Finding into death of Jack Elliot Atkinson

IN THE CORONERS COURT COR 2023 006867 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Simon McGregor Deceased: Jack Elliot Atkinson Date of birth: 26 February 1997 Date of death: 11 December 2023 Cause of death: 1a: Drug toxicity (1,4 butanediol, gamma hydroxybutyrate, methylamphetamine, cocaine, bromazolam, flubromazepam, nordiazepam, ketamine) Place of death: 5 Roslyn Street Strathmore Victoria 3041 Keywords: Mixed drug toxicity, novel psychoactive substances

INTRODUCTION

1. On 11 December 2023, Jack Elliot Atkinson was 26 years old when he died at home. At the time of his death, Jack lived at 5 Roslyn Street, Strathmore, Victoria, with his mother, Angela.

2. Jack was an only child and grew up in the Strathmore area. In his school years he had a passion for sport, particularly golf, and played junior football with the local club. When he was around 12 years of age, Jack’s parents separated, and he remained living with his mother. Angela noticed a change in Jack’s demeanour when he was around 14 years old and recalled that he started smoking and doing graffiti and became ‘a bit cheeky’. She also became aware that he was experimenting with marijuana. Jack left high school prior to year 12 and undertook a plumbing pre-apprenticeship, also working casually at a fruit and vegetable grocer in Brunswick.1

3. From around the age of 20, Angela, who is a mental health nurse, noticed a dramatic change in Jack’s moods and behaviour and encouraged him to seek help. Jack ultimately agreed and attended a private rehabilitation facility but was asked to leave in the third week of the fourweek program when diazepam was detected in his system during routine drug screening.2

4. In the period 2017 to 2020, Jack attended his regular general practitioner (GP) clinic and disclosed experiencing anxiety and depression, and cocaine, gambling and GHB addictions.3 The medical records indicate that Jack commenced cocaine use at around 16 years of age.4

5. In May 2022, Jack was admitted to The Hader Clinic, a private rehabilitation facility, and successfully completed a 28-night treatment program aimed at treating alcohol and other drug addictions. Jack engaged well with the program, maintained abstinence from drugs and alcohol, and showed significant progress in increasing self- awareness and developing coping skills to manage his thoughts, emotions, and behaviours.5

6. Shortly after being discharged from the Hader Clinic, Jack went on an overseas holiday that included a visit to Ibiza with a family friend. Angela believed that he resumed illicit drug use during this trip.6 1 Statement of Angela Maher dated 25 July 2024, Coronial Brief.

2 Ibid.

3 Statement of Dr T K Vishakantegowda, Coronial Brief.

4 Records of SIA Medical Clinical, Coronial Brief.

5 Statement of Jakline Barkho, Coronial Brief.

6 Statement of Angela Maher dated 25 July 2024, Coronial Brief.

7. When he returned to Australia, Jack was able to find employment in the construction industry and continued to live at home with his mother, but their relationship deteriorated as a result of his ongoing aggressive moods and behaviours.7

8. Between 2022 and 2023, Jack was prescribed mirtazapine to treat depression8 and Valium in small quantities to treat methylamphetamine and GHP withdrawal. He was last seen by his regular GP, Dr T K Vishakantegowda, on 13 November 2023. At this consultation he disclosed methylamphetamine, GHB and steroid use, and requested Valium to assist with withdrawal symptoms. An ECG revealed sinus tachycardia (120 beats/min) and he was prescribed five Valium 10 mg tablets and referred to the Royal Melbourne Hospital for further assessment.9

9. On 17 and 20 November 2023, he consulted with different GPs within the same clinic, and on 20 November 2023 was prescribed ten Valium 5 mg tablets.10

10. In the weeks before his passing, Angela found an ice pipe hidden in a paper towel roll in the kitchen and confronted Jack about it, but he responded that it was ‘a joke, it’s a friend’s’.

Angela recalled that Jack became more and more withdrawn in this period.11

THE CORONIAL INVESTIGATION

11. Jack’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.

12. 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.

13. 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 7 Statement of Angela Maher dated 25 July 2024, Coronial Brief.

8 Angela stated that Jack never took this medication: Statement of Angela Maher dated 25 July 2024, Coronial Brief.

9 Statement of Dr T K Vishakantegowda, Coronial Brief.

10 Ibid.

11 Statement of Angela Maher dated 25 July 2024, Coronial Brief.

comments or recommendations in appropriate cases about any matter connected to the death under investigation.

14. Victoria Police assigned an officer to be the Coronial Investigator for the investigation of Jack’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.

15. This finding draws on the totality of the coronial investigation into the death of Jack Elliot Atkinson 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.12

16. In considering the issues associated with this finding, I have been mindful of Jack’s human rights to dignity and wellbeing, as espoused in the Charter of Human Rights and Responsibilities Act 2006, in particular sections 8, 9 and 10.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

17. On 10 December 2023, Angela attended her street Christmas party in the afternoon. She returned home and went to bed at approximately 6:30-7:00 pm. Before going to bed, she messaged Jack to tell him she was going to bed and did not receive a reply.

18. At about 3:00 am on 11 December 2023, Angela awoke to find that the house was uncomfortably warm and the heater still on. She went to the hallway to turn the heater off and found Jack face-down and unresponsive on the lounge room floor. Angela immediately called Jack’s father, John, who lived across the street. John came straight over and called 000, commencing CPR on instruction from 000 call-taker.

19. Ambulance Victoria and police members arrived a short time later and confirmed that there were no signs of life, and Jack was formally pronounced deceased at 3:30 am.13 12 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.

13 Ambulance Victoria Verification of Death Form.

Identity of the deceased

20. On 11 December 2023, Jack Elliot Atkinson, born 26 February 1997, was visually identified by his father, John Atkinson.

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

Medical cause of death

22. Specialist Forensic Pathologist Dr Hans de Boer from the Victorian Institute of Forensic Medicine conducted a partial autopsy on 13 December 2023 and provided a written report of his findings dated 2 April 2024.

23. The internal examination of the heart and lungs revealed mild coronary artery disease, but no substantial underlying natural disease.

24. A post-mortem computed tomography (CT) scan showed no relevant findings in addition to the results of external and internal examination. There was no intracranial haemorrhage or other evidence of intracranial pathology.

25. Dr de Boer found no evidence of violence or injury contributing to death.

26. Toxicological analysis of post-mortem blood samples identified the presence of: a) Gamma hydroxybutyrate (~240 mg/L) and 1,4 butanediol; b) Methylamphetamine (~0.3 mg/L) and cocaine (~0.01 mg/L), plus metabolites; c) Bromazolam, desalkylgidazepam and flubromazepam; d) Nordiazepam (~0.04 mg/L); e) Tadalafil;14 and f) Ketamine.

27. Dr de Boer explained that the level of gamma hydroxybutyrate (GHB) in the blood was high, most likely due to ingestion of the precursor 1,4 butanediol. GHB is a structural analogue of the neurotransmitter gamma-aminobutyric acid (GABA), which can have sedative, hypnotic 14 A medication used to treat erectile dysfunction and pulmonary arterial hypertension. Tadalafil may be misused recreationally, commonly in combination with party drugs such as MDMA, GHB, ketamine, and amyl nitrite (poppers).

(sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant and muscle relaxant properties. The effects of GHB are highly dependent on habituation, but GHB toxicity is well-reported and may lead to coma, hypotension, respiratory depression and seizures.

28. Methylamphetamine and cocaine are both common illicit drugs, used for their potent stimulant properties. Both are associated with sudden death, and for cocaine these fatal side-effects are not necessarily dose dependent.

29. Bromazolam and flubromazepam are novel benzodiazepines, also classified as so-called ‘novel psychoactive substances’ (NPSs). Desalkylgidazepam may be an artifact of the bromazolam. NPSs, or ‘designer drugs’, are structural or functional analogues of controlled substances, designed to mimic their effects. They have no established therapeutic use, and information about their pharmacological mechanism, effects and toxicity is very limited.

Many deaths have been linked to the consumption of NPSs but the exact pharmacological mechanism by which these substances lead to adverse effects is not well defined.

30. Nordiazepam is a well-known anxiolytic agent and has sedative effects. The level of nordiazepam found in Jack’s blood was low, but its effects may have contributed to the sedative effects of other drugs.

31. Ketamine is a registered anaesthetic agent but is often abused for its sedative, hallucinogenic and dissociative effects.

32. Dr de Boer noted that the simultaneous use of multiple drugs may cause unpredictable toxic effects, especially those with antagonistic effects such sedative and stimulant drugs, and concluded that the combination of the drugs detected could cause death in absence of contributing factors.

33. On the basis of his findings, Dr de Boer provided an opinion that the medical cause of death was 1(a) drug toxicity (1,4 butanediol, gamma hydroxybutyrate, methylamphetamine, cocaine, bromazolam, flubromazepam, nordiazepam, ketamine).

34. I accept Dr de Boer’s opinion.

FINDINGS AND CONCLUSION

35. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: g) the identity of the deceased was Jack Elliot Atkinson, born 26 February 1997;

h) the death occurred on 11 December 2023 at 5 Roslyn Street, Strathmore, Victoria, 3041, from 1(a) drug toxicity (1,4 butanediol, gamma hydroxybutyrate, methylamphetamine, cocaine, bromazolam, flubromazepam, nordiazepam, ketamine); and i) the death occurred in the circumstances described above.

36. Having considered all of the circumstances, I am satisfied that Jack’s death was the unintended consequence of the deliberate ingestion of drugs.

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

37. My investigation into Jack’s sad and untimely death highlights the risks of using illicit drugs, particularly those purchased from unregulated markets, where the actual content and makeup of the drug is unknown. Drugs obtained from unregulated markets may not be what the user expects: they may be more potent, or adulterated, or even completely different to what was represented by the seller. Where this occurs, the potential for harms including overdose and death is increased.

38. The appearance of novel psychoactive substances (NPSs) (such as the bromazolam and flubromazepam found in Jack’s system) in unregulated markets has substantially increased these risks, because NPSs are often substituted for other drugs and represented as being other drugs. The rapid evolution of NPSs means that suppliers may not even know what they are offering in the market, and the highly variable effects between NPSs with respect to onset of action, potency, interactions with other drugs and other effects on the body mean that developing informed safe use practices is extremely difficult.

39. I share the concerns of other coroners of this Court15 that the number of Victorian overdose deaths involving NPS benzodiazepines has risen quite suddenly in recent years, and that this increase may be indicative of an emerging trend, rather than a transitory feature of drug-related harms. For this reason, I have distributed this Finding for information to the Victorian Department of Health, with a view to assisting the Department in understanding and responding to the risks presented by NPSs in Victoria.

15 See Coroner Jamieson, A (27 September 2023) Finding into death without inquest of Ryan Chisholm (COR 2020 006085); Coroner Jamieson, A (12 February 2024) Finding into death without inquest of Zoha Khan (COR 2021 004464).

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

I direct that a copy of this finding be provided to the following: Angela Maher, Senior Next of Kin John Atkinson, Senior Next of Kin Professor Euan Wallace, Secretary to the Department of Health Detective Leading Senior Constable Mark Vetter, Coronial Investigator Signature: ___________________________________ Coroner Simon McGregor Date: 01 April 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 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.