Deceased
Helen Barbara Minett
Demographics
55y, female
Coroner
- Coroner Linton
Date of death
2009-09-28
Finding date
2014-05-15
Cause of death
Multiple drug toxicity in a woman with coronary artery atherosclerosis
AI-generated summary
A 55-year-old woman with complex medical history including chronic pain, previous multiple abdominal surgeries, gastrointestinal disorders, mental health issues including DID, and suicidal ideation died from multiple drug toxicity following a morphine overdose. She ingested approximately 800mg of morphine mixture on the morning of 28 September 2009. Her GP, Dr Felicity Wild, attended the home and found her sedated with respiratory rate of barely 5 breaths/minute and signs of morphine toxicity. Dr Wild made a fatal error in judgment by not calling an ambulance, based on the erroneous belief that the patient's prior abdominal surgeries prevented adequate drug absorption and that she could not die from overdose despite previous survival from smaller overdoses. Expert evidence confirmed the patient would almost certainly have survived with appropriate emergency management including naloxone administration. The case highlights dangers of blurred professional boundaries affecting clinical judgment in high-risk patients.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Coroners Act 1996 [Section 26(1)] Western Australia
RECORD OF INVESTIGATION OF DEATH Ref No: 12/14 I, Sarah Helen Linton, Coroner, having investigated the death of Helen Barbara MINETT with an inquest held at the Perth Coroner’s Court, Court 51, CLC Building, 501 Hay Street, Perth on 24-27 March 2014, find the identity of the deceased person was Helen Barbara Minett and that death occurred on 28 September 2009 at 142 Apsley Road, Willetton as a result of multiple drug toxicity in a woman with coronary artery atherosclerosis in the following circumstances: Counsel Appearing: Kate Ellson assisting the Coroner Melanie Naylor (Tottle Partners) appearing on behalf of Dr Wild TTaabbllee ooff CCoonntteennttss Inquest into the death of Helen Barbara MINETT Page 1
Helen Barbara Minett (the deceased) was a 55 year old lady with a complex medical history. She suffered abuse during a traumatic childhood, which had led to many of her health problems.1
The deceased suffered from a large number of medical conditions and had undergone more than one major abdominal surgical procedure.2 She suffered from chronic pain and was receiving regular doses of opioids and other drugs of addiction in the form of morphine, codeine, buprenorphine and diazepam, in an attempt to manage her pain.3
The deceased also had significant mental health issues and had a long history of suicidal ideation. She had first attempted suicide as a teenager in New Zealand,4 and later many times as an adult.5
From August 2004 until her death, the deceased’s general practitioner was Dr Felicity Wild, a member of St Luke’s GP Medical Group. The deceased had a close relationship and very regular contact with Dr Wild during that period.
On the morning of 28 September 2009 the deceased overdosed on a large quantity of oral morphine hydrochloride solution (morphine mixture), while alone at home. The deceased rang a friend after the overdose, which led to Dr Wild being contacted.6 1 Exhibit 1, Tabs 6 and 11.
2 Exhibit 1, Tab 10.
3 Exhibit 2, Tab 29.
4 Exhibit 1, Tab 6.
5 Exhibit 1, Tabs 6 and 10.
6 Exhibit 1, Tab 7.
Inquest into the death of Helen Barbara MINETT Page 2
Dr Wild attended the deceased’s home later that morning. Initially, the deceased was drowsy but ambulatory. She later fell into a heavily sedated sleep with slow respiration. Dr Wild decided to leave the deceased at home and not telephone an ambulance nor take her to hospital herself, as she thought the deceased would recover from the overdose spontaneously based on past history.7 That did not occur.
In the early afternoon the deceased’s husband, Mr Minett, returned home and Dr Wild left the deceased in his care. The deceased was asleep and unresponsive at this time.8
When Mr Minett went to bed at 9.30pm that evening, the deceased was still alive, but heavily sedated. At approximately 12.30am the following morning, Mr Minett awoke and checked the deceased. He found her not breathing and cool to the touch. After telephoning a friend and then Dr Wild, he telephoned an ambulance.9
A post-mortem examination was conducted by forensic pathologist Dr McCreath on 2 October 2009.11 The cause of death was determined by Dr McCreath to be multiple drug toxicity in a woman with coronary artery atherosclerosis.
An inquest was held from 24 to 27 March 2014 in the Perth Coroner’s Court. The primary issues for investigation were whether the deceased ingested the fatal amounts of drugs with the intention of taking her own life, whether the decision of Dr Wild not to request an ambulance was appropriate in the circumstances, and whether her failure caused or contributed to the death of the deceased.
7 Exhibit 1, Tab 10; Exhibit 2, Tab 28.
8 Exhibit 1, Tab 10; Exhibit 2, Tabs 19 and 28.
9 Exhibit 1, Tab 6; Exhibit 2, Tab 19.
10 Exhibit 1, Tab 12.
11 Exhibit 1, Tab 14.
Inquest into the death of Helen Barbara MINETT Page 3
The documentary evidence adduced at the inquest was substantial. It included a police report with various witness statements obtained as part of the investigation, the St John Ambulance patient care record and notes, the deceased’s Fremantle Hospital records, the clinical records from St Luke’s GP Medical Group, the handwritten medical records of Dr Wild and a handwritten diary of the deceased, written in the last year of her life.
Oral testimony was provided by Mr Minett, Sheree Minett, Margaret Bartlett, Joyce Plumb, Sergeant Berens, First Class Constable Holtom, Dr Dunjey, Dr Mansfield, Professor Joyce, Professor Winterton, Wayne Boisson and Dr Wild.
The deceased was born in 1954 in New Zealand and spent her formative years there. As an adult, the deceased disclosed memories of sexual, physical and emotional abuse by family members and others while growing up in New Zealand.12 Those events had a lasting impact upon her, both physically and psychologically, resulting in her first suicide attempt (the first of many) at the age of 16 years.13
The deceased met Clement Minett when she was 16 years old. They became friends first, and later formed a relationship and married in 1982.14 They had two sons together, born in 1983 and 1984.15
After the birth of her sons, the deceased had the first of a number of major surgeries, being a hysterectomy and oophorectomy (against a background history of polycystic ovaries). Further surgeries were performed in New Zealand for a variety of reasons, including a vertical banded gastroplasty in 1991 for obesity.16 12 Exhibit 1, Tabs 6, 11; Exhibit 2, Tab 19.
13 Exhibit 1, Tab 6; Exhibit 2, Tab 19.
14 Exhibit 2, Tab 19.
15 Exhibit 3, Tab 4.
16 Exhibit 2, Tab 17.
Inquest into the death of Helen Barbara MINETT Page 4
As for her mental health, there is no record of the deceased having any psychiatric review while in New Zealand. She was, however, treated for episodes of depression related to stressors of ill health on two occasions.17
In 1996 the Minett family moved to Perth. The move was, in part, designed to provide the deceased with some psychological reassurance that she was safe from her childhood abusers.18
The deceased was by all accounts a fun and caring woman who made friends easily. She apparently settled in well following the move to Western Australia, and took an active interest in the local community. She became a member of the Riverton Baptist Community Church and also joined a related women’s group called Women Interested in Growing and Sharing (WINGS), eventually joining the leadership team of that group.19
The deceased also joined the WA State Marching Team and volunteered as part of a Restorative Justice program that involved visiting prisoners.20
However, it was apparent to those close to her that the deceased’s health continued to deteriorate.21
18 Exhibit 1, Tab 6.
19 Exhibit 1, Tab 7; Exhibit 2, Tab 21.
20 Exhibit 3, Tab 1.
21 Exhibit 1, Tabs 6 and 10.
Inquest into the death of Helen Barbara MINETT Page 5
shares their belief system.22 It would seem the deceased was such a person.
The deceased first attended the St Luke’s GP Medical Group on 1 August 2000, when she saw Dr Lachlan Dunjey.23 The deceased presented with suicidal thoughts triggered by flashbacks and memories of her childhood abuse.24 The deceased raised with Dr Dunjey her fear that she had multiple personality disorder (MPD) or some type of possession.25
What was formerly known as MPD is now known as Dissociative Identity Disorder (DID). According to the DSM – IV Criteria, the essential feature of DID is the presence of two or more distinct identities or personality states that recurrently take control of behaviour, resulting in amnesic periods. The alternative identities frequently have different names and characteristics that contrast with the primary identity. It reflects a failure to integrate various aspects of identity, memory and consciousness. Individuals with DID frequently report having experienced severe physical and sexual abuse, especially during childhood.26 It seems it is a controversial diagnosis, not widely accepted in psychiatric circles, and hence does not fit well within the public mental health system.27
There is a connection between DID and PTSD, as it is usual that a person with DID would have experienced traumatic stress, which has caused the dissociation. As acknowledged by Dr Dunjey, a practitioner who did not believe in DID would be likely to diagnose a patient as suffering from PTSD rather than DID.28
Dr Dunjey diagnosed the deceased with depression and sought to manage her condition with medication. He advised her not to attempt to probe into her memories 22 ts 59 (Dr Dunjey).
23 Exhibit 2, Tab 15; Exhibit 3, Tab 3.
24 Exhibit 2, Tab 15.
25 Exhibit 2, Tab 15; Exhibit 3, Tab 3; ts 61 (Dr Dunjey).
26 Exhibit 9.
27 ts 53 (Dr Mansfield); ts 75 (Dr Dunjey).
28 ts 58 (Dr Dunjey).
Inquest into the death of Helen Barbara MINETT Page 6
until her depression was controlled and she was not suicidal.29
While under Dr Dunjey’s care, the deceased attempted suicide on at least one occasion. On 1 October 2000, the deceased was admitted to Fremantle Hospital after attempting suicide by taking a drug overdose.30 She was referred by the hospital to Bentley Mental Health Service for out-patient management. It seems that the deceased coincidentally was treated by Dr Dunjey’s brother, Dr Malcolm Dunjey, who was a psychiatric medical officer at Bentley Hospital.31 Dr Malcolm Dunjey held the view of many psychiatrists that he did not believe in MPD/DID as a diagnosis, and he told the deceased of his view.32 The deceased was given a working diagnosis of PTSD.33 This encounter apparently reinforced in the deceased’s mind that she would not find assistance with mainstream mental health services in Perth.34 She stopped seeing Bentley Health Service after May 2001.
The deceased continued to explore her belief that she might have MPD/DID, rather than, or in addition to, PTSD. On 23 March 2001 the deceased told Dr Dunjey that she had read a book about MPD and on 2 April 2001 she told Dr Dunjey that she was aware of ‘alters’ or alternative personality states, and had started a ‘map’ depicting these.35 Dr Dunjey did not explore these issues with the deceased.36
In relation to her physical health, Dr Dunjey referred the deceased for various scans and tests in November 2000 relating to fainting episodes or collapses, and she was also referred for vaginal repair, apparently to correct significant incontinence.37 29 Exhibit 2, Tab 15; Exhibit 3, Tab 3; ts 61 – 63, 76 (Dr Dunjey).
30 Exhibit 4, Tab 4; Outpatient Notes; Exhibit 2, Tab 15; ts 62 (Dr Dunjey).
31 Exhibit 1, Tab 7; Exhibit 2, Tab 15.
32 Exhibit 2, Tab 21 [19]; ts 134 - 135 (Plumb, J).
33 Exhibit 1, Tab 11.
34 ts 135 (Plumb, J).
35 Exhibit 2, Tab 15.
36 ts 67 (Dr Dunjey).
37 Exhibit 2, Tab 16.
Inquest into the death of Helen Barbara MINETT Page 7
Accordingly, in August 2001 Dr Dunjey relinquished his care of the deceased to Dr Mansfield.38
Dr Mansfield first met the deceased on 25 August 2001 and she later became her regular patient.39 Dr Mansfield noted that the deceased had three main medical issues while in her care, as well as the ongoing issues with her mental health.
The deceased had gastro-intestinal issues, dating back to a vertical band gastroplasty in the early 1990’s. In 2002 she was vomiting at least once a day due to food getting stuck. A gastroscopy showed only a 1 cm gastric outlet.
Accordingly, she was referred to Mr Leon Cohen, a general surgeon and endoscopist, who performed a Roux-en-y gastric bypass in October 2002 to provide a larger opening from her stomach.40 Following the surgery, the deceased required iron and vitamin supplements and developed chronic constipation.41
She was subsequently required to self-catheterize several times a day, which left her subject to urinary tract infections, requiring repeated courses of antibiotics.42 38 Exhibit 2, Tab 15; ts 67 (Dr Dunjey).
39 Exhibit 2, Tab 16; ts 40 - 41 (Dr Mansfield).
40 Exhibit 2, Tab 16; Exhibit 3, Tab 2.
41 Exhibit 2, Tab 16.
42 Exhibit 2, Tab 16.
Inquest into the death of Helen Barbara MINETT Page 8
The third main medical issue was treatment for suspected cardiovascular disease, based upon her strong family history of heart disease.
As to her mental health, Dr Mansfield considered that the deceased had a very clear diagnosis of DID,43 maintaining that she fit the DSM-IV criteria for DID perfectly.44 She did not, however, refer her for psychiatric treatment for this disorder, as the deceased was reluctant to see anyone else and Dr Mansfield’s previous experience when treating patients with DID was that there were no psychiatrists in Perth who had any acceptable outcomes dealing with this disorder.45 Dr Mansfield did, however, receive advice from one psychiatrist to attempt the use of a beta blocker, Inderal.
She prescribed the beta blocker to the deceased in June 2002.46 Other than that, Dr Mansfield did not consider there was any other treatment available to the deceased for her DID.
Dr Mansfield told the court that in the period she treated the deceased she was not aware of any suicide attempts by the deceased, although she was aware of her suicidal alternative personality, referred to as “Susie”.47 There was, however, an event involving a suspected drug overdose by the deceased on 7 September 2003. On that occasion, Dr Mansfield attended the deceased’s home as the deceased’s friends were concerned that she would not wake. Dr Mansfield monitored her condition until she awoke after three hours, and then left her in the care of friends.48 At that stage, the strongest medication the deceased was prescribed was Panadeine Forte.49
The deceased also reported various assaults during this time, but she did not permit Dr Mansfield to collect evidence of these assaults, nor report them to police.50 43 Exhibit 2, Tab 16.
44 ts 42 (Dr Mansfield).
45 ts 42 (Dr Mansfield).
46 Exhibit 3, Tab 3.
47 ts 43 (Dr Mansfield).
48 Exhibit 2, Tab 16; ts 45 (Dr Mansfield).
49 ts 45 (Dr Mansfield).
50 Exhibit 2, Tab 16.
Inquest into the death of Helen Barbara MINETT Page 9
Dr Wild assumed management of the deceased’s medical care in August 2004.54 Dr Wild accepted the deceased’s diagnosis of DID as valid, although she had little experience with the condition prior to treating the deceased.55
According to the clinical notes, the deceased consulted Dr Wild approximately 106 times at the clinic.56 This figure does not include those occasions on which Dr Wild spoke to the deceased by telephone, or saw her at her home or elsewhere. Most of those occasions were documented in separate medical notes contained in exercise books.57 It is apparent from those notes that from an early stage the deceased was generally in daily contact with Dr Wild, via a telephone call from Dr Wild to the deceased each evening, and this continued until her death.58 Dr Wild described the calls as an informal extension of the therapeutic relationship.59
As Dr Wild described it, her role was primarily as the deceased’s doctor, but she also at times acted in the capacity of her carer, spiritual counsellor and simply as a friend.60 The changing nature of the relationship from simply doctor/patient to more personal involvement is 51 Exhibit 1, Tab 16.
52 ts 44 – 45 (Dr Mansfield).
53 Exhibit 2, Tab 30, Flag 1 [3].
54 Exhibit 1, Tab 10.
55 ts 299 (Dr Wild).
56 Exhibit 1, Tab 10.
57 Exhibit 7B.
58 Exhibit 2, Tab 30, Flag 1 [7]; Exhibit 7B.
59 Exhibit 1, Tab 10.
60 Ts 316 (Dr Wild).
Inquest into the death of Helen Barbara MINETT Page 10
revealed in the content of the notes in the exercise books.61
In the period that Dr Wild managed the deceased’s care, it is apparent that the deceased had a large number of serious medical issues. They included the intermittent chronic urinary retention and constipation noted by Dr Mansfield.62
On 9 January 2006 the deceased underwent surgery for creation of a defunctioning loop ileostomy to help relieve her chronic constipation and associated abdominal pain.
This resulted in the creation of a stoma.63 The surgery appeared to be successful, but the deceased later developed a number of bowel obstructions that required hospitalisation. As a result, she underwent further surgery on 30 October 2006 performed by Mr Cohen, in the form of a total colectomy and proctectomy.64
At the same time the deceased was undergoing the gastrointestinal procedures, she was being treated for pain related injuries by Consultant Rheumatologist, Dr Andrew Taylor. Dr Taylor arranged that Dr Wild was authorised to prescribe buprenorphine patches and morphine mixture to manage the deceased’s pain.65 She was authorised to take 8 mls per day of a 10mg/ml morphine mixture, which equated to a total dose of 80mg per day.66
Despite the procedures performed by Mr Cohen, the deceased was hospitalised at Fremantle Hospital due to a bowel obstruction on 8 July 2008, for which she underwent a laparotomy, requiring to be taken to the theatre twice in the same day due to complications. She was taken to the ICU post operatively and it was thought she suffered a cardiac event while there. She was finally discharged on 18 July 2008.67 She was admitted again 61 Exhibit 7B.
62 Exhibit 1, Tab 10.
63 Exhibit 3, Tab 2.
64 Exhibit 3, Tab 2.
65 Exhibit 3, Tab 3.
66 Exhibit 3, Tab 3.
67 Exhibit 3, Tab 4.
Inquest into the death of Helen Barbara MINETT Page 11
to Fremantle Hospital due to a bowel obstruction on 27 January 2009.68
The deceased also suffered chronic dehydration due to high output from her stoma and was admitted to Fremantle Hospital in March 2009 for that reason.69
On 19 November 2008 the deceased was reviewed at the Fremantle Hospital Pain Medicine Unit by Dr Stephanie Davies. She was prescribed Pregabalin (Lyrica) and her ongoing use of Fentanyl patches and 80 mg per day of morphine mixture was supported, although it was suggested the deceased should consider reducing her opioids by 10% of her daily dose. A change to Norspan patches was also suggested as a future option.70 At the time of her death the deceased was booked to see Dr Davies again at the Pain Medicine Unit in order to obtain another prescription of Pregabalin.71 Her main current pains at that time were located in the left upper quadrant of her abdomen and in her left lower back, radiating into her thigh.72
On 23 January 2009 the deceased saw a Renal Physician, Dr Robyn Kirwan, due to chronic renal impairment.73 The deceased had previously been admitted to hospital with acute renal failure in association with withdrawal from benzodiazepines and opiates.74 Dr Kirwan reviewed the deceased and in May 2009 he referred her to urologist Dr (Jessica) M.A. Yin for review. He was concerned that she was retaining urine again, which might lead to chronic renal failure resulting in her requiring weekly dialysis in hospital.
The deceased also suffered recurrent angina, noted by Dr Wild in her report as one of the deceased’s most 68 Exhibit 3, Tab 4.
69 Exhibit 3, Tab 4.
70 Exhibit 3, Tab 4.
71 Exhibit 3, Tab 3; ts 295 (Dr Wild).
72 Exhibit 3, Tab 3.
73 Exhibit 2, Tab 18; Exhibit 3, Tab 4.
74 Exhibit 2, Tab 18.
Inquest into the death of Helen Barbara MINETT Page 12
significant physical issues in 2009.75 She was taking medicine daily for her heart condition.76
In addition to her physical health issues, the deceased also continued to experience mental health problems while under Dr Wild’s care. Dr Wild noted that the two major aspects of her psychiatric health during this period were her attempts at suicide and suicidal ideation generally, as well as her DID.77 Dr Wild’s clinical notes document the deceased’s struggle with suicidal thoughts from January 2005 until her death. Although the deceased sometimes expressed a contemplation of committing suicide by hanging or some other means, and had self-harmed by cutting herself, it appears that her actual suicide attempts only ever involved overdoses of medication.78
It is apparent that the deceased deliberately overdosed on her prescribed medication many times. Dr Wild’s notes document overdoses on numerous occasions.79 Many of the overdoses involved large quantities of medication, particularly morphine mixture.80 According to Dr Wild, the deceased appeared to experience little effect from the overdoses,81 although it seems that Dr Wild did not attend the deceased on these occasions and her information about them came from reports.82
The most recent suicide attempt, prior to her death, was in May 2009. The deceased was reported to have taken 500 mg of morphine mixture combined with amitriptyline, Panadeine Forte and Norspan (buprenorphine). At that time Dr Wild noted that the deceased was cared for by friends and slept maybe four hours. Afterwards, she told Dr Wild “I’d do anything to kill myself.”83 75 Exhibit 1, Tab 10; ts 291 (Dr Wild).
76 Exhibit 1, Tab 10.
77 Exhibit 1, Tab 10.
78 Exhibit 1, Tab 10; Exhibit 7A.
79 Exhibit 1, Tab 10; Exhibit 7A.
80 Exhibit 1, Tab 10; Exhibit 7A.
81 ts 298 (Dr Wild).
82 ts 298 (Dr Wild).
83 Exhibit 1, Tab 10; Exhibit 7A; Exhibit 7B (Book 38).
Inquest into the death of Helen Barbara MINETT Page 13
The deceased also described feeling suicidal in midAugust 2009, although no suicide attempt was recorded.84
Dr Wild noted that the deceased had been trialled on antidepressant medication when she first consulted Dr Dunjey, but it did not appear to have been particularly beneficial and, indeed, the deceased reported it had made her more suicidal.85 Dr Wild did prescribe the antidepressant Citalopram at one stage, but the deceased refused to continue taking it.86
According to Dr Wild, the deceased’s DID was a significant challenge to the management of her health.87 Although Dr Dunjey had never experienced the deceased in an altered state,88 both Dr Mansfield and Dr Wild reported to have experienced the deceased switching to her ‘alter’ personalities on various occasions.89 Indeed, on the occasion that the deceased declined to continue taking Citalopram, the refusal was apparently given by one of the ‘alter’ personalities.90
Similarly to Dr Mansfield, Dr Wild did not attempt to refer the deceased to a psychiatrist or any mental health services for her DID. This was because Dr Wild understood from the deceased that she was opposed to the idea of referral as it was unlikely another therapist would accept her diagnosis of DID and, on that basis, the deceased did not believe she would benefit from the public mental health system.91 Further, the deceased did not have private health insurance and would, in any event, have also struggled in the private health sphere to find a therapist who could manage her well, given her other medical complications.92 84 Exhibit 1, Tab 10; Exhibit 7A; Exhibit 7B (Book 38).
85 Exhibit 1, Tab 10.
86 Exhibit 1, Tab 10.
87 Exhibit 1, Tab 10.
88 ts 67 (Dr Dunjey).
89 Exhibit 2, Tab 16; ts 43 (Dr Mansfield).
90 Exhibit 1, Tab 10.
91 Exhibit 1, Tab 10; ts 300 (Dr Wild).
92 Exhibit 1, Tab 10; ts 301 (Dr Wild).
Inquest into the death of Helen Barbara MINETT Page 14
Joyce Plumb met the deceased through WINGS. From about 2000 they became very friendly.94 At some stage the deceased began to share her memories of her childhood with Mrs Plumb.95 Mrs Plumb is not a qualified counsellor,96 however, she adopted a role for the deceased as a nonconventional counsellor,97 undertaking what she described as ‘prayer therapy’.98 She was also sometimes involved in assisting with some of the deceased’s physical care99 and attending medical appointments with her.100
Mrs Plumb claimed to have first-hand experience of the deceased’s various alternative personalities.101 In particular, Mrs Plumb had experience with one alternative personality she named Susie, as she was associated with the deceased’s suicidal tendencies.102
Mrs Plumb was aware that the deceased had attempted suicide on a number of occasions and often provided 93 Exhibit 1, Tab 10.
94 Exhibit 2, Tab 21.
95 Exhibit 2, Tab 21.
96 Exhibit 1, Tab 7 [6].
97 Exhibit 1, Tab 7 [6]; Exhibit 2, Tab 21 [18] – [19]; ts 300 (Dr Wild).
98 Exhibit 2, Tab 21 [48] – [51].
99 ts 118 (Plumb, J).
100 ts 120 (Plumb, J).
101 Exhibit 1, Tab 7; Exhibit 2, Tab 21 [14].
102 Exhibit 1, Tab 7 [16]; ts 126 (Plumb, J).
Inquest into the death of Helen Barbara MINETT Page 15
support to her on those occasions.103 She had also experienced occasions when the deceased overdosed on her medicine in an attempt to induce sleep, rather than to take her life.104
Margaret Bartlett met the deceased through the Riverton Baptist Community Church in about 2000.107 From approximately 2005 the deceased moved in with Mrs Bartlett and her family. Mrs Bartlett acted as her fulltime carer, for which she was paid a small allowance.108
As the deceased’s carer, Mrs Bartlett was actively involved in the deceased’s medical care, and generally had control of the deceased’s medication.109
Mrs Bartlett was aware of occasions when the deceased apparently overdosed on her medication. On these occasions, the deceased would sleep it off. Mrs Bartlett believed these overdoses to be accidental.110
However, Mrs Bartlett also experienced what she believed to be the deceased’s alternative personalities, arising from her DID.111 Mrs Bartlett was aware that at least one of those personalities had made comments about self-harming, and she considered it possible that one of the deceased’s alternative personalities might be suicidal.112 103 Exhibit 1, Tab 7 [17]; Exhibit 2, Tab 21; ts 127, 138 (Plumb, J).
104 Exhibit 2, Tab 21 [38].
105 ts 142 (Plumb, J).
106 ts 142 – 144 (Plumb, J).
107 Exhibit 2, Tab 22 [1].
108 Exhibit 2, Tab 22 [10] – [11].
109 Exhibit 2, Tab 22 [46] – [48].
110 Exhibit 2, Tab 22 [42]; ts 149 – 150 (Bartlett, M).
111 Exhibit 2, Tab 22 [24] – [27]; ts 156 (Bartlett, M).
112 Exhibit 2, Tab 22 [55] – [56].
Inquest into the death of Helen Barbara MINETT Page 16
Sheree Minett married the deceased’s husband, Clement Minett in December 2012.117 Prior to that, she was known as Sheree Veron.
Mrs Minett came to know the deceased through WINGS and the Riverton Baptist Church and they became friends.118 Later, Mrs Minett took on a carer role for the deceased. Although Mrs Minett is a qualified carer, her role of caring for the deceased was unpaid and involved generally assisting her but did not include administering her medication.119
Mrs Minett was aware of the deceased having other personalities or alters, but she had not experienced one expressing suicidal ideation and was not aware of any actual suicide attempts by the deceased.120 She had, however, experienced occasions when the deceased had taken more than her normal dose of medication. On those occasions, the deceased would sleep it off.121
Mrs Minett did not give any evidence of an understanding with the deceased not to call an ambulance if she overdosed. She indicated in her statement that if she had ever been concerned about the 113 ts 150 - 151, 154, 155 (Bartlett, M).
114 ts 151 (Bartlett, M).
115 Ts 159 – 160 (Bartlett, M).
116 ts 152 (Bartlett, M).
117 Exhibit 2, Tab 20 [7]; .ts 80 (Minett, S).
118 Exhibit 2, Tab 20 [4] – [7].
119 Exhibit 2, Tab 20 [3]; ts 81 - 84 (Minett, S).
120 Exhibit 2, Tab 20 [41]; ts 90 – 91 (Minett, S).
121 Exhibit 2, Tab 20 [37] – [38]; ts 92 - 93 (Minett, S).
Inquest into the death of Helen Barbara MINETT Page 17
deceased’s breathing she would have called an ambulance.122
As mentioned above, the deceased and Clement Minett were married in 1982 and had two sons together. The relationship was happy initially, but became troubled after they moved to Perth and the deceased’s physical and mental health deteriorated. They had periods of marital separation in the last years of the deceased’s life.123 Mr Minett also continued to work away from home often, which resulted in further periods where they lived separately from each other.124
When Mr Minett was at home and the deceased was living at the marital home, Mr Minett provided the deceased with assistance with her physical care.125 However, as mentioned previously, Mrs Bartlett usually managed the deceased’s medication.126 Mr Minett only rarely handled medication for the deceased.127
As to her mental health issues, Mr Minett had some limited knowledge of her traumatic childhood experiences, but the deceased did not generally discuss these matters with him. She reserved much of her disclosure for Joyce Plumb.128 He had, however, observed the deceased’s alternative personalities at times and accepted her diagnosis of DID.129
In relation to her suicide attempts, it was generally agreed by the witnesses that the deceased sought to conceal them from her husband and this was possible as he was not part of her close support team.130 He was aware that she sometimes took an extra dose of 122 Exhibit 2, Tab 20 [38].
123 ts 10 – 11 (Minett, C).
124 ts 11 (Minett, C).
125 ts 11 - 12 (Minett, C).
126 ts 19 (Minett, C).
127 ts 20, 22 (Minett, C).
128 ts 14 - 15 (Minett, C); ts 140 - 141 (Plumb, J).
129 Exhibit 1, Tab 19 [21] – [22].
130 ts 24 (Minett, C), 120, 141 (Plumb, J), 309, 328 (Dr Wild).
Inquest into the death of Helen Barbara MINETT Page 18
morphine mixture, and when he was aware it had occurred he noted that she appeared to sleep it off.131
In the last month of her life, the deceased’s physical health continued to deteriorate. September 2009 was a particularly bad month health-wise and Dr Wild described the deceased’s state of health at that time as “disastrous”.137
As mentioned earlier, the deceased had been referred to a urologist, Dr Yin. Dr Yin saw the deceased on 7 September 2009 and noted that she would require an anatomical assessment as well as urodynamic studies.138 This did not occur before her death.139 The deceased was reportedly very apprehensive about these investigations as they were invasive and unpleasant140 and also triggered memories of her abuse.141
Dr Kirwan, who had referred the deceased to Dr Yin, had also indicated in the referral (which was seen by the 131 ts 20 – 21, 23 - 24 (Minett, C).
132 ts 12, 26 - 27 (Minett, C).
133 ts 27 (Minett, C).
134 ts 14 (Minett, C).
135 ts 26 (Minett, C).
136 Exhibit 1, Tab 6 [22].
137 ts 301 (Dr Wild).
138 Exhibit 3, Tab 3.
139 Exhibit 3, Tab 3.
140 ts 302 (Dr Wild).
141 Exhibit 1, Tab 10 [40].
Inquest into the death of Helen Barbara MINETT Page 19
deceased)142 that the deceased’s kidney functioning was very poor and she was very likely heading towards requiring dialysis at some point, which would have been extremely difficult for the deceased to manage.143
That was the last time the deceased went to hospital. On discharge, the deceased reported that she was told to consider a pureed or liquid diet and that the bowel obstruction was unfixable.146
The deceased was also experiencing issues with her vision, and was concerned that she would no longer be able to legally drive.147
On a personal level, the deceased was experiencing emotional stress due to the ongoing stresses in relationships with members of her family and support group and coping with the news of the deaths of two family members in New Zealand.148
The deceased last saw Dr Wild in the clinic on 25 September 2009, three days before her death. On that occasion Dr Wild recorded that the deceased had two main current pains, one in her abdomen and one in her left lower back, radiating to her thigh.
142 Exhibit 1, Tab 10 [41].
143 ts 302 (Dr Wild).
144 ts 33 (Minett, C), 86 – 87 (Minett, S), 145 Exhibit 1, Tab 10 [42]; ts 303 (Dr Wild).
146 Exhibit 1, Tab 10 [43].
147 Exhibit 1, Tab 10 [46], ts 303 (Dr Wild).
148 Exhibit 1, Tab 10 [51].
Inquest into the death of Helen Barbara MINETT Page 20
• Pregabalin (Lyrica) – 150 mg/twice daily;
• Norspan 10 patch (Buprenorphine) – applied once weekly;
• Endep (Amitriptylene) - 20 mg at night and 10 mg in the morning;
• Panadeine Forte tablets – 8 x daily; and
• Ordine (morphine mixture) 10mg/ml solution – 5 ml twice daily (which was 2 ml in excess of her authorised total of 8 ml/day)- therefore equating to a total dose of 100mg per day rather than the authorised 80mg per day.
She was also taking 3 to 8 aspirin tablets per day for knee pain.150
The deceased reported that she was never pain free and graded her pain severity at 7 or 8 out of 10 before each morphine dose, reducing to 4 out of 10 after taking the morphine.151
On 26 September 2009 the deceased’s carer, Margaret Bartlett, went interstate for 10 days for family reasons.152 The deceased returned to her family home in Mrs Bartlett’s absence, to be cared for by her husband.
Mrs Bartlett understood that the deceased had a feeling of abandonment, but she also understood it was necessary for Mrs Bartlett to go.153
150 Exhibit 1, Tab 10 [49].
151 Exhibit 1, Tab 10 [49].
152 Exhibit 1, Tab 10 [53]; ts 153 (Bartlett, M).
153 Exhibit 1, Tab 10 [53]; ts 153 (Bartlett, M).
154 Exhibit 1, Tab 10 [55].
Inquest into the death of Helen Barbara MINETT Page 21
Accordingly, the deceased was staying at her home with Mr Minett, although they were sleeping in separate bedrooms.159 Unusually, Mr Minett had been left in charge of the deceased’s medications for the period while Mrs Bartlett was absent.160 This included the deceased’s morphine mixture.161
Despite the fact it was a public holiday, Mr Minett was required to attend an occupational health and safety course relating to his impending work on a mine site, commencing the following day.162
Prior to leaving the house for the course, Mr Minett left a small bottle of morphine mixture containing two doses next to the deceased’s bed. Mr Minett hid the larger bottle of morphine mixture, containing the deceased’s remaining doses of morphine mixture, in an unlocked chest of drawers in his bedroom.
Mr Minett left his home at about 8.00am. As far as he was aware the deceased was asleep in her bedroom when 155 ts 123 – 124 (Plumb, J).
156 ts 36 – 37 (Minett, C).
157 ts 37 (Minett, C).
158 Exhibit 1, Tab 10 [56]; ts 304 (Dr Wild).
159 Exhibit 2, Tab 19 [36].
160 Exhibit 2, Tab 19 [36], Tab 22 [50]; ts 153 (Bartlett, M).
161 Exhibit 2, Tab 19 [36].
162 ts 242 (Minett, C).
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he left the house.163 There was no carer available that day, so the deceased was left alone in the house.164
Sometime that morning the deceased telephoned Mrs Plumb. In her statement to police Mrs Plumb put the time as approximately 11.30am.165 The telephone records show a telephone call of 843 seconds duration was made from the deceased’s home telephone to Mrs Plumb’s home telephone at 9.41am that morning, and a later call of 39 seconds duration was made at 11.06am.166 In oral evidence Mrs Plumb was only able to recall one telephone conversation with the deceased and she appeared to accept that the call she had originally thought was made at 11.30am was most likely the call recorded at 9.41am.167 That is consistent with the time of the later call to Dr Wild, as noted below.
When the deceased called Mrs Plumb that day she announced herself as Susie, which Mrs Plumb knew to be an alternative personality of the deceased that exhibited suicidal tendencies.168 Susie told Mrs Plumb that she thought she had done something really bad and then told Mrs Plumb that she had taken a large dose of the deceased’s medicine,169 being ten times her normal dose of morphine.170 Susie told Mrs Plumb that she had done so as the deceased hadn’t slept for five days and she wanted her to sleep.171 Mrs Plumb had also stated to police that Susie told her she had done so because she wanted to die,172 but she did not recall this in oral evidence.173
Susie said to Mrs Plumb “can you help us”, apparently referring to herself, being Susie, and the deceased.174 Mrs Plumb asked Susie if she wanted her to ring Dr 163 ts 243 (Minett, C).
164 ts 244 - 245 (Minett, C).
165 Exhibit 1, Tab 7 [20].
166 Exhibits 5 and 6.
167 ts 125, 128 (Plumb, J).
168 Exhibit 2, Tab 21 [33].
169 ts 126 – 127 (Plumb, J).
170 Exhibit 1, Tab 7 [25]; ts 128 – 129 (Plumb, J).
171 Exhibit 1, Tab 7 [31]; ts 126 - 127 (Plumb, J).
172 Exhibit 1, Tab 7 [31].
173 ts 127 (Plumb, J).
174 ts 127 (Plumb, J).
Inquest into the death of Helen Barbara MINETT Page 23
Wild, and Susie agreed that she did.175 Accordingly, Mrs Plumb hung up and rang Dr Wild at home, as she was not at work that day.176 Dr Wild recalls receiving the telephone call at around 10.00am.177
Mrs Plumb told Dr Wild about the telephone call from the deceased.178 Dr Wild recalled Mrs Plumb told her that the deceased had said that she had taken an overdose of 80ml (800mg) of morphine mixture.179 Dr Wild immediately rang the deceased and spoke to her, in her alternative personality of Susie.180
Susie confirmed that she had taken her biggest ever overdose of morphine and said it was “a stupid thing to do.”181 She reported feeling nauseated and sleepy.182 Dr Wild confirmed that the deceased was at home alone and advised her that she would come and see her.183
Dr Wild lived some distance from the deceased’s home and did not have a key. Therefore, it took her some time to drive there and locate a key, eventually obtaining one from Mrs Plumb.184 Dr Wild understood that the deceased had heard Dr Wild trying to enter unsuccessfully and had subsequently rung Mrs Plumb to advise her, which would account for the second recorded call from the deceased’s home to Mrs Plumb at 11.06am185 Dr Wild recalls entering the deceased’s house at about 11.00am,186 although based upon that call, it was likely to have been some time after 11.06am.
When Dr Wild arrived, the deceased was still awake but she was very sleepy and her speech was slurred. The deceased told Dr Wild that she had taken 1000 mg of morphine mixture and she expressed concern about Mr 175 Exhibit 1, Tab 7 [32] – [33]; ts 127 - 128 (Plumb, J).
176 Exhibit 1, Tab 7 [34]; Exhibit 2, Tab 21 [34]; ts 128 (Plumb, J).
177 ts 305 (Dr Wild).
178 ts 128 – 129 (Plumb, J).
179 Exhibit 1, Tab 10 [57]; ts 306 (Dr Wild).
180 Exhibit 1, Tab 10 [58]; ts 306 (Dr Wild).
181 Exhibit 1, Tab 10 [58]; ts 306 (Dr Wild).
182 Exhibit 1, Tab 10 [58].
183 Exhibit 1, Tab 10 [58]; ts 306 (Dr Wild).
184 Exhibit 1, Tab 10 [59]; ts 130 (Plumb, J), 306 (Dr Wild).
185 Exhibits 5 & 6.
186 Exhibit 1, Tab 10 [59]; ts 306 (Dr Wild).
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Minett’s reaction if he found out what she had done.187 On the basis of the supply of morphine mixture that Mrs Bartlett had left for the deceased, Dr Wild considered it was unlikely the deceased had ingested any more than 800mg.188
Dr Wild acknowledged that an overdose of this amount was of serious concern189 and in any other patient she would have sent them straight to hospital.190 However, based upon her previous experience of the deceased when she had overdosed on amounts of morphine mixture up to 500mg, Dr Wild had formed the erroneous conclusion that the deceased was incapable of killing herself by an overdose of medication.191 Dr Wild theorised that this was because the deceased did not absorb the medication as an otherwise healthy person would, because of her abdominal surgeries and reliance on a stoma bag, and she was also quite resistant to the sedating effects of any absorbed drug.192 Dr Wild essentially believed that the deceased’s ability to absorb drugs taken orally was impaired, and the bulk of the drugs passed through into the stoma bag.193 Accordingly, Dr Wild mistakenly believed the deceased would simply sleep a bit longer than usual.194
Dr Wild was aware that the deceased was still wearing a Norspan 10 transdermal patch (buprenorphine). She did not remove the patch, despite the fact that it would add to the level of opiates in her system. Dr Wild considered that the patch would be making a trivial contribution to the problem and was not of great significance in the overall picture of the overdose. Further, she was unwilling to remove it as it was intended to last a week and it remained the only analgesia for the deceased if she awoke, given the deceased had drunk her remaining 187 Exhibit 1, Tab 10 [60]; ts 306 (Dr Wild).
188 Exhibit 1, Tab 10 [63] – [64]; ts 306 (Dr Wild).
189 Exhibit 1, Tab 10 [65].
190 ts 307 (Dr Wild).
191 Exhibit 1, Tab 10 [65]; ts 307 (Dr Wild).
192 Exhibit 1, Tab 10 [65]; ts 307 (Dr Wild).
193 Exhibit 2, Tab 8 [4(e) (vii)], [15(e)-(g)]; ts 307 (Dr Wild).
194 ts 307 (Dr Wild).
Inquest into the death of Helen Barbara MINETT Page 25
allocation of morphine mixture for the week.195 Accordingly, Dr Wild chose not to remove the patch.
Dr Wild states that she saw no indication of any pills having been consumed by the deceased as part of her overdose,196 although the later toxicology results indicate to the contrary. It is unclear whether evidence that the deceased had taken pills at the time might have altered the path that Dr Wild ultimately took that day, although it seems unlikely as Dr Wild had previously noted that the deceased struggled to absorb medication in tablet form.197
The deceased was still capable of walking when Dr Wild first arrived. Dr Wild observed the deceased walk to the toilet and empty her stoma bag. Whilst the deceased was sitting on the toilet, she dozed off a few times but was roused by Dr Wild each time. The deceased then walked herself back to bed, lay down on her side and went to sleep.198
Dr Wild did not attempt to rouse her and left her sleeping. In oral evidence, she told the court that at that time she had not realised that it was of any value to deliberately wake up the patient and keep them moving in those circumstances.199 Instead, she thought at the time that it was of some benefit to the deceased that she was sleeping, given her usual problems with insomnia.200
Mr Minett came home from his course, as scheduled, at about 2.30pm.201 The deceased was still asleep.
Dr Wild understood from her conversation with the deceased that the deceased did not want Dr Wild to inform Mr Minett that she had taken an overdose.202 In an attempt to comply with that request, Dr Wild was, by 195 ts 306 – 307 (Dr Wild).
196 Exhibit 1, Tab 10 [65]; Exhibit 2, Tab 28 [15(h)].
197 ts 294 (Dr Wild).
198 ts 306 (Dr Wild).
199ts 308 (Dr Wild).
200 ts 308 – 309 (Dr Wild).
201 Exhibit1, Tab 6 [28]; ts 246 (Minett, C).
202 ts 306 (Dr Wild).
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her own admission, probably “fairly uninformative”203 to Mr Minett. They had only a very brief conversation. Dr Wild did not see any need to tell Mr Minett about the overdose as she was confident that the deceased would sleep it off and then wake up. Although she could not recall the exact words used, Dr Wild thought she had said something like, “[The deceased] is asleep. She’s taken a bit of extra morphine… just keep an eye on her.”204 Mr Minett’s recollection of the conversation accords with Dr Wild’s.205
Dr Wild could not recall whether she told Mr Minett to monitor the deceased’s breathing,206 but Mr Minett gave evidence that Dr Wild told him to keep an eye on the deceased and make sure she was breathing.207
Prior to leaving, Dr Wild had measured the deceased’s breathing rate at “barely 5 per minute” but she noted they were good, big breaths and her colour was normal.208 Although Dr Wild acknowledges that a respiratory rate of 5 breaths per minute is never a good sign, she did not consider it to be particularly unusual for the deceased and it did not give her cause for concern at the time.209 Dr Wild has indicated that she has since come to understand that the kind of breathing the deceased was exhibiting at the time was actually agonal gasps, not good, big breaths, which indicated that it was an emergency situation requiring an ambulance as the deceased was close to death.210
Dr Wild did not give Mr Minett any instructions as to what to do if the deceased’s breathing changed or stopped, or she did not wake up,211 before she left. The deceased was lying on her side already, so there was no 203 ts 309 (Dr Wild).
204 ts 309 (Dr Wild).
205 ts 248 (Minett, C).
206 ts 309 (Dr Wild).
207 ts 249 – 250 (Minett, C).
208 Exhibit 1, Tab 10 [61].
209 Exhibit 2, Tab 28 [16]; ts 307 – 308 (Dr Wild).
210 Exhibit 2, Tab 28 [17] – [21]; ts 308 (Dr Wild).
211 ts 253 (Minett, C), Inquest into the death of Helen Barbara MINETT Page 27
discussion about putting the deceased in the coma or recovery position.212
Dr Wild left the deceased’s house shortly after Mr Minett returned home. Mr Minett then proceeded to check on the deceased at least every 15 minutes whilst he prepared his belongings to go away the next day.213 He did not observe the deceased change position and she did not wake,214 despite Mr Minett trying to wake her by shaking her and yelling at her.215
By the evening, Mr Minett had become concerned that the deceased had not woken up.216 Mr Minett recalls that he rang Dr Wild at that stage from the home telephone landline.217 However, the telephone records show that the only call between Mr Minett and Dr Wild that evening was made by Dr Wild to the Minett house at 7.23pm.218 This accords with Dr Wild’s recollection of telephoning the deceased at about 7.30pm, expecting her to be awake by then.219 I accept that Dr Wild telephoned Mr Minett, rather than the other way around.
During their telephone conversation, Mr Minett informed Dr Wild that the deceased was still asleep. This information surprised Dr Wild as she had thought the deceased would have passed the point of sedation and woken up by then.220 She could not recall whether Mr Minett had told her he had unsuccessfully tried to rouse the deceased at that time, but acknowledged that she was set in a mindset that the deceased would be alright in any event.221
It was at this point that Dr Wild apparently informed Mr Minett that the deceased had taken an overdose of morphine.222 Although Mr Minett’s recollection of that 212 ts 309 (Dr Wild).
213 ts 250 (Minett, C).
214 ts 257 (Minett, C).
215 Exhibit 2, Tab 19 [61]; ts 250 (Minett, C).
216 ts 253 (Minett. C).
217 Exhibit 2, Tab 19 [62]; ts 253 – 255 (Minett, C).
218 Exhibits 5 and 6.
219 Exhibit 1, Tab 10 [68]; ts 310 – 311 (Dr Wild).
220 ts 310 - 311 (Dr Wild).
221 ts 311 (Dr Wild).
222 Exhibit 1, Tab 10 [68]; ts 311 (Dr Wild).
Inquest into the death of Helen Barbara MINETT Page 28
conversation is vague, he accepts that it is likely that this is when he was told.223 There was no discussion about calling an ambulance.224 Dr Wild did not express any concern to Mr Minett that the deceased had not awoken and Mr Minett took his cue from her.225
After the phone call, Mr Minett continued to check the deceased approximately every 15 minutes until he went to bed, in a separate bedroom, at about 9.30pm.226
At approximately 12.30am the following morning, Mr Minett woke up and went in to the main bedroom to check on the deceased. The deceased was cool to the touch and not breathing. Mr Minett realised immediately that she had died.227
It appears from the telephone records that Mr Minett first telephoned Mrs Plumb,228 although he does not recall that being the first telephone call he made.229 After calling Mrs Plumb, he then called Dr Wild.230 Dr Wild told Mr Minett to call an ambulance,231 which he immediately did.232 Dr Wild recalls being “absolutely appalled”233 when Mr Minett rang her and told her that the deceased had stopped breathing. She hoped that the deceased might still be able to be resuscitated, which is why she told him to call an ambulance.
The ambulance arrived at the house just before 1.00am and was met outside by Mr Minett.234 The paramedic and ambulance officer were taken inside to the deceased and observed that she was lying on her side with the duvet pulled up to her neck, as though she was sleeping.235 The paramedic, Wayne Boisson, made an 223 ts 271 – 272 (Minett, C).
224 Exhibit 2, Tab 19 [63]; 225 ts 274 (Minett, C).
226 Exhibit 2, Tab 19 [60], [65].
227 Exhibit 2, Tab 19 [65] – [66], ts 264, 279 (Minett, C).
228 Exhibits 5 and 6.
229 ts 264 – 265, 267 – 268 (Minett, C).
230 Exhibits 5 and 6.
231 ts 264 (Minett, C).
232 Exhibits 5 and 6.
233 ts 311 (Dr Wild).
234 Exhibit 1, Tab 8A [4] – [8], Tab 12.
235 Exhibit 1, Tab 8A [11] – [12].
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initial assessment that she was showing classic signs of a three hour death.236 Based on St John Ambulance protocols they did not attempt to resuscitate the deceased but performed tests to confirm death.237
Mr Boisson and his partner then went to the kitchen and told Mr Minett that his wife had died.238 Mr Boisson asked Mr Minett to ring the deceased’s doctor. Mr Minett rang Dr Wild and spoke to her briefly, before passing the phone to Mr Boisson. As he did so, Mr Minett mentioned the deceased had taken a morphine overdose.239
Mr Boisson spoke to Dr Wild on the telephone. Mr Boisson asked Dr Wild if she could attend the house to complete a death certificate. Dr Wild initially indicated that she was unwilling to come. Mr Boisson explained that if she did not attend, he would need to call the police to attend. Dr Wild then indicated that she would come, and that it would take her approximately 40 minutes to get there.240
Mr Boisson also asked Dr Wild during that call about the morphine overdose and she advised that the deceased may have taken 80 mls of morphine that morning and she had done it before and slept it off.241
After speaking to Dr Wild, Mr Boisson handed the telephone back to Mr Minett and went outside the house with the other ambulance officer, Florian Breitenbach.
They discussed the circumstances of the case, which had aroused their suspicions. The exact details of the conversations that prompted Mr Boisson’s concerns are not available to the court, as he wrote the statements on a piece of paper that has apparently been lost during the course of the police investigation.242 However, to the best of his recollection Mr Boisson was concerned that Mr Minett’s account that he had been checking regularly on 236 Exhibit 1, Tab 8 A [19]; ts 218 (Boisson, W).
237 ts 218 (Boisson, W).
238 Exhibit 1, Tab 8 A [23] – [24]; ts 219 (Boisson, W).
239 Exhibit 1, Tab 8 A [28] – [29].
240 Exhibit 1, Tab 8 A [31] – [35]; ts 221 – 222 (Boisson, W).
241 Exhibit 1, Tab 8 A [36] – [39]; ts 219, 224 - 225 (Boisson, W) 242 ts 221.
Inquest into the death of Helen Barbara MINETT Page 30
the deceased did not ring true,243 and there was an unexplained delay in calling an ambulance, following the morphine overdose and after she was found unresponsive.244 He was also concerned about comments Mr Minett had made about monitoring the deceased’s breathing;245 in particular a statement to the effect that the doctor had told him to watch the deceased “as her breathing starts to slow down”.246
As a result of their discussion, the ambulance officers decided to telephone the police. Mr Boisson rang a police officer from the Coronial Unit and asked for police officers to attend the scene.247
One of the first police officers to attend the scene was First Class Constable Stephen Berens. Constable Berens spoke to the ambulance officers and then entered the house with his partner. They spoke briefly with Mr Minett, who exhibited a calm demeanour. This was noted by the police officers as unusual.248 They did not see or speak to Dr Wild. As a result of the information provided by the ambulance officers and their observation of the scene, Constable Berens and his partner contacted their supervisor and cleared the house, declaring it a crime scene.249
Sergeant Robert Holtom next attended the scene and spoke to Constable Berens and his partner, as well as one of the ambulance officers.250 Sergeant Holtom also spoke to Mr Minett and Dr Wild.251 Following these conversations, Sergeant Holtom was sufficiently concerned that an unlawful act had occurred to contact Major Crime Squad.252 Officers from Major Crime and forensic officers attended the scene. The Major Crime officers concluded, based on their own visual observation 243 Exhibit 1, Tab 8B [13].
244 ts 227 (Boisson, W).
245 Exhibit 1, Tab 8A [49] – [50] – [53].
246 Exhibit 1, Tab 8B [13] - [14].
247 Exhibit 1, Tab 8A [42] – [43], Tab 12; ts 225 – 226 (Boisson, W).
248 ts 100 – 102 (Berens, S).
249 ts 101 (Berens, S).
250 ts 106 – 107 (Holtom, R).
251 ts 107 - 109 (Holtom, R).
252 ts 109, 111 (Holtom, R).
Inquest into the death of Helen Barbara MINETT Page 31
of the scene, an initial examination of the scene by forensic officers, and all known facts at that time, there did not appear to be any criminality in relation to the death.253 The matter was then left to be investigated by police from the Coronial Investigation Unit.
Dr McCreath conducted a post-mortem examination of the deceased on 2 October 2009.254 In the examination Dr McCreath found narrowed coronary arteries (coronary atherosclerosis), extensive abdominal adhesions, a colostomy, froth in the airways and hypertensive changes in the kidneys. Initially the cause of death was undetermined, pending further investigations.255
Toxicological examination revealed the presence of multiple drugs in the deceased’s system.256 The majority were at therapeutic levels. However, the blood total codeine level was in the toxic fatal range and a very high blood morphine level was also found, consistent with that found in terminally ill cancer patients.257 In her supplementary report, taking into account the toxicological results, the cause of death was determined by Dr McCreath to be multiple drug toxicity in a woman with coronary artery atherosclerosis.258
254 Exhibit 1, Tab 14; Exhibit 7B.
255 Exhibit 1, Tab 14 – Confidential Report to the Coroner dated 2 October 2009.
256 Exhibit 1, Tab 13.
257 Exhibit 1, Tab 13.
258 Exhibit 1, Tab 14 – Supplementary Confidential Report to the Coroner dated 15 June 2010.
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medications, her illness and death.259 He had been provided with a large number of materials relevant to the coronial investigation, as itemised in his report, although not a full copy of the post mortem examination report prepared by Dr McCreath.260
Dr Joyce later prepared an addendum to his first report, dated 22 February 2014, as his earlier report did not include the period before 2 October 2008.261 At this time, Dr Joyce had been provided with a fully copy of the post mortem examination report and some information on the deceased’s dispensed drugs from 29 July 1999 to 23 September 2009.262
Dr Joyce considered the concentrations of drugs detected in specimens collected from the deceased at the time of post-mortem examination, as recorded in the toxicology report.263
Dr Joyce concluded that the concentrations of the following drugs were of no toxicological significance:
• salicylates and salicylic acid (from aspirin); and
• doxylamine (from Mersyndol).264
• desmethyldiazepam and diazepam; and
• amitriptyline and nortriptyline.266
260 Exhibit 2, Tab 1, pp 1 - 2.
261 Exhibit 2, Tab 1A.
262 Exhibit 2, Tab 1A, p 1.
263 Exhibit 1, Tab 13.
264 Exhibit 2, Tab 1, p 8.
265 Exhibit 2, Tab 1, p 10.
266 Exhibit 2, Tab 1, p 8.
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prescribed).267 He concluded it points to an overdose of a paracetamol-containing formulation, of which the deceased had two – Panadeine Forte and Mersyndol.268
Accordingly, failure to detect buprenorphine in the deceased’s samples does not prove that it did not contribute to opioid toxicity.270
• Codeine (Total) Approx 5.1mg/L
• Codeine (Free) .45mg/L
• Morphine (Total) Approx 8mg/L
• Morphine (Free) 0.72mg/L
Some of the morphine found in the post mortem blood came from codeine, as codeine transforms to morphine in the body, to a level of about 10% of the drug.272 However, the amounts of morphine in this case were much higher than 10% of the codeine, which is consistent with the history of morphine ingestion by the deceased.273
In relation to the morphine concentration, Dr Joyce noted that while morphine is liable to post-mortem redistribution to some degree, the possibility of postmortem redistribution does not confuse the interpretation in this case because the concentrations are so high that the interpretation is unambiguous.274 Dr Joyce observed the free morphine concentration was an amount expected to be lethal, and the total morphine 267 Exhibit 2, Tab 1, p 8.
268 Exhibit 2, Tab 1, p 8.
269 Exhibit 1, Tab 14, Confidential Report to the Coroner, p 2.
270 Exhibit 2, Tab 1, p 9.
271 Exhibit 1, Tab 13.
272 Exhibit 2, Tab 1, p 9.
273 Exhibit 2, Tab 1, p 10; ts 174 (Dr Joyce).
274 Exhibit 2, Tab 1, p 9.
Inquest into the death of Helen Barbara MINETT Page 34
concentration was also very high, “even among morphine poisoning fatalities.”275 Both the free and total morphine concentrations greatly exceeded the concentrations usually required for analgesia in cancer patients.276 Dr Joyce concluded that the great majority of the morphine concentrations came from an acute overdose.277 The morphine itself would have been sufficient to cause death.278
Dr Joyce also observed that the codeine concentrations, free and total, were much higher than expected from the deceased’s prescribed doses of codeine, which indicated that this drug had also been taken in acute overdose.279 The simultaneously high paracetamol concentration points to the Panadeine Forte as the source, with perhaps a smaller contribution from Mersyndol.280 If taken on its own, in Dr Joyce’s opinion the deceased would almost certainly have survived the codeine overdose without any medical treatment.281
Looked at in combination, the opiate drug concentrations will be lethal in practically everyone without intensive medical care.282 Accordingly, in Dr Joyce’s unchallenged opinion the circumstances of the deceased’s death are consistent with opiate toxicity.283 The deceased’s clinical position on 28 September 2009 was consistent with such a conclusion, as she was showing the clinical signs of morphine toxicity, most notably her sedation and very low respiratory rate.284
Dr Joyce’s conclusion was not affected by the information provided in relation to the deceased’s history of opiate prescribing in the years preceding her death.285 Dr Joyce accepted that the opiate prescribing during the year 2005 meant that the deceased had, at least at that 275 Exhibit 2, Tab 1, p 10.
276 Exhibit 2, Tab 1, p 10.
277 Exhibit 2, Tab 1, p 10.
278 ts 173 (Dr Joyce).
279 Exhibit 2, Tab 1, p 10; ts 187 (Dr Joyce).
280 Exhibit 2, Tab 1, p 10.
281 ts 188 – 189 (Dr Joyce).
282 Exhibit 2, Tab 1, p 10.
283 Exhibit 2, Tab 1, p 10; ts 173 (Dr Joyce).
284 ts 165 – 166, 174 -175, 179 (Dr Joyce).
285 Exhibit 2, Tab 1A, p 14.
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time, a very high degree of tolerance to opiate/opioid drugs, as well as benzodiazepine drugs.286 However, as noted in his initial report, “[t]olerance is relative”, and even people with a very high degree of acquired tolerance to opiate drugs will die if given a high enough dose.287
Dr Joyce indicated that opiates are drugs that bring toxicity at doses not much greater than tolerated doses; hence a physician should be getting very anxious about the patient if double the daily dose was taken. So in the case of the deceased, a dose of 160 mg would give anxiety about the patient’s wellbeing, and anything above that “would cause a greater degree of anxiety.”288 An amount ten times the normal dose, as in the present case, “would inform a practitioner that the patient may be in peril of their lives.”289
Dr Joyce accepted that a possible hypothesis for the deceased’s tolerance to very high level of opiates was that the doses were not being entirely absorbed into the body, given the deceased’s gastrointestinal surgery procedures may have had the consequence of impaired absorption of drugs.290 However, even in those circumstances, in Dr Joyce’s opinion “[i]t would not be reasonable to put that conjecture up against the fact of an 800 mg ingestion.”291 The fact that the deceased had taken an amount that would generally be expected to be lethal, and was ten times the dose that the deceased was known to tolerate, would outweigh any individual pieces of information that might suggest survivability in the circumstances.292
In his oral evidence, Dr Joyce explained that the reason why opiates can lead to death is their abilities to suppress breathing and to interfere with function of the cardiovascular system.293 Therefore, on identifying a situation where a patient is in risk of their health or 286 Exhibit 2, Tab 1A, pp 3 - 4.
287 Exhibit 2, Tab 1, p 11.
288 ts 173 (Dr Joyce).
289 ts 173, 181 - 182 (Dr Joyce).
290 ts 169 – 170, 175 – 176, 184 - 185 (Dr Joyce).
291 ts 176 (Dr Joyce).
292 ts 176 (Dr Joyce).
293 ts 167 (Dr Joyce).
Inquest into the death of Helen Barbara MINETT Page 36
survival from an opiate overdose, the first management is to check their airways are clear and they are breathing, and to provide assistance if they are not.
Keeping them awake, where possible, can also be helpful if the patient is not in hospital.294 That should be followed as quickly as possible with the administration of the usual antidote to opiate toxicity, a narcotic antagonist drug called naloxone hydrochloride (naloxone) that is given intravenously.295 Naloxone is generally carried by ambulance officers, so it would usually be most appropriate to summon an ambulance, who can administer naloxone and take the patient to hospital where the emergency treatment can be continued.296 This would include repeat dosing of naloxone, as well as ventilation if necessary.297
Also, in relation to the Norspan patch, Dr Joyce indicated that the instruction to ambulance officers dealing with opioid overdoses is to look for patches and remove them.298
Dr Joyce was not supportive of managing such a patient at home and he did not know whether it could be done safely. In Dr Joyce’s opinion, if home management in such circumstances were to be attempted, observations would need to be done by someone with nursing training, preferably a doctor or ambulance officer, and there would need to be oxygen resuscitation supplies readily available.299
Acccording to Dr Joyce, patients who have taken opiate overdoses, and who are treated appropriately before developing hypoxic brain and tissue damage, will survive without sequelae, as a rule.300 In particular, if encountering an opiate overdose at a time when the patient is still conscious, the patient should survive the treatment. Therefore, in Dr Joyce’s unchallenged expert 294 ts 179 – 180 (Dr Joyce).
295 ts 177 (Dr Joyce).
296 ts 177 – 178, 183 (Dr Joyce).
297 ts 177 (Dr Joyce).
298 ts 181 (Dr Joyce).
299 ts 183 (Dr Joyce).
300 Exhibit 2, Tab 1, p 12.
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opinion, the deceased’s death was preventable, if the usual proper management course had been followed.301
Doctor Winterton is a doctor of medicine and a Clinical Associate Professor, specialising in paediatrics and community practice. Dr Winterton became involved in the investigation into the death of the deceased at the invitation of Dr Wild’s legal representatives, as part of proceedings brought by the Medical Board of Australia against Dr Wild in the State Administrative Tribunal (the Tribunal).
Dr Winterton provided an expert opinion regarding complaints by the Board against Dr Wild in relation to her conduct while managing the medical care of the deceased.302 By order of the Tribunal, Dr Winterton also participated in a conference with two other experts and prepared a joint statement identifying the issues and the matters of agreement and disagreement between them, for the benefit of the Tribunal.303 Despite being engaged by Dr Wild, in providing expert evidence to the Tribunal Dr Winterton’s overriding duty was to assist the Tribunal impartially, and the reports were prepared in that context.304
Dr Winterton acknowledged that, in caring for the deceased, Dr Wild was faced with an extraordinarily complicated patient with a multitude of medical problems and a multitude of psychological problems. In those circumstances, Dr Winterton accepted Dr Wild had taken on a difficult and challenging task and he concluded that Dr Wild had acted, in her opinion, in the best interest of the deceased. However, Dr Winterton also considered that Dr Wild had become enmeshed with the deceased and had lost sight of some of the boundary posts that should, and must, exist in the doctor-patient relationship, particularly when dealing with patients 301 ts 183 (Dr Joyce).
302 Exhibit 1, Tab 27.
303 Exhibit 2, Tab 26.
304 Exhibit 1, Tab 27.
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such as the deceased.305 This opinion was shared by the two experts with whom Dr Winterton conferred for the Tribunal proceedings.306 The consequence of Dr Wild losing her ability to view the deceased’s care with professional objectivity was the events of 28 September 2009, culminating in the death of the deceased.307
In regard to the events of 28 September 2009, Dr Winterton’s opinion was that on that occasion Dr Wild did not act in the best interest of the deceased.308 When faced with the circumstances of the deceased having reportedly taken an overdose of 1000 mg and the patient being sleepy, with slurred speech and a respiratory rate of five breaths per minute, best practice would have been to call an ambulance and stay by the patient’s side until the ambulance arrived.309 Dr Winterton concluded that Dr Wild’s decision not to call an ambulance was based on a false premise (as to the deceased’s level of tolerance of opiates) and thus, she made a wrong decision.310
Dr Winterton in conjunction with the experts associated with the Tribunal proceedings also described Dr Wild’s failure to call an ambulance as a grave error in judgment. The three experts recognised that the deceased’s death was most likely preventable. If Dr Wild had called an ambulance, the deceased’s life could probably have been saved by either opiate antagonists (naloxone) administered by ambulance officers and/or urgent transfer for treatment to an emergency department.311
306 Exhibit 2, Tab 26, p 2 - 4.
307 ts 195 (Dr Winterton).
308 Exhibit 2, Tab 27, p 7.
309 Exhibit 2, Tab 27, p 7 - 8.
310 Exhibit 2, Tab 27, p 8.
311 Exhibit 2, Tab 26, p 1; ts 191, 197 (Dr Winterton).
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proceedings is set out in Medical Board of Australia and Wild [2012] WASAT 37.
In brief, the Tribunal made findings that Dr Wild acted carelessly and acted improperly in relation to her relationship with, and treatment of, the deceased, as defined in the relevant legislation. Those findings were based upon Dr Wild’s own admission that her conduct in relation to the deceased amounted to acting improperly and acting carelessly in certain specified aspects, as set out in a Minute of Orders agreed between the parties.
The finding that Dr Wild acted carelessly related to her conduct on 28 September 2009, when she failed to provide any medical assistance to the deceased, failed to call an ambulance and left her in the care of Mr Minett without arranging any alternative medical or other assistance.
The Tribunal ordered that Dr Wild be suspended from practise for a period of three months and that her registration as a medical practitioner be subject to specified conditions, including limitations on her ability to provide counselling and therapy to patients and supervision requirements.
Dr Lachlan Dunjey, who gave evidence in these proceedings, has performed the role of Dr Wild’s supervisor, and continues to do so. He has found Dr Wild to be compliant with the supervision requirements and considers she has reflected on the circumstances of the deceased’s death and has insight about the matter.312 Dr Wild also gave evidence that she had reflected on the events of that day many times and had gained insight as to what went wrong. She confirmed she would not adopt the same course of medical treatment if a similar situation presented itself today.313 312 ts 74, 77 (Dr Dunjey).
313 ts 315 (Dr Wild).
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The attending paramedic, Mr Boisson, initially provided a statement to police at 4.00am in the morning on 29 September 2009, while still at the deceased’s home.314 When contacted in relation to this inquest, Mr Boisson volunteered additional information to his first statement, which was then included in a second statement, signed and dated 26 March 2014.315
In his second statement, Mr Boisson stated that he used a scrap piece of paper to write down quotes of conversations he had with Mr Minett, as well as conversations he overhead between Mr Minett and Dr Wild.316 Mr Boisson handed the scrap piece of paper to the police officer who took his statement on 29 September 2009.317 As mentioned above, that piece of scrap paper has apparently been lost.318
Without being able to refer to his contemporaneous notes from the night, Mr Boisson was reliant upon his memory, five years later, of the conversations that he had, and overheard, that night. However, Mr Boisson did have an independent memory of a particular comment Mr Minett made that night, described by Mr Boisson as follows: “He also made a comment along the lines of, the doctor had told him, ‘to watch her as her breathing starts to slow down’.319
In oral evidence, Mr Boisson indicated that he believed this comment by Mr Minett was made prior to Mr Minett telephoning Dr Wild and advising her that the deceased had died.320 Although he did not have access to his 314 Exhibit 1 Tab 8A.
315 Exhibit 1, Tab 8B.
316 Exhibit 1, Tab 8B [23] – [24].
317 Exhibit 1, Tab 8B [25].
318 ts 221.
319 Exhibit 1, Tab 8B [14].
320 ts 220 (Boisson, W).
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contemporaneous notes, he indicated that he recalled the statement quite clearly as being along the lines of what he included in his statement, although he did not know the exact words used.321
It was put to Mr Boisson by Dr Wild’s counsel that it was possible Mr Minett had said that Dr Wild told him to watch the deceased, ‘in case her breathing slows.’322 While Mr Boisson appeared to accept it was possible, he was fairly confident that the words used were as he indicated in his second statement.323
The statement recalled by Mr Boisson was put to both Mr Minett324 and Dr Wild when they gave oral evidence.
Mr Minett’s recollection of the events of the evening was vague. He did not recall his conversation with the ambulance officers in any detail.325 However, when asked about whether he had been told by Dr Wild to watch the deceased’s breathing, he agreed that he was advised “just to watch her breathing”326 and that he understood Dr Wild had wanted him to monitor the deceased’s breathing, “to make sure she was breathing in a normal pattern.”327
Dr Wild was also asked whether she ever told Mr Minett to watch the deceased’s breathing as her breathing starts to slow down. Dr Wild was adamant that she did not say that to Mr Minett and she would never have said anything like that.328 She suggested that either Mr Minett and/or the paramedic had misheard.329
At the time Dr Wild left the deceased in Mr Minett’s care, the deceased’s respiratory rate was apparently at barely five breaths per minute.330 As noted by Dr Winterton in 321 ts 233 – 234 (Boisson, W).
322 ts 234 (Boisson, W).
323 ts 235 (Boisson, W).
324 ts 240 (Minett, C).
325 ts 270 (Minett, C).
326 ts 281 (Minett, C).
327 ts 281 (Minett, C).
328 ts 310 (Dr Wild).
329 ts 310 (Dr Wild).
330 Exhibit 1, Tab 10 [61].
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oral evidence, there was really only one way to go if her respiration rate was to slow from that rate, namely to stop breathing altogether.331 Therefore, if Dr Wild had told Mr Minett to watch the deceased’s breathing as it slowed, it could be inferred that she was telling Mr Minett to watch as the deceased ceased breathing. This would be completely contrary to Dr Wild’s evidence that she expected the deceased to recover fully from the overdose, with no ill effects.
Given that Mr Boisson’s contemporaneous notes have, regrettably, been lost, I am left only with his best recollection. While I accept that the events of the night were unusual and, for that reason, Mr Boisson had a reasonably clear recollection even so many years on, his evidence taken at its highest was that the words said were to the effect of that statement. He also accepted it was possible something else was said by Mr Minett.
Mr Minett was vague as to what Dr Wild told him, but he did not recall her telling him anything matching exactly what Mr Boisson recalls him saying.
332 ts 142 (Plumb, J).
333 ts 143 (Plumb, J).
334 ts 142 – 144 (Plumb, J).
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According to Mrs Plumb, the deceased had found previous experiences with mainstream mental health care, following previous suicide attempts, distressing and she did not believe she would find help for her mental health problems in that system.335
Mrs Plumb believed that this request was known to Sheree Minett, Margaret Bartlett and Dr Wild, being those people closest to the deceased and the people who would have the decision to make if she had taken an overdose. She did not, however, have a conversation expressly about this request with Dr Wild herself, and only believed the deceased had told Dr Wild but did not recall when.336
Mrs Minett gave evidence before Mrs Plumb, so she was not asked about her knowledge of such a request.
However, Mrs Minett did give evidence that the deceased had not found her dealings with psychiatrists and psychologists satisfactory in the past.337
Mrs Bartlett agreed that she had a memory of the deceased making a lasting request not to be put into the mental health system again after going to Bentley Hospital.338 However, Mrs Bartlett denied that she, or any of the deceased’s other carers, had made a decision as to how to help the deceased in the future if she took an overdose339 and did not recall ever discussing with the deceased whether an ambulance should be called, in the event she took a drug overdose.340
Dr Wild acknowledged that she was aware that the deceased thought seeking traditional psychiatric or psychological help was a waste of time and that she ‘would rather die’ than be admitted as a psychiatric inpatient.341 Dr Wild did not recall having any discussion with Mrs Plumb, Mrs Bartlett or Mrs Minett about the 335 ts 142 - 143 (Plumb, J).
336 ts 144 (Plumb, J).
337 ts 91 (Minett, S).
338 ts 150, 154 (Bartlett, M).
339 ts 151 (Bartlett, M).
340 ts 159 (Bartlett, M).
341 ts 300 – 301 (Dr Wild).
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deceased’s desire not to be hospitalised after an overdose, although she accepted it was possible she had.342
However, Dr Wild also gave oral evidence that she is personally opposed to suicide, assisted suicide and euthanasia, and is a signatory to a group of doctors called ‘Medicine with Morality’ who lobby politicians to support legislation valuing human life.343 Accordingly, it was Dr Wild’s evidence that, if she had understood that the deceased was in mortal danger on 28 September 2009, she would have called an ambulance even though she was aware of the deceased’s desire not to be sent to a psychiatric unit.344
On the evidence above, I find that the deceased had a deep-seated fear of being admitted as a psychiatric inpatient in the public health system, and she had conveyed that fear to her carers and doctor. However, I also find that there is no evidence of an express agreement amongst the carers or with Dr Wild not to call an ambulance if the deceased attempted suicide by overdose. I accept that, on the basis of the evidence as a whole, the failure of Mrs Plumb, Mr Minett and Dr Wild to call an ambulance on 28 September 2009 was not related to any attempt to abide by the wishes of the deceased, but rather arose from their false belief that the deceased did not absorb drugs in the usual way, and hence could not die from a drug overdose.
I accept and adopt Dr McCreath’s conclusion, as noted above, that the cause of death was multiple drug toxicity in a woman with coronary artery atherosclerosis.345
However, I also accept the evidence of Dr Joyce that the coronary artery disease was not the primary contributor 342 ts 326 - 327 (Dr Wild).
343 ts 313 – 314 (Dr Wild).
344 ts 299, 300 - 301, 314 (Dr Wild).
345 Exhibit 1, Tab 14 – Supplementary Confidential Report to the Coroner dated 15 June 2010.
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to the death. Rather, the opiate toxicity, in particular the morphine toxicity, was the primary cause of death in the sense that, but for the acute overdose of morphine, the deceased would not have died at that time.346
While it is not in dispute that the deceased took an acute overdose of morphine sometime in the morning of 28 September 2009, the state of mind of the deceased at the time she ingested the morphine mixture is unclear.
The circumstances in which the deceased took an overdose of codeine are even less clear, although Dr Joyce was able to determine that it was an acute overdose, rather than simply due to the deceased taking a bit too much medication over a few days.347
Around the time of her death in late September 2009, the deceased’s husband and her carers had observed that the deceased’s health was deteriorating significantly. Their views were borne out by the general evidence of Dr Wild as to the deceased’s state of health in the month of September.348 However, despite her deteriorating health, none of the witnesses believed the deceased was suicidal and was deliberately attempting to take her life on 28 September 2009.349
It is apparent that the deceased had taken drug overdoses on many previous occasions. While the deceased often expressed suicidal ideation and there was suicidal intention on many of the occasions when she had taken previous overdoses,350 it was also understood by those close to the deceased that her intention was often equally to simply enable her to get some sleep, as she was chronically sleep deprived.351 346 ts 173 (Dr Joyce).
347 ts 187 (Dr Joyce).
348 Exhibit 1, Tab 10 [37] – [50].
349 Exhibit 2, Tab 19 [78]; ts 94 (Minett, S); ts 127 (Plumb, J); ts 160 (Bartlett, M); 350 Exhibit 1, Tab 10, [17] – [18].
351 Exhibit 1, Tab 7 [17]; Exhibit 2, Tab 21 [38]; ts 138 (Plumb, J); ts 298 (Dr Wild).
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Further, as on each occasion the deceased had survived the overdose, it is possible that she may have been under the same misapprehension as Dr Wild and her other carers, namely that she could not take her own life by this mechanism.
An additional complicating feature is that the deceased’s suicide attempts were often associated with an alter personality, as was the case on 28 September 2009.352 It is difficult to assess the true state of mind of the deceased if she was, indeed, in an altered mental state at such a time.
Looking at the events of the day in question, Mrs Plumb’s evidence was that when the deceased telephoned her in the morning, she identified herself as Suzie and told Mrs Plumb that she had taken a lot of medicine in order to help the deceased to sleep.353 She then said to Mrs Plumb, “can you help us?” and agreed to Mrs Plumb’s suggestion that Mrs Plumb call Dr Wild.
That version of events does not point to an intention by the deceased to take her own life, even though the act of deliberately taking such an extraordinarily large amount of morphine would suggest otherwise.
Accordingly, I am obliged to make an open finding as to the manner of death.
This case highlights the perils involved in doctors allowing the boundaries with their patients to become blurred.
By her own admission to the Tribunal, Dr Wild had failed to maintain proper professional boundaries with the deceased.354 As a result, by September 2009, Dr Wild and the deceased were enmeshed in a relationship that 352 Exhibit 1, Tab 7 [16]; Exhibit 2, Tab 22 [56].
353 ts 126 – 127 (Plumb, J).
354 Medical Board of Australia and Wild [2012] WASAT 37 [11].
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crossed the usual boundaries and Dr Wild had lost her ability to be objective when it came to the care of the deceased.
Dr Wild’s counsel submitted that there was no evidence led at inquest that would support the conclusion that Dr Wild’s failure to call an ambulance on the day in question was due to the blurred relationship. However, Dr Winterton was expressly asked during the inquest about his reference to Dr Wild being enmeshed with the deceased’s problems in his report.355 He explained his use of the term, relating to Dr Wild’s crossing of boundaries with the deceased, and noted that “it really does make it very difficult that when you’re faced then with a critical decision you don’t quite see it straight.”356
Dr Winterton then went on further, in answer to a question about the consequences of Dr Wild’s inability to view the deceased’s case with appropriate professional objectivity, and he responded that the consequence was the events of that day in September 2009 and “the ultimate result”, which I understood to be a reference to the deceased’s death.357
Dr Winterton had a detailed understanding of the nature of the relationship between the deceased and Dr Wild, and of the events of 28 September 2009. I accept his evidence that the crossing of professional boundaries by Dr Wild affected her ability to view the deceased’s clinical situation objectively and caused her to reach erroneous conclusions on that day from the information available to her and make the wrong decision.
On 28 September 2009, Dr Wild was called by Mrs Plumb and informed about the deceased’s report of taking an extremely large morphine overdose. One might have expected Dr Wild to have called an ambulance to attend the deceased at that stage. However, she elected to attend the deceased at home, which was not in itself an improper approach to take given she may have had 355 ts 193 – 194 (Dr Winterton).
356 ts 194 (Dr Winterton).
357 ts 195 (Dr Winterton).
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some doubt as to the effect of the overdose on the deceased.
Once Dr Wild attended the deceased’s home on the morning of 28 September 2009 and observed the deceased showing signs of sedation and morphine toxicity, proper medical management required her to ensure the deceased was breathing while summoning an ambulance to take the deceased to hospital, where her continuing safety could be assured and the overdose could be reversed.358
If she had done so, in the opinion of all the medical experts the deceased’s death would almost certainly have been prevented.359
However, because of her inability to exercise clear clinical judgment in relation to the deceased, Dr Wild allowed herself to take false assurance from her knowledge that the deceased had apparently survived previous overdoses (although not of the same magnitude) and overlook the obvious signs that the deceased was experiencing morphine toxicity.360
By failing to recognise it was a medical emergency and to follow standard best medical practice in such circumstances, Dr Wild failed in her professional obligations and missed an opportunity to save the deceased’s life.
She also left Mr Minett in the unenviable position of caring for his spouse in a medical emergency, without full knowledge of the circumstances and without the appropriate skills to deal with it. As a result, he was left in the distressing position of finding his wife deceased in her bed in the early hours of the morning and having to deal with the aftermath, including finding out that if he had thought to call an ambulance, he might have saved her.361 358 ts 183 (Dr Joyce).
359 ts 183 (Dr Joyce); Exhibit 2, Tab 26, p 1; ts 191, 197 (Dr Winterton).
360 ts 327 (Dr Wild).
361 ts 259 (Minett, C).
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It was these failures that resulted in the Tribunal’s finding that Dr Wild had acted carelessly in her care of the deceased and, taken in conjunction with other admitted conduct, led to the penalty of a period of suspension from practice.
As Dr Wild’s counsel correctly points out in written submissions, the Board did not seek the more serious finding against Dr Wild in the Tribunal that she was incompetent.362 I note that Dr Winterton referred in his initial report to Dr Wild admitting to acting incompetently on 28 September 2009363 but I assume he was not using that term as it is defined in the Medical Practitioners Act 2008 (WA).
Notwithstanding that Dr Wild had been the subject of the earlier proceedings, Counsel Assisting submitted that it was open for me to refer the evidence of the inquest to the Australian Health Practitioners Regulation Agency to allow it to assess whether there are any new matters arising during this inquest that it wishes to investigate.364
Although there was some potential, arising from the evidence of Mr Boisson and Mrs Plumb, to suggest that the original understanding of why Dr Wild failed to call an ambulance might be cast in some doubt, that evidence was of a limited nature and was not supported by the evidence of other witnesses.
On the whole of the evidence, I am satisfied that the evidence does not support an inference that Dr Wild failed to provide or request medical treatment for any reason other than her erroneous belief that the deceased could not die by way of drug overdose.
I accept Dr Wild’s counsel’s submission that the fact that she made admissions in the disciplinary proceedings in the Tribunal and gave candid evidence at the inquest, accepting the errors she made in the care of the 362 Submissions to the Coroner on behalf of Dr Felicity Wild dated 5 May 2014, [7.20] – [7.22].
363 Exhibit 2, Tab 27, p. 8 364 Submissions filed on behalf of Counsel Assisting the Coroner dated 17 April 2014, p 31.
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deceased on 28 September 2009, reflects insight.365 Further, Dr Dunjey continues to supervise Dr Wild and considers her progress to be satisfactory and her insight to be good.
Counsel Assisting submitted that it was open on the evidence for me to form a belief that an indictable offence has been committed in connection with the deceased’s death.366
I have considered the evidence before me, and I do not consider that the evidence is sufficient for me to form a belief that an indictable offence has been committed in connection with the deceased’s death by any person.
Accordingly, I do not propose to refer the matter to the Director of Public Prosecutions.
S H LINTON CORONER 15 May 2014 365 Submissions to the Coroner on behalf of Dr Felicity Wild dated 5 May 2014, [8.1(e)] – [8.1(f)].
366 Submissions filed on behalf of Counsel Assisting the Coroner dated 17 April 2014, p 32.
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