not receiving
adequate treatment or support... If they are not receiving adequate treatment they are
35 Family Violence Protection Act 2008, section 8(1)(c): [A] person who is, or has been, a relative of the relevant person.
36 Family Violence Protection Act 2008, section 5(1)(a)(i)
37 The Coroners Prevention Unit is a specialist service for Coroners established to strengthen their prevention role and provide them with professional assistance on issues pertaining to public health and safety
38 The VSRFVD provides assistance to Victorian Coroners to examine the circumstances in which family violence deaths occur. In addition the VSRFVD collects and analyses information on family violence-related deaths. Together this information assists with the identification of systemic prevention-focused recommendations aimed at reducing the incidence of family violence in the Victorian Community
39 Carers Victoria (Australia), ‘Statement for the Victorian Coroner’ dated 19 January 2017
44,
slightly more prone to violence than the rest of the community, although many times more
likely to be the victims of violence.”
Violent behaviour is more likely to be exhibited by a person suffering from schizophrenia
where that person is not receiving the appropriate level of mental health intervention.
In Mr Kozarov’s case, there were no clear indications from the available information that Roger posed an increased risk of family violence in this instance. The fact, had it been known to its fullest extent, that Roger was experiencing a re-emergence of severe psychotic symptoms, of itself, would not have furthered any assessment as to the risk of family violence
occurring.
Roger’s treating psychiatrist, Dr Yogananda Ballekere, observed that following the psychotic episode which led to Roger’s diagnosis in 2000; there had been no reports of further florid psychotic episodes or psychiatric admissions, nor were there any reports of Roger displaying violent or dangerous behaviour towards his family. Roger had been fully compliant with all
his medication and appointments, as well as being employed on a casual basis.“!
The action taken by Roger’s treating psychiatrist in increasing his medication and increasing the regularity of appointments with the attendance of his sister, was appropriate under the
circumstances.
Mrs Kozarov noted in her statement that she and Mr Kozarov became increasingly concerned
that Roger’s condition was deteriorating:
“When Roger was sick, he would get very angry and yell. Sometimes the medication would help and Roger would be normal...When Roger gets angry, he sits and I can see his leg
shaking.”
In the days before Mr Kozarov’s death, Mrs Kozarov observed Roger’s behaviour and noted:
“My husband and I got a little bit scared because we have seen this behaviour many times before and we knew something wasn’t quite right. It made me very nervous and scared in my
stomach because I knew [Roger] was sick again... I knew he had to go back to see a doctor
40 Mental Health Carers Australia, ‘Statement [for] Investigation into family violence within mental health caring environments’ dated February 2017,1
4! Coronial Brief, Statement of Yogananda Ballekere dated 30 April 2015.
® Coronial Brief, Statement of Paraska Kozarov dated 6 February 2015, 72
as soon as possible... He had been taking his medication, but it was not working very well
now."
Whilst Roger’s family had concerns regarding his behaviour in the week leading: up to the fatal incident, it appears that they were not extensively included as part of Roger’s mental
health treatment or reported to Dr Ballekere.
The findings outlined by the Royal Commission into Family Violence (RCFV) noted that despite mental health professionals being well placed to respond to family violence, a lack of
resources and education has meant that responses to family violence remain suboptimal.“#
I note that had Dr Ballekere further explored the risk Roger posed to his family and of Roger’s frustrations, these enquiries may have helped identify Roger’s previous use of verbal and emotional violence towards his parents and any factors which may have triggered this behaviour. With the knowledge gained from these enquiries, Dr Ballekere may have been better placed to extend his assessment of Roger and, as such, develop and implementa more
comprehensive safety plan to support the safety of Roger and his family.
The available evidence indicates that Dr Ballekere did adhere to the guidelines governing his practice as they existed at the time and it is unlikely, given Roger’s lack of presenting risk factors or prior use of physical violence that this method of inquiry would have led to interventions that would have prevented the fatal incident. Nonetheless, going forward, it is important that mental health professionals are supported to develop family violence sensitive practice so that opportunities for intervention, as outlined in this case, are acted upon in an
effort to prevent future family violence and family violence related deaths
I confirm that there is significant work being undertaken regarding the intersection of psychiatric services and family violence. The Royal Commission into Family Violence
(RCFV) raises these issues in three recommendations and I endorse the following:
(a) Recommendation 97 proposes the Chief Psychiatrist issue guidelines regarding the treatment of and response to family violence. Specifically, that family violence risk be assessed particularly on discharging or transferring a person receiving treatment or
when consulting with family or carers in relation to treatment planning;
8 Thid, 74 44 State of Victoria, Royal Commission into Family Violence Report, Vol IV, Chapter 19, 30
(b) | Recommendation 98 advocates for specialist family violence advisor positions to be located in major mental health and drug and alcohol services and provide practice
support for practitioners in these sectors; and
(c) Recommendation 102 endorses the development of a family violence learning agenda by the Chief Psychiatrist in consultation with Psychiatric and Medical peak bodies.
This would include undergraduate and graduate training in relation to family violence as well as ongoing professional development. This now exists by way of the Mental Health Workforce Strategy (released in July 2016) and the planned establishment of
the Centre for Mental Health Workforce Learning and Development.”
I also note that, more broadly, intervention with families has been identified as being crucial for the treatment and recovery of individuals with schizophrenia and has been found to increase recovery and survival rates in people experiencing schizophrenia, reduce experiences of relapse and rehospitalisation, increase patient compliance with interventions and support
better patient social adjustment.”
I further note that providing families with education regarding a family member’s illness has been identified as an important step in the treatment of people with schizophrenia. This can assist family members in developing their knowledge and skills in coping with caring for
people with schizophrenia.*”
In 2015, the Victorian Government published its 10-Year Mental Health Plan which identifies a strategy to improve mental health services and results for Victorians who experience mental
illness. As a part of this plan, the Victorian Government has outlined the following relevant
project outcomes
(a) That the needs and experiences of carers and family members of people with a mental
illness are recognised and supported;
45 “Co-ordinate the development of a family violence learning agenda for medical practitioners” Family Violence Reform, http://www.vic.gov.au/familyviolence/recommendations/recommendationsdetails.html?recommendation_id=155
46 Gabi Pitschel-Waltz, Stefan Leucht, Josef Bauml Werner Kissling and Rolf Engel, The effect of family interventions on relapse and rehospitalisation in schizophrenia: a meta-analysis, (2001), Schizophrenia Bulletin, Volume 27, Issue 1,
73-92
47 Jacqueline Sin and Ian Norman, Psychoeducational interventions for family members of people with schizophrenia: a mixed-method systemic review, (2013) The Journal of clinical psychiatry No. 12, 1145-62
48 State of Victoria, Victoria’s 10-Year Mental Health Plan, (2015), 2-3, available online at:
https://www2.health. vic.gov.au/about/publications/policiesandguidelines/victorias-1 Q-year-mental-health-plan
(b) That people with mental illness and their carers are provided with the skills and support
to manage their mental health; and
(c) That carers and people with a mental illness are able to access support services and public
treatment support.
required.
(a) _ the identity of the deceased was Mr Jovan Kozarov, born 9 October 1952;
(b) the death occurred on 6 February 2015 at 18 Janet Crescent, Bundoora, Victoria, from
an incised neck wound; and
(c) _ the death occurred in the circumstances described above.
the internet.
(a) Ms Bilyana Sapazovski, senior next of kin;
(b) Detective Senior Constable Julio Salerno, Victoria Police, Coroner’s Investigator; and
(c) DrNeil Coventry, Chief Psychiatrist, Office of the Chief Psychiatrist.
Signature:
CAITLIN ENGLISH ACTING STATE CORONER Date: 15 August 2019
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