Deceased
RT
Demographics
66y, male
Coroner
Coroner Ingrid Giles
Date of death
2023-09-17
Finding date
2025-03-18
Cause of death
Complications of excess alcohol intake in a man with heart disease
AI-generated summary
A 66-year-old man died from complications of excess alcohol intake in the setting of underlying heart disease. He had a 40+ year history of heavy daily alcohol consumption (12+ cans of beer plus whiskey daily), chronic pain from previous bowel surgery and hernia, and undiagnosed mild heart disease. Post-mortem toxicology showed ethanol 0.16 g/100mL and evidence of alcoholic ketoacidosis (elevated beta-hydroxybutyrate). He was on melatonin, indomethacin, mirtazapine and tramadol for pain, anxiety and depression. The coroner identified no specific clinical errors but used this case to highlight systemic gaps in Victoria's alcohol harm reduction strategy, noting a 20-year gap since the last coordinated action plan despite consistent evidence on what interventions reduce alcohol-related deaths.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
IN THE CORONERS COURT COR 2023 005203 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Ingrid Giles Deceased: Mr RT1 Date of birth: 1956 Date of death: 17 or 18 September 2023 Cause of death: 1a: COMPLICATIONS OF EXCESS ALCOHOL
INTAKE IN A MAN WITH HEART DISEASE Place of death: Dalyston Victoria 3992 Keywords: Alcohol toxicity, chronic alcoholism, ethanol, heavy alcohol consumption, alcohol harm reduction 1 This Finding has been de-identified by order of Coroner Ingrid Giles which includes an order to replace the name of the deceased, and the names of other persons related to or associated with the deceased, with a pseudonym of a randomly generated letter sequence for the purposes of publication.
Background
Mr RT was raised in Dandenong alongside his two older brothers. Throughout his life, Mr RT fathered seven children including a set of triplets who, sadly, passed away shortly after their birth.
In the 1980s, Mr RT met Ms MT whom he went on to marry. Throughout their relationship, Ms MT observed Mr RT’s alcohol consumption, including that ‘he drank every day, starting in the morning until he went to bed at night’.
Over the years, Mr RT’s alcohol consumption increased. During the 1980s and 1990s, he drank approximately 12 cans of beer daily. Eventually, Ms MT recalled he ‘would drink his 12 or so cans of beer and then drink his bottle of whiskey’. He would also attend the local public house (pub) to drink and meet friends.
Around 1997 or 1998, Mr RT and Ms MT separated, though they remained good friends and spoke daily.
Additionally, Mr RT smoked marijuana on a daily basis. According to Ms MT, he ‘gave [it] up for a short while’ but had re-commenced in the 12 months leading up to his death.
There is no evidence that Mr RT attended counselling or other rehabilitation programs to assist him in relation to his alcohol consumption.
Medical History
In 2013, Mr RT underwent a Hartmann’s procedure (a proctosigmoidectomy) to remove part of his colon due to a perforated bowel. He used a stoma bag since, and evidence indicates he encountered issues with the same. Around September 2022, Mr RT was referred to the Stomal Therapy service of Bass Coast Health, however Medicare records suggest he did not action this referral.
Mr RT experienced chronic pain for several years prior to his death. He described to Ms MT that he ‘had a hernia and a bowel condition’ which caused him ‘lots of pain’. Mr RT’s pain
escalated in the few years prior to his death; Ms MT recalled that he ‘didn’t get out much in the last 5 or so years [because] he couldn’t walk a whole lot’. Ms MT attributed Mr RT’s alcohol consumption to his need to cope with his pain.
Mr RT sporadically visited various general medical practitioners (GP) in his area. In May 2023, Mr RT visited a GP and requested a renewed prescription for melatonin to alleviate symptoms associated with insomnia. During this consultation, Mr RT explained that he saw other GPs and queried ‘a possible diagnosis of bowel cancer’ and was referred for a computedtomography (CT) scan.
Evidence indicates that Mr RT experienced mental ill health and had diagnoses including anxiety and depression. At the time of his death, Mr RT was prescribed melatonin, indomethacin, mirtazapine and tramadol.
Mr RT’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.
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.
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.
Victoria Police assigned an officer to be the Coronial Investigator for the investigation of Mr RT’s death. The Coronial 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.
This finding draws on the totality of the coronial investigation into the death of Mr RT 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.2
In the lead up to Mr RT’s death, his son, Mr PT, had been living with him.
On 16 September 2023, Mr RT travelled to Ms MT’s house and ‘had a drink’. He told Ms MT that he was in pain and Ms MT recalled there was ‘nothing out of the ordinary (. . . ). It’s normal for him to tell me he wasn’t feeling well all the time’. The following day, on 17 September 2023, at approximately 10:30pm, Mr RT and Ms MT spoke on the phone, and he sounded ‘chirpy’.
The same day, Mr PT spent the night at Ms MT’s house and was ‘on [her] couch until about 1am’ on 18 September 2023, when he left to return to Mr RT’s house. At approximately 2am, Mr PT returned home. Upon entering the living room, Mr PT located Mr RT unresponsive on the couch and contacted emergency services. By approximately 3:13am, Ambulance Victoria and Victoria Police arrived at the scene.
At 3:20am, paramedics declared Mr RT deceased.
At the scene, Victoria Police members did not locate any suspicious circumstances.
Burke considered the Victoria Police Report of Death for the Coroner (Form 83) and postmortem CT scan and provided a written report of his findings dated 16 November 2023.
The post-mortem examination revealed mild cardiomegaly (enlargement of the heart), mild coronary artery disease and interstitial and perivascular fibrosis, however, there were no acute changes identified. The post-mortem CT also demonstrated mild enlargement of the heart and sight hyperinflation of the lungs. There was also coronary artery calcification observed.
Toxicological analysis of post-mortem samples identified the presence of the following drugs: Ethanol (alcohol) 0.16 g/100mL Amisulpride ~ 0.3 mg/L Clozapine ~ 0.2 mg/L
Post-mortem toxicology also identified the presence of beta-hydroxybutyrate at a concentration of 1.8 mmol/L – noting that the normal range is 0-0.61 mmol/L. Dr Burke commented that beta-hydroxybutyrate is produced during the metabolism of fatty acids, in the absence of adequate carbohydrates – which is known as alcoholic ketoacidosis. Alcoholic ketoacidosis is associated with a raised heart rate and respiratory rate, dehydration and abdominal pain. In severe cases, the condition may cause death.
Dr Burke provided an opinion that the medical cause of death was 1(a) complications of excess alcohol intake in a man with heart disease.
Accessible at: https://www.coronerscourt.vic.gov.au/sites/default/files/202502/COR%202023%20005162%20Form%2038%20-%20Finding%20into%20Death%20without%20Inquest.pdf.
proportion of all alcohol-related deaths, as most deaths resulting from chronic alcohol use are not reportable under the Coroners Act 2008 (Vic), given they are largely classified as deaths that are due to ‘natural causes’ and therefore, unless they are also ‘unexpected’, will not usually be reported to the coroner.
More broadly, alcohol is a factor in a myriad of deaths in the absence of the complications of chronic consumption. Such circumstances include homicides where alcohol use was implicated; suicides of people who had a history of alcohol use and/or who were alcohol affected; fatal motor vehicle collisions where a driver or other involved person was affected by alcohol; drownings of people intoxicated by alcohol; and many others.
To explore what might be done to address the deadly toll of alcohol in the Victorian community, I commenced an analysis of certain of the deaths I am currently investigating in which the person, prior to death, had been engaged in alcohol use for an extended period, and the death was the direct result of alcohol consumption. My hope was that, through examining the circumstances of deaths falling into this broad category, I might be able to identify some commonalities pointing to potential areas for intervention to reduce alcohol-related harms.
However, from review of the material I was unable to identify any meaningful commonalities.
The alcohol-related deaths under my investigation were of people who had diverse sociodemographic profiles, patterns of alcohol use, mental health histories, and histories of engagement in treatment for alcohol related harms. They died in diverse circumstances linked to their alcohol use, reflecting the diverse ways tin which alcohol can cause harms across the Victorian community.
The unit may review the medical care and treatment in cases referred by the coroner, as well as assist with research related to public health and safety including by providing data and statistics into the prevalence of certain deaths.
i. The Parliament of Victoria Drugs and Crime Prevention Committee’s Inquiry into Strategies to Reduce Harmful Alcohol Consumption (Inquiry), which delivered its final report in March 2006 after two years of consultation and work;5 ii. The Victorian Government’s Alcohol Action Plan 2008-2013, which was published in May 2008 by the Victorian Department of Health and described specific actions to be taken as well as a broader framework for change to address alcohol misuse in Victoria;6 iii. The Victorian Auditor-General’s Office report “Effectiveness of Justice Strategies in Preventing and Reducing Alcohol-Related Harm”, published in June 2012, which examined the roles of Victoria Police, the Department of Justice and the Victorian Commission for Gambling and Liquor Regulation in preventing and reducing alcoholrelated harm in Victoria;7 iv. The VicHealth Alcohol Strategy 2019-2023, which was published in August 2019;8 and v. The Australian Government Department of Health and Aged Care’s National Alcohol Strategy 2019-2028, published in December 2019, which was intended to guide state and territory governments as well as communities and health service providers in their responses to alcohol-related harms. This succeeded the National Alcohol Strategy 20062011 (there was no strategy in place during the intervening period 2012-2018).9
Accessible at: Reports - Inquiry into strategies to reduce harmful alcohol consumption - Parliament of Victoria.
6 Ministerial Taskforce on Alcohol and Public Safety, Restoring the balance: Victoria's Alcohol Action Plan 2008-2013, published May 2008. Accessible at: Victoria's Alcohol Action Plan 2008-2013 - May 2008.
7 Victorian Auditor-General’s Office, Effectiveness of Justice Strategies in Preventing and Reducing Alcohol-Related Harm, tabled on 20 June 2012. Accessible at: Effectiveness of Justice Strategies in Preventing and Reducing AlcoholRelated Harm | Victorian Auditor-General's Office.
8 VicHealth, Alcohol Strategy 2019-2023, published 5 August 2019. Accessible at: VicHealth Alcohol Strategy 2019– 2023 | VicHealth.
9 Australian Government Department of Health, National Alcohol Strategy 2019-2028, Canberra: Department of Health published December 2019. Accessible at: National Alcohol Strategy 2019–2028 | Australian Government Department of Health and Aged Care.
10 See in this regard Inquiry into the health impacts of alcohol and other drugs in Australia – Parliament of Australia.
11 Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions.
submissions to this Inquiry; I selected the Alcohol Change Australia submission for review because: (i) it specifically addresses alcohol-related harms; and (ii) the member organisations of Alcohol Change Australia include a number of highly respected public health bodies.
ii. Taxation: Different types of alcohol products are taxed differently at present in Australia, and some taxation arrangements contribute to harmful alcohol use. Changes to how alcohol is taxed may reduce harms.12 iii. Regulation: The way that alcohol is made available (through sale and service) to the Victorian community is subject to regulatory controls. There are a number of areas (including but not limited to density of venues where alcohol is served or sold, times when alcohol is available, ways alcohol can be purchased, enforcement of regulations relating to alcohol service and sale, training requirements for those who serve or sell alcohol, and permitted types of alcohol promotions) where changes to regulation may reduce harms associated with alcohol use.
iv. Healthcare: It is critical to ensure that appropriate treatment is available in a timely manner to persons experiencing alcohol dependence or other alcohol-related health problems, and/or who are seeking assistance to reduce or cease alcohol use. This includes early intervention programs to support persons who may be at risk of harmful alcohol use.
12 For completeness, some alcohols (such as beer and spirits) are taxed proportionately to their alcohol content while other alcohols (such as wines) are taxed based on their price. As such, cheaper wine products are taxed less than premium wines, despite that their alcohol concentrations may be the same. Submissions of Alcohol Change Australia identify that ‘high-volume, high-alcohol wine (such as cask wine) is often being sold at low prices’ (see Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions at page 7).
v. Advertising: There are links between advertising and other alcohol promotion (for example via sponsorships) and harmful alcohol use. Advertising restrictions may be a potent harm reduction initiative, particularly if they result in a reduction in young people’s exposure to alcohol product advertising. 13 vi. Product labelling: Alcohol drink containers present opportunities to communicate information about alcohol use and its health impacts.14 vii. Education for young Victorians: There is a strong imperative to ensure that in schools and other contexts, young people are provided appropriate and effective education in responsible alcohol use and alcohol-related harms.15 viii. Community education: The negative impacts of alcohol use in the Victorian community may be addressed by taking action to increase general awareness about individual, family and community harms associated with alcohol consumption, and how to prevent or reduce them.16 ix. Social attitudes towards alcohol: Certain social attitudes support harmful alcohol consumption, such as the expectation that alcohol is consumed on social occasions and at celebratory events, and tolerance of high consumption levels. If these social attitudes can be changed, harmful alcohol use can be reduced.
14 See in this regard Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions page 7-8.
15 See in this regard Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions page 6. The need for education for young Victorians is also reflected in the recent finding of Coroner Catherine Fitzgerald in relation to the death of a 16year-old boy from complications of acute alcohol intoxication – see in this regard the Finding into death without Inquest of LG, 12 December 2024. Accessible at: https://www.coronerscourt.vic.gov.au/sites/default/files/New Deidentified COR%202022%20007423%20Form%2038%20-20Finding%20into%20Death%20without%20Inquest.pdf 16 See in this regard Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions page 7-9.
‘There is now general agreement in both the national and international literature as to what is the most effective range of responses available to policymakers to address alcohol-related harms.’17
This was echoed in the 2024 Alcohol Change Australia submissions to the Inquiry that: ‘We know what works and it is time to implement a systematic, coordinated and evidence-based approach to reduce harm from alcohol in Australia.’18
This 2024 call to action, nearly two decades on from the Drugs and Crime Prevention Committee’s final report, led me to examine how the Victorian Government is currently coordinating its efforts to reduce alcohol related harms.
In particular, I noted that after the Victorian Government’s Alcohol Action Plan 2008-2013 expired, there did not appear to be any follow-up action plan to build on what was trialled, implemented and achieved. This was to my mind unfortunate, given that effecting change in such diverse domains as social attitudes, community education and regulation requires sustained effort. The Drugs and Crime Prevention Committee observed in 2006 that: ‘In an area as complex as alcohol and other drug policy it is neither possible nor desirable to achieve sustainable and long term change overnight. Incremental or gradual change is not only the most feasible way of moving forward but also the most desirable. As well, it is an approach that recognises community attitudes and the reality of the political and bureaucratic environments in which policy change occurs.’19
Perhaps efforts to renew the Victorian Alcohol Action Plan were redirected towards the development of the National Alcohol Strategy 2019-2028, which was endorsed by State and Territory governments. However, if this is the case, it raises a further question about what Victoria has done under the auspices of the National Alcohol Strategy 2019-2028, noting the Strategy emphasises the central role of States and Territories in implementation: 17 Parliament of Victoria Drugs and Crime Prevention Committee, Inquiry into Strategies to Reduce Harmful Alcohol Consumption: Final Report, Volume 1. Accessible at: Reports - Inquiry into strategies to reduce harmful alcohol consumption - Parliament of Victoria, page xi.
18 Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions page 2.
19 Parliament of Victoria Drugs and Crime Prevention Committee, Inquiry into Strategies to Reduce Harmful Alcohol Consumption: Final Report, Volume 1. Accessible at: Reports - Inquiry into strategies to reduce harmful alcohol consumption - Parliament of Victoria, page xiii.
‘Jurisdictional implementation allows for governments to take action relevant to their jurisdiction with a national harm minimisation approach and strategies should reflect local circumstances and address emerging issues and drug types. It is expected that jurisdictions will prioritise actions that are evidence-informed and demonstrated to have the greatest impact on preventing and reducing alcohol-related harms.’20
Further to this point, my attention was directed to an April 2024 report in which Alcohol Change Australia documented a ‘lack of public monitoring or reporting’22 relating to the Strategy, and conducted their own analysis of the Strategy to establish that: ‘There has been minimal or no change in alcohol use and harms across a range of indicators since the Strategy was introduced in 2019.’23
However, this situation clearly highlights the need for Victoria to lead its own program of work (whether described as a ‘strategy’, an ‘action plan’ or otherwise) to address alcoholrelated harms in the community. This program of work should describe what specific actions are undertaken, the timeframes within which they should be implemented, who is responsible for them, and how they will be evaluated for effectiveness. It should also incorporate public reporting on implementation and evaluation of these actions to address alcohol-related harms.
I expect that identifying and prioritising actions to be undertaken within the program of work will be straightforward; as already discussed, there is longstanding consensus on what needs to be done.
21 Ibid at page 32.
22 Alcohol Change Australia, A Mid-Point Review of the National Alcohol Strategy 2019-2028: How is Australia tracking on reducing alcohol use and harms? Published April 2024 and accessible at Alcohol-Change-Australia-report-A-midpoint-review-of-the-National-Alcohol-Strategy-April24.pdf page 2.
23 Ibid.
commenced, including stakeholder consultations to inform strategy development.24 This could potentially be the vehicle for developing the program of work described above, however, as the scope and outcomes of the strategy have not yet been formalised, I cannot confirm whether this is the case. Therefore, a pertinent comment will be made in this respect.
Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Mr RT (whose full legal name is known to the Court), born 1956; b) the death occurred on 17 or 18 September 2023 at Dalyston Victoria 3992, from 1(a) complications of excess alcohol intake in a man with heart disease; and c) the death occurred in the circumstances described above.
Having considered all of the circumstances, I find that Mr RT’s death occurred in the context of an extended history of excessive alcohol consumption and on the background of heart disease, of which he was unaware. I also note that Mr RT experienced chronic pain for several years, which intensified in the years leading up to his death, and that he managed the same, in part, through self-medication with alcohol.
While there is evidence that Mr RT experienced mental ill health, there is no indication that he consumed alcohol in the lead up to his death with the explicit intention to take his own life.
Having made comments about the prevalence of alcohol-related harm in the Victorian community, I consider that the circumstances of Mr RT’s death bring into focus a range of prevention opportunities in this sector.
24 Victorian Government Department of Health, ‘Alcohol and Other Drug Strategy: What we heard overview’, November
COMMENT Pursuant to section 67(3) of the Act, I make the following comment:
I note that I recently handed down three recommendations in my Finding without Inquest into the Death of Kathleen Arnold, who died in circumstances of alcohol toxicity.25 The recommendation relevant to the present finding is ‘that the Victorian Government, led by the Victorian Department of Health, develop: (i) a new Alcohol Action Plan; or (ii) a program of work (including specific actions, timeframes, accountabilities, and public reporting on implementation and evaluation) to address alcohol-related harms in Victoria’.
I have noted this recommendation in Mr RT’s finding for the purposes of completeness and to reflect the range of circumstances in which people in this State die, very tragically, from the effects of alcohol, which underpins the need for a range of strategies to address alcoholrelated harm in all its various forms. The Victorian Government and Department of Health may wish to consider and provide comment on Mr RT’s death in the context of their responses to this recommendation, which are due to be received on or around 12 May 2025.
I convey my sincere condolences to Mr RT’s family for their loss.
ORDERS AND DIRECTIONS 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: Ms MT, Senior Next of Kin Secretary of the Victorian Department of Justice and Community Safety Secretary of the Victorian Department of Health Secretary of the Australian Government Department of Health and Aged Care Victorian Alcohol and Drug Association 25 Finding into death without Inquest into the Death of Kathleen Arnold (COR 2023 005162), dated 11 February 2025, COR 2023 5162, Accessible at: https://www.coronerscourt.vic.gov.au/sites/default/files/202502/COR%202023%20005162%20Form%2038%20-%20Finding%20into%20Death%20without%20Inquest.pdf.
Alcohol Change Victoria Alcohol Change Australia FARE Australia Leading Senior Constable Catherine Garnham, Coronial Investigator Signature: Coroner Ingrid Giles Date: 18 March 2025 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 Comi 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 detennination is made, unless the Supreme Comt grants leave to appeal out of time under section 86 of the Act.
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