Finding into death of Parth Dayalal Patel

IN THE CORONERS COURT Court Reference: COR 2021 1294

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Caitlin English, Deputy State Coroner Deceased: Parth Dayalal Patel Date of birth: 25 November 1997 Date of death: 10 or 11 March 2021 Cause of death: 1(a) Asphyxia 1(b) Helium and plastic bag over head Place of death: 2704/42-48 Balston Street, Southbank, Victoria

INTRODUCTION

1. On 10 or 11 March 2021, Mr Patel was 23 years old when he took his own life. At the time of his death, Mr Patel lived at Melbourne with a housemate.

THE CORONIAL INVESTIGATION

2. Mr Patel’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent, or result from accident or injury.

3. 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.

4. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.

5. The Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Mr Patel’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

6. This finding draws on the totality of the coronial investigation into Mr Patel’s death, including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1 1 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.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased

7. On 12 March 2021, Parth Dayalal Patel, born 25 November 1997, was visually identified by his friend, Abishek Panchal.

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

Medical cause of death

9. Forensic Pathologist, Dr Joanna Glengarry, from the Victorian Institute of Forensic Medicine (VIFM), conducted an inspection on 12 March 2021 and provided a written report of her findings dated 15 March 2021.

10. Toxicological analysis of post-mortem samples did not identify the presence of any alcohol or any commons drugs or poisons.

11. Dr Glengarry provided an opinion that the medical cause of death was “1(a) Asphyxia” and “1(b) Helium and plastic bag over head”.

12. I accept Dr Glengarry’s opinion.

Circumstances in which the death occurred

13. Mr Patel moved to Australia from India in 2017 to study. He joined his good friend, Abhishek Panchal, in Melbourne and they lived together for the next two or so years with others.

14. Mr Panchal described Mr Patel as very introverted, and he often needed to convince Mr Patel to socialise with friends. Over the time they lived together, Mr Panchal observed Mr Patel to experience financial distress and later what appeared to be undiagnosed depression.

15. Mr Patel’s mental health indeed appears to have deteriorated at some point – he disengaged from his university studies and isolated himself by playing video games alone at home.

16. At the end of 2020, Mr Patel moved to an apartment at Melbourne with Sayali Zalse.

Mr Panchal noted that Mr Patel continued to appear withdrawn – playing computer games and eating less food. He stated that he discussed this with Mr Patel but Mr Patel assured him that he was okay. Conversely, Ms Zalse noted that she had never observed Mr Patel to appear depressed.

17. It appears that Mr Patel did not seek medical assistance in regard to his mental health during this time.

18. However, by January and February 2021, Mr Patel’s mental health appeared to have improved – he was socialising with friends, had resumed his studies, and was communicating regularly with his family in India. In addition, Mr Patel enjoyed a camping trip and a trip to Adelaide with friends.

19. In early March 2021, Mr Patel invited Mr Panchal to stay for a couple of days. Mr Panchal described his friend as “really happy” during this time and they enjoyed playing video games and ordering food. He believed Mr Patel had turned the corner with his mental wellbeing.

20. On the morning of 10 March 2021, Mr Patel left his apartment. While he informed Ms Zalse that he was going to university, he in fact went to Kmart in Richmond where he purchased a helium balloon tank. That afternoon, he attended Imagine Marco Apartments at 42-48 Balston Street at Southbank where he had pre-booked an apartment.

21. During the course of the day and evening, Mr Patel and Ms Zalse text messaged each other.

Ms Zalse noted that there was nothing in the text messages that raised any concerns about Mr Patel’s mental state. At about 9.30pm, Mr Patel text messaged Ms Zalse that he would stay overnight at university because he had classes early the next day. Ms Zalse replied that she had cooked him dinner, but Mr Patel insisted it would be too much effort to return home.

Ms Zalse was adamant that he should return home and Mr Patel the replied that he would try.

At 11.00pm, he had still not returned so Ms Zalse text messaged Mr Patel to let him know that she was going to bed and covered his dinner.

22. At some point, Mr Patel wrote a series of post-it notes and placed them around the rented apartment. He then lay on the floor of the walk-in wardrobe where he placed a hose connected to the helium tank into a plastic bag that he had placed over his head. As a result of asphyxia from the plastic bag and inhalation of helium, Mr Patel passed away.

23. Mr Patel was discovered by staff at 11.00am the next day who contacted emergency services.

24. Victoria Police subsequently attended and found Mr Patel’s handwritten notes, which indicated he had intentionally taken his own life.

25. Leading Senior Constable James Pearson, Coroner’s Investigator, concluded that it appeared Mr Patel was suffering from undiagnosed depression and perceived pressures that he had

placed on himself to succeed and to please family, which ultimately led him to take his own life. I accept this conclusion.

FINDINGS AND CONCLUSION

26. Pursuant to section 67(1) of the Act I make the following findings:

(a) the identity of the deceased was Parth Dayalal Patel, born 25 November 1997;

(b) the death occurred on 10 or 11 March 2021 at 2704/42-48 Balston Street, Southbank, Victoria, from asphyxia and helium and plastic bag over head; and

(c) the death occurred in the circumstances described above.

27. Having considered all of the evidence, I am satisfied that Mr Patel intentionally took his own life.

COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.

1. Mr Patel’s death highlights two issues previously investigated by this court – the vulnerability of international students and easy access to helium as a means of suicide. I make the following observations in the context of Mr Patel not having sought medical assistance for his fluctuating mental health, and that at the time of his death he had disengaged from his university studies.

The vulnerability of international students

2. In 2019, Coroner Audrey Jamieson delivered her seminal finding regarding the death of an international student.2 Her Honour has also recently delivered a further finding, which provided updates regarding developments in this area and called for further initiatives.3

3. As part of her investigation into the death of Zhikai Liu, her Honour obtained statistics regarding other similar suicides. The Coroners Prevention Unit (CPU)4 identified 27 suicides 2 See Finding into Death Without Inquest regarding Zhikai Liu, 10 January 2019, available at: https://coronerscourt.vic.gov.au/sites/default/files/2019-01/16%201035.pdf 3 See Finding into Death Without Inquest regarding Nguyen Pham Dinh Le, 13 January 2021, available at: https://coronerscourt.vic.gov.au/sites/default/files/2021-01/Nguyen_186222.pdf 4 The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner. The unit assists the Coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations. The CPU also reviews medical care and treatment in cases referred by the coroner. The CPU is comprised of health professionals with training in a range of areas including medicine, nursing, public health, and mental health.

of international students between 2009 and 2015 in Victoria but noted that this was likely an under-estimation. The CPU reported the following:

(a) males comprised 22 (81.5%) of the 27 international student suicides;

(b) the deceased’s country of citizenship was Asia for 24 (88.9%) of the suicides;

(c) only 22.2% of the deceased attended a health service for a mental health-related issue;

(d) compared with Australian-born students, there was a lower prevalence of self-harm and previous suicide attempts, however international students more frequently experienced education and financial stressors; and

(e) there was a lower prevalence of diagnosed mental illness amongst international students compared to Australian-born students, and a corresponding higher proportion of deceased with suspected mental illness or with no evidence of mental ill health.

4. The CPU noted that in comparison with Australian-born students, there appeared to be a lower proportion of diagnosed mental illness amongst international students and lower engagement with health services for mental health-related issues. This appeared to suggest that were increased barriers to international students accessing mental health treatment.

5. The research detailed in her Honour’s finding indicated that while international students in Australia experienced a range of stressors that impacted their mental health, they were less likely than Australian-born students to seek assistance for mental health issues because of cultural, financial, linguistic, and other hurdles. Indeed, the CPU identified that lack of helpseeking for deteriorating mental health was a recurring theme in the international suicide cohort.

6. While her Honour was unable to find that Zhikai Liu’s death would have been prevented had he engaged with a health service to treat his deteriorating mental state, her Honour found that such engagement would have created a prevention opportunity that did not otherwise exist.

7. Coroner Jamieson’s subsequent recommendations included:

(a) a recommendation that the Australian Government Department of Education and Training work with Victorian international student education providers as well as other organisations involved in international student education and support in Victoria, to identify strategies to engage vulnerable students with mental health support; and

(b) a recommendation that the Australian Government Department of Education and Training consider how critical incident reports provided by registered educational providers to international students could be used to inform interventions to reduce suicide amongst international students studying in Victoria.

8. The Hon Dan Tehan MP, Minister for Education, responded to her Honour’s recommendations as follows:5

(a) the Department had undertaken initial discussions with various stakeholder groups and proposed to undertake a National Consultation on International Student Mental Health and Wellbeing; and

(b) the Department would investigate and continue discussions across the sector, and with governments, to inform the sector’s further development of strategies to address mental health.

9. In the finding into the death of Nguyen Pham Dinh Le, her Honour revisited the vulnerability of international students. As part of her investigation, her Honour obtained further advice from the CPU who consulted with organisations and individuals engaged in international student welfare, updated its data profile, and reviewed the initiatives that had been implemented since the publication of the finding into the death of Zhikai Liu. Given her Honour’s finding is publicly available, I will not detail all of the CPU’s advice. However, the following is particularly relevant:

(a) the updated CPU data identified 47 suicides of international students between 2009 and 2019. The annual frequency varied between one (2010) and eight (2018) suicides, with an average of just over four suicides per year. The data revealed:

(i) the majority of the deceased were studying at university (33 of 47, 70%) rather than at TAFE (5 of 47, 10.6%) or a registered training organisation (2 of 47, 4.3%); in seven cases (14.8%) the type of the education institution could not be confirmed; 5 The Minister’s response is available at: https://coronerscourt.vic.gov.au/sites/default/files/201904/2016%201035%20Response%20to%20recommendations%20received%20from%20Minister%20for%20Education_ LIU.pdf

(ii) the majority of the international student suicides were male (33 of 47, 70.2%), and the majority were aged 24 years or under (30 of 47, 63.8%); and (iii) most international students who suicided in Victoria between 2009 and 2019 were citizens of countries in Asia (37 of 47, 78.7%). The most frequently occurring countries of citizenship were China (eight deaths), South Korea (six deaths), Hong Kong (five deaths) and India (five deaths).

(b) In October 2019, the insurer Bupa published a report titled, ‘Mental Wellbeing Survey of Prospective International and Overseas Students’, based on surveys conducted with prospective international students who had inquired about study in Australia. The report indicated that:

(i) this cohort experienced lower levels of average life satisfaction than an Australian comparison group and they were at higher risk for depression; (ii) approximately one in two prospective international students were assessed as vulnerable to experiencing psychological distress; (iii) almost one in four reported feeling extreme pressure to succeed in planned studies; and (iv) younger students, and students intending to study foundation or undergraduate qualifications, were assessed at greater risk for experiencing psychologist distress.

(c) The researchers concluded that international and overseas students appeared to be a risk group for low feelings of life satisfaction, depression, and associated distress, relative to Australia’s adult population, before they arrive in Australia to study. The report made a number of recommendations to reduce mental health stigma and increase intervention opportunities;

(d) In June 2020, Orygen6 published its report titled, ‘International Students and their Mental Health and Physical Safety’, which was based on interviews with a wide range of stakeholders, including international students, peak bodies, universities, and English 6 Orygen provides specialist mental health services for young people aged 15 to 25 years who reside in the western and north-western regions of metropolitan Melbourne. Orygen also undertakes research.

language schools. The report revealed a number of challenges that impact on international students’ mental wellbeing including financial, employment and housing stress, difficulty accessing services, language barriers to help-seeking, and experiences of racism and harassment;

(e) Orygen’s report identified a number of ‘good practice’ themes such as promoting a sense of belonging, mental health education, and prevention, amongst others. The report included recommendations for initiatives and activities that could be considered in each of these themes, as well as examples from across the education sector to illustrate what is already being done; and

(f) the Productivity Commission's Mental Health report (report no. 95), which was finalised in June 2020 and released to the public on 16 November 2020, included a consideration of international student mental health. The report’s authors concluded it was essential to encourage students to seek help for mental health issues and noted that international students are less likely than others to see help because of barriers such as language and cultural differences.

10. Recognising that the implementation of initiatives to address the identified prevention themes would be complex and challenging, her Honour noted that an individual or a single coordinating institution should lead the coordination to further wellbeing initiatives for international students obtaining tertiary qualifications in Victoria. Her Honour therefore made a recommendation that the Victorian Department of Health take on the role of leading and coordinating efforts to support mental health and wellbeing of international students studying in Victoria, and to ensure international students can access mental health treatment.

11. Professor Euan Wallace, Secretary of the Department of Health, provided a response7 to her Honour’s recommendation, noting the following:

(a) the department had convened a working group comprising Study Melbourne of the Department of Jobs, Precincts and Regions, and Multicultural Affairs of Department of Families, Fairness and Housing to discuss the investigation findings and associated recommendation. Members agreed that the Department of Health would convene a taskforce, including lived experience representatives, to work through the key themes identified in Coroner Jamieson’s finding and consider those themes in the context of 7 The Secretary’s response is available at: https://coronerscourt.vic.gov.au/sites/default/files/202109/2018%206222%20Response%20to%20recommendations%20from%20Department%20of%20Health_LE.pdf

available relevant research. The taskforce will determine immediate and longer-term actions to promote mental health and wellbeing and to prevent suicide in Victoria’s international student population; and

(b) a new Suicide Prevention and Response Office is being established, as recommended by the Royal Commission into Victoria’s Mental Health System. Suicide prevention and response for international students will be part of this Office’s remit. This new Office will be briefed on this matter for as soon as it is established and asked to progress both suicide prevention in general and preventative measures specific to international students.8

12. It appears that the vulnerability and mental health of international tertiary students is being addressed and a number of initiatives are on the way to being implemented. There is no need for me to make a further recommendation beyond what Coroner Jamieson has already recommended while this work is being undertaken. I look forward to the outcomes of the Department of Health’s taskforce and the establishment Victoria’s Suicide Prevention and Response Office.

Previous coronial findings regard suicides attributed to helium inhalation

13. In 2019, this court handed down two findings in regard to two males who had used helium as a means to suicide.9 10

14. In the finding regarding the death of Jae William James Manning, Coroner Rosemary Carlin noted that she had investigated a number of suicides by inhalation of inert gas that year. Data compiled by CPU in that case revealed that between 2000 and 2018, 118 people died via helium gas inhalation in Victoria.11 I note that updated CPU data records a further 21 deaths occurring between 2019 and 2021.12

15. Her Honour noted that helium is widely used in Victoria for blowing up balloons and can be purchased for this purpose at many outlets from general retailers through to specialist 8 Department of Health, Mental health reform, Recommendation 26: Governance arrangements for suicide prevention and response efforts, 3 September 2021, https://www.mhrv.vic.gov.au/recommendation-26-governance-arrangementssuicide-prevention-and-response-efforts.

9 Finding into Death Without Inquest regarding Jae William James Manning, 13 June 2019, available at: https://coronerscourt.vic.gov.au/sites/default/files/2019-07/JaeWilliamJamesManning_131518.pdf.

10 Finding into Death Without Inquest regarding Mr L, 17 July 2019, available at: https://coronerscourt.vic.gov.au/sites/default/files/2019-07/MrL_507717.pdf.

11 Although not indicated in the finding, the CPU identified that the number of suicides attributed to helium inhalation had risen from five in the period from 2000 to 2004 to 55 in the period from 2014 to 2018.

12 Statistics for 2021 only available until 30 June.

industrial gas suppliers. It is not scheduled in the Standard for the Uniform Scheduling of Medicines and Poisons (Poisons Standard), which means that access to helium is not regulated or restricted in Australia.

16. In her finding, her Honour discussed preventive measures that could be implemented to prevent suicides via helium inhalation such as regulating access to helium in Victoria and dilution of helium with oxygen. Her Honour ultimately made the following recommendations:

(a) that the Department of Health and Human Services explore whether the deleterious substances provisions of the Drugs Poisons and Controlled Substances Act 1981 (Vic) should be amended to include the major gases used in inert gas inhalation suicide in Victoria; and whether such an amendment would have any practical impact on Victorians’ ability to access these gases for purposes of suicide; and

(b) that the Australian Competition and Consumer Commission (ACCC) declare undiluted helium in balloon kits to be an unsafe product and make 20% oxygen dilution of helium in balloon kits compulsory.

17. In her response, Kym Peake, Secretary of the Department of Health and Human Services,13 acknowledged that inert gases had the potential to be misused. Ms Peake noted that the legislation allowed a retailer with reasonable cause to refuse sale if they believed the substance will be misused. However, in practice it would be very difficult to establish that intended use was for the purpose of suicide. The department also did not capture data on such instances.

Given this, it was difficult to conclude that legislative change would result in a reduction in suicides.

18. In the finding regarding the death of Mr L, delivered shortly thereafter, Coroner Simon McGregor repeated Coroner Carlin’s identification of possible preventative measures and recommended:

(a) that the ACCC undertake a study of different inert gases to consider their safety and suitability for use as balloon gas and their effectiveness in reducing or delaying the lethality of balloon gas inhalation; and 13 Ms Peake’s response is available at: https://coronerscourt.vic.gov.au/sites/default/files/201911/2018%201315%20and%202017%202906%20Response%20to%20recommendations%20from%20DHHS_MANNI NG%20and%20BELL_Redacted.pdf.

(b) that Consumer Affairs Victoria consider what regulatory approaches could be made to reduce the accessibility of helium as a means of suicide.

19. Simon Cohen, Deputy Secretary of the Department of Justice and Community Safety, responded to the second recommendation.14 Mr Cohen discussed a number of options including a Victorian ban on the supply of pressurised helium cannisters, mandatory modifications, mandatory warning labels, and the establishment of a licensing scheme.

Mr Cohen concluded that only mandatory modifications would address misuse through inhalation. Given Victoria had limited powers to legislate in this field, Mr Cohen indicated the department would continue to work with the ACCC and health agencies to support holistic and national consideration of the issues involved and provide appropriate support. Mr Cohen also identified that a national approach may be needed to leverage voluntary changes in the industry.

20. In the background of these two findings and other previous similar coronial findings, the ACCC15 were consulting the bottled gas industry and retailers about possible amendments to valve and nozzles for helium cannisters that were available to the public, which would make it more difficult to remove gas from the cannister. In September 2019, the ACCC wrote to the court in regard to three finalised coronial investigations and six open investigations.16 The three finalised investigations, including the two findings noted above, all recommended that the ACCC take some action to prevent inhalation as a suicide means. The ACCC advised that to date regulators had been unable to identify successful approaches to address helium inhalation issues. Proposed design modifications to cylinders or control vales were considered but it was ultimately determined that these modifications could be overcome by persons insistent on inhaling the gas. There were also issues regarding the performance and safety of diluting helium.

21. In conclusion, the ACCC noted there were a number of multi-faceted and complex issues involved in the area and had reservations as to whether its powers and ability could deliver 14 Mr Cohen’s response is available at: https://coronerscourt.vic.gov.au/sites/default/files/202002/2017%205077%20Response%20to%20recommendations%20from%20Department%20of%20Justice%20and%20Co mmunity%20Safety_MRL_Redacted.pdf.

15 The ACCC had also previously made an unsuccessful submission to the Advisory Committee on Chemicals Scheduling to include helium in the Standard for the Uniform Scheduling of Medicines and Poisons (Poisons Standard).

16 The ACCC’s response is available at: https://coronerscourt.vic.gov.au/sites/default/files/201911/2017%202906%2C%202017%205077%20Response%20to%20recommendation%20from%20ACCC_BELL_MrL_ Redacted_0.pdf.

the preventive and effective measures sought. The ACCC intended to conduct further nonpublic consultation with international regulators and the gas industry.

22. I note that the ACCC has also recently informed the Court that the ACCC funded research by the Australian National University (ANU) School of Physics, which found that balloon performance characteristics were undiminished if helium was diluted with 21% oxygen.17

23. I note that the Commonwealth Department of Health also provided a response to the finding regarding the death of Mr L.18 Caroline Edwards, Acting Secretary, informed the court that a watching brief was being maintained on the matter of whether helium is appropriately included in the Poisons Standard with a view to revisit the decision not to include it if new evidence of possible harm is presented. For this reason, I will direct a copy of this finding be sent to Dr Brendan Murphy, Secretary.

Conclusion

24. Given the difficulties faced in restricting the sale of helium to the public and the apparent futility in modifying cannister/valve design, further coronial recommendations in this area would appear to be fruitless. This is a disappointing conclusion given the data supports the number of suicides attributed to helium inhalation will continue to rise.

25. However, I urge the ACCC to proceed in its ongoing prevention work with as much haste as possible, to address this significant product safety issue that has played a role in the loss of lives. I will direct a copy of this finding be sent to the ACCC for this purpose.

26. The way forward therefore appears to be a focus on suicide prevention. I have already outlined above the initiatives that are planned to target the international student cohort.

27. I note that Victoria has also released the ‘Victorian suicide prevention framework 2016-2025’, which aims to halve the suicide rate over the next 10 years. This initiative includes expanding the Hospital Outreach Post-suicidal Engagement (HOPE), which will provide enhanced support and assertive outreach for people leaving an emergency department or medical ward following treatment for an attempted suicide, serious planning or intent, amongst others.19 17 Letter from Neville Matthew, General Manager of the Consumer Product Safety Branch, dated 9 June 2021.

18 Unpublished.

19 Department of Health, Suicide prevention in Victoria, https://www.health.vic.gov.au/prevention-andpromotion/suicide-prevention-in-victoria.

28. I note that the Royal Commission into Victoria’s Mental Health System also made a number of recommendations focussed on mental health education (including anti-stigma and antidiscrimination), community support, and suicide prevention. As noted above, this included the establishment of the Suicide Prevention and Response Office, which will produce a new suicide prevention and response strategy for Victoria.20 I look forward to the implementation of these initiatives.

I convey my sincere condolences to Mr Patel’s family for their loss.

Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I direct that a copy of this finding be provided to the following: Chanchalben & Dayalal Jivrajbhai Patel, senior next of kin Professor Euan Wallace, Secretary, Victorian Department of Health Mr Tim Grimwade, Executive General Manager, Consumer Product Safety Australian Competition and Consumer Commission Dr Brendan Murphy, Secretary, Commonwealth Department of Health Leading Senior Constable James Pearson, Victoria Police, Coroner’s Investigator Signature: ___________________________________ Caitlin English, Deputy State Coroner Date: 17 January 2022 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.

20 Department of Health, Mental health reform, Recommendation 26: Governance arrangements for suicide prevention and response efforts, https://www.mhrv.vic.gov.au/recommendation-26-governance-arrangements-suicide-preventionand-response-efforts.