Inquest into the Death of Shannon Elizabeth MURPHY

Coroners Act, 1996 [Section 26(1)] Western Australia

RECORD OF INVESTIGATION INTO DEATH Ref No: 26/16 I, Evelyn Felicia VICKER, Deputy State Coroner, having investigated the death of Shannon Elizabeth MURPHY with an Inquest held at Perth Coroners Court, Court 51, CLC Building, 501 Hay Street, Perth, on the 1617 and 29 August 2016 find the identity of the deceased was Shannon Elizabeth MURPHY and that death occurred on 27 April 2012 at Armadale Kelmscott Memorial Hospital as a result of Methylamphetamine Intoxication leading to agitated delirium and extreme exertion induced cardiac arrhythmia in the following circumstances - Counsel Appearing : Ms Aneta Sukoski assisting the Deputy State Coroner Mr Ben Humphris appeared on behalf of the Commissioner of Police Table of Contents Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 1.

INTRODUCTION On the 27 April 2012 Shannon Elizabeth Murphy (the deceased) died at Armadale Kelmscott Memorial Hospital (AKMH) following a prolonged period of physical activity during which she attempted to enter a number of properties, apparently looking for her son. Her behaviour was extreme, drug-induced and resulted in her being involved in a series of incidents in which she suffered injury, both as a result of her actions and assaults by another person. By the time police intervened she was irrational and unable to care for herself.

Police restrained her for her own safety and placed her on the ground, cuffed her loosely and held her hands to prevent further injuries. They immediately placed her on her side so as not to impede her breathing. They had already called for an ambulance to attend.

The deceased’s conscious state declined rapidly as the ambulance paramedics appeared and police commenced CPR while paramedics set up equipment. Aggressive resuscitation continued on the way to AKMH and at hospital, but the deceased never regained consciousness and died that night.

The deceased was 33 years old.

Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 2.

The assaults earlier in the evening, prior to the arrival of the police, have been dealt with by the District Court of Western Australia where it was acknowledged those events did not cause the death of the deceased.1 Under the provisions of the Coroners Act 1996 (WA) wherever there has been a death in which the police have been involved there must be a public inquest to provide independent review of the actions of the police involved in the incident (s3, s22 (1)(b)). The sole issue before this court is whether the actions of the police officers involved with the deceased that evening either caused or contributed to her death at the time it occurred.

BACKGROUND The Deceased The deceased was born on 30 May 1978 in Tasmania. Her father died when she was 13 years old and her mother still lives in Tasmania.2 The deceased has an older sister who has mental health problems. Both girls were bought up in a violent environment while their father was still alive.

The deceased did not finish high school and was home educated by her mother due to her behaviour at school.

She disliked school intensely.3 The deceased did not have a good relationship with her mother or sister and had a son 1 Exhibit 1, Tab 3 2 Exhibit 1, Tab 4 3 Exhibit 1, Tab 4 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 3.

who was 15 years old at the time of her death. He lived with his grandmother and aunty in Tasmania.4 The deceased had been in a long-term on/off relationship and lived with her defacto at the time of her death. They had originally both been in Tasmania, but had moved to Western Australia. The deceased travelled between Tasmania and Western Australia, staying with her defacto when she was in WA. The deceased’s defacto did not get along with the deceased’s mother and they were effectively estranged.

The deceased had been in Tasmania a few months prior to her death where she worked part-time in a deli in Launceston, Tasmania. She had been enrolled in a laboratory technician’s course at the Polytechnic Launceston, Tasmania, and was attempting to have that course transferred to Western Australia so she could complete her training. The deceased’s mother believed this was because of her interest in illicit drugs. Although the deceased had started various courses she had never completed any.

The deceased’s defacto described her as frail and petite, but always sticking up for herself. He considered she had issues with drugs and was possibly “bipolar”.5 It is not clear if she was ever diagnosed with any mental health issues, 4 Exhibit 2, Tab 38 5 Exhibit 1, Tab 38 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 4.

but certainly her behaviour would support psychiatric or psychological issues. Most of her friends and associates appear to have moved in fairly violent and drug-related circles and hospital visits would suggest her irrational behaviour was escalating in the period before her death.6 While in Western Australia the deceased was living with her defacto in a motor home at the rear of 16 Lilika Street, Armadale. She was not obtaining any benefits in Western Australia and she and her defacto existed on his unemployment benefits.7 The deceased worked out to keep herself fit and budgeted well with her available income. She would not spend beyond her means. She had a volatile temper and, in conjunction with her fitness, could be quite difficult to handle if she became violent.

The deceased’s defacto reported her as frequently overdosing but not physically self-harming.

The deceased suffered from the condition of osteogenic imperfecta, hepatitis C and possibly bipolar disorder. She also suffered depression. She was known to take a variety of prescribed drugs, anti-depressants and anti-psychotics, and at the time of her death was apparently taking therapeutic doses of venlafaxine. She also took quetiapine and on occasions OxyContin.

6 Exhibit 2, Tab 19 7 Exhibit 2, Tab 38 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 5.

Approximately two weeks before her death the deceased had presented at AKMH complaining of psychotic symptoms when using amphetamines. She was also recorded as exhibiting violence/aggressive behaviour, which had resulted in police intervention the previous month. There is a recording of domestic violence and reported assaults between her and her defacto. An entry on the 14 April 2012 states “potential for aggressive behaviour, violent, spitting, trying to stab police, guns, tried to grab a syringe whilst in emergency.”8 The deceased’s defacto stated that he and the deceased had intended to return to Tasmania the week following her death. They had a one-way ticket and intended to stay there while they sorted their lives out. The deceased had told a friend in Tasmania that she wanted to go home. They were waiting for a motor vehicle compensation payout due to injuries the deceased had suffered in a motor cycle crash with her defacto.9 Events of Friday the 27 April 2012 Prior To Police Attendance During the day of the 27 April 2012 the deceased had been at home with her defacto who was working on a vehicle with a friend. At the end of the afternoon her defacto drove the friend home and while he was away the deceased spoke with the occupants of the house at 16 Lilika Street. She had 8 Exhibit 1, Tab 19 9 Exhibit 2, Tab 38 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 6.

taken a quantity of methylamphetamines, although no one reported exactly how much or acknowledged seeing her doing so. She was reported to generally use once a month and was not generally known to drink alcohol. This was in addition to her prescribed medication.

The occupant of the house where the motor home was located stated she saw the deceased at approximately 8 pm while her defacto was out. That lady then moved inside her home and was not sure of the activities of the deceased from that point.10 At approximately 8.40 pm the next-door neighbour at 14 Lilika Street heard someone climb over her fence and then walk straight into her residence through an unlocked sliding door.11 The neighbour had not seen the deceased before and described a woman who appeared to be “spacedout” and not thinking correctly. She described her eyes as very wide and her movement as unnatural. She was looking for her son and was quite insistent he was in the house.

She appeared to look in every room while searching for her son. Two male visitors to that house eventually guided the deceased out of the door and shut and locked it behind her.

One of those men then called the police to report the 10 Exhibit 2, Tab 39 11 Exhibit 2, Tab 44 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 7.

incident,12 apparently at 8.50 pm,13 although the first police task recorded complaint is at 8.47 pm in Lilika Street, with another shortly afterwards at 8.59 pm from Kyogle Place.14 The deceased then approached another resident on Lilika Street, who had come out to see what was happening. She asked if she could look inside his house for her son. When he refused the deceased pushed him in the chest but desisted when he continued to refuse her access.

The deceased then left Lilika Street and made her way down Numulgi Street to Kyogle Place. She continued to be looking for her son when searching the streets and attempting to enter some of the homes. She wandered around the streets screaming for her son and calling for “Trish”.15 Eventually, the deceased entered the rear yard of 1 Kyogle Place, Armadale, and had a brief discussion with the occupant from 7 Kyogle Place. She climbed over a fence from 1 Kyogle Place into 3 Kyogle Place and was headed towards the backyard when the occupant from 7 Kyogle Place struck her hard, in the middle of her back with a thick stick, which observers reported being approximately a meter in length.

The deceased fell face forward on to the ground and hit her head, but other than crying out and screaming, did not 12 Exhibit 2, Tab 43 13 Exhibit 1, Tab 3A 14 Exhibit 1, Tab 4 pp.19-20.

15 Exhibit 2, Tab 45 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 8.

retaliate. The occupant of 7 Kyogle Place then walked away.16 The deceased managed to get to her feet and continued to the rear gate of 3 Kyogle Place and appeared to be attempting to get in. The occupants came and asked her what she was doing and she responded, but they were not able to make out what she was saying before she rushed towards the open front door and pushed the male resident out of her way, before wrestling with the female resident as she tried to get into the house.

The deceased forced her way into the home and was wrestling with the occupants who were attempting to keep her away from the children.

Eventually, they managed to get her outside to talk to her and found her to be confused and disorientated and unable to tell them who she was and where she was from which seemed to distress her.17 They found her to be garbled and disjointed and probably suffering from the effects of drugs.

She then started to become aggressive again and the occupants of 3 Kyogle Place retreated back into their house.

The occupant of 7 Kyogle Place returned to 3 Kyogle Place and this time he was carrying an aluminium crutch which the residents of 3 Kyogle Place had apparently left in their 16 Exhibit 1, Tab 4; Exhibit 2, Tab 45 17 Exhibit 2, Tab 48 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 9.

front yard following their use of them some weeks earlier.

The occupant of 7 Kyogle Place again began to assault the deceased. She fell down and when she sat back up she was struck again so hard the crutch broke. She was described as offering no physical resistance, but being verbally provocative which caused the male occupant of 7 Kyogle Place to become enraged. It appeared he was intoxicated.

The deceased was picked up and thrown against a wall near 3 Kyogle Place. She appeared to be stunned before she was able to get to her feet and continued to abuse him. He again took hold of her and this time forced her to the ground, pinning her down. He stood up and dragged her for a short distance towards number 7 Kyogle Place. He then let go of the deceased and returned to his home with his defacto.

The deceased stood up and walked towards 7 Kyogle Place while screaming and yelling. The occupant of 7 Kyogle Place returned and punched her and continued to punch and kick her before again leaving18.

The deceased stood up and staggered back towards 3 Kyogle Place while picking up a section of the broken crutch. She hit the vehicles in front of 3 Kyogle Place before walking up to the door and using the crutch to smash a mirror in the front door. She then smashed a glass window alongside the door and attempted to squeeze through the opening to get 18 Exhibit 2, Tab 50 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 10.

into the house. There were shards of glass and the deceased cut herself numerous times during the struggle to get into the house while the occupants were trying to push her out of the house.

The occupant from 7 Kyogle Place returned to the deceased and pulled her back through the window and hit her with a wheel brace. The deceased was still clothed at this time.

The occupant of 7 Kyogle Place eventually managed to pull the deceased out of the hole in the window. She was bleeding as a result of the further injuries to her head. It was at this point her jeans were pulled from her which left her wearing her underpants and singlet.

The occupant of 7 Kyogle Place again returned to his residence, but the deceased followed him and fell over. She was then approached by the occupant of 7 Kyogle Place, who attempted to speak to her for a while, before there was another altercation between them and she was struck again.

The deceased attempted to move away towards 5 Kyogle Place where she bumped into an electrical pole and fell over a small fence. The resident of 5 Kyogle Place had telephoned the police twice by this stage, once at 9.13 pm and then again at 9.15 pm. The residents of 4 and 5 Kyogle Place were on their driveways and the deceased saw the owner of 4 Kyogle Place, a gentlemen older than those she had been dealing with and began to run towards him, still Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 11.

with what appeared to be a part of the crutch in her hand.

As she ran she fell over the low fence between the two properties and landed on her head. She was then propped against the fence between houses 5 and 7.19 It was as the deceased was crouched against the fence between 5 and 7 Kyogle Place the police arrived.

The Police The two police officers dispatched to Kyogle Place by Police Operations Centre (POC) were Constables Jim Merttens (Merttens) and Lachlan Perhavec (Perhavec). Merttens had been in the police force for two and a half years at that stage and Perhavec for one and a half years. They had been in Maddington in a marked police sedan (JV104) when they were tasked, at approximately 9.10 pm, to attend the incident at Kyogle Place.

It was reported to them as a female attempting to get into an address, which they interpreted to mean an attempted burglary. They were in Maddington and given a priority two to drive there. Priority two requires police to drive with lights and sirens activated and permits them to drive at a capped level above the speed limit to attend an incident. All police officers are trained to drive to priority two emergency driving 19 t.17.8.16, p.124 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 12.

standards. Perhavec was driving JV104 and Merttens was the passenger.

Senior Constable Hall (Hall) was a police general purpose dog handler and on the evening of the 27 April 2012 was on duty alone in a marked Ford Falcon utility police vehicle (TK113) with his dog.20 He was working a night shift from 6 pm until 4 am. He heard of an incident at Kyogle Place, Armadale, over police communications and, as he was in the vicinity, called POC to say he was able to assist with the incident. He was given a priority two to attend the scene.

JV104 was ahead of Hall when they pulled into the top of Kyogle Place, which is a cul-de-sac. Hall parked his vehicle behind JV104.

All three police officers had completed training at the academy in both the ‘use of force’ which includes use of empty hand tactics and various weapons, and ‘police life support’, a first aid qualification.

All three police officers thought they were attending an attempted burglary.21 20 Exhibit 2, Tab 34 21 t.16.8.16, pp.20, 36; t.29.8.16, p.135 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 13.

EVENTS AFTER POLICE ARRIVAL The police, on leaving their vehicles, were drawn to the sounds of a commotion further around the corner in the cul-de-sac at number 5 Kyogle Place. While there was street lighting at the entry of the cul-de-sac, where the police vehicles were parked, the lighting further in was not as good, but the police officers heard some male voices calling them over to 5 Kyogle Place.

5 Kyogle Place is owned by Mr O’Rourke and his next door neighbour at number 7 is Mr Steer. Mr O’Rourke and Mr Steer directed the police officers attention towards the deceased. She was in the driveway of Mr O’Rourke’s home, near the garage slumped against the fence.22 The deceased was only wearing her socks, underwear and a singlet and was covered in blood from the previous events of the evening.23 To the police the deceased was obviously unwell and injured. This was not the situation they had believed they would be confronting. Hall was the senior officer present and as such was responsible for the situation.24 The three police officers did not discuss this but fell automatically into a pattern as to the best way to handle the incident.

22 t.29.8.16, p.136 23 t.16.8.16, p.21 24 t.16.8.16, pp.21, 37 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 14.

On observing the state of the deceased Hall immediately used his personal radio to contact police communications and request the attendance of an ambulance.25 Some of the residents had already rung for an ambulance. Police communications acknowledged Hall’s call for an ambulance and confirmed they would attend to that matter.

In response to the visible blood, the police officers put on disposable gloves and noted that, aside from the apparently fresh injuries both in the deceased’s hair and on her person, she also appeared to have a number of yellow and brown bruises along her legs.

The three police officers stood around the deceased, out of arms reach, and attempted to assess the situation. From their perspective she was shouting and waving her arms around. At one point she appeared to roll to her side, and then sat back up against the fence. She was agitated, aggressive, incoherent and obviously drug affected. She told the police officers she had a knife, although none of them could see one, and was threatening to spit blood on them.

She told them she had AIDS. Hall could see the deceased had a mouth full of blood and was mindful he did not want her to be able to spit blood at him.26 Hall opened his Taser access, but did not withdraw it or take it off safety.

25 t.16.8.16, p.137 26 t.29.8.16, p.139 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 15.

The three police officers had torches they were shining on the scene. None of them could see a knife. Hall believed she was reaching behind herself to find a knife at the time he took the top off his Taser, but when she brought her hand out with nothing in it he removed his hand from his Taser.

Neither Merttens nor Perhavec believed she had a knife although she was threatening them with one. The police officers described the deceased as managing to get to her feet and making a forward motion, they believed towards Hall, although Mr Steer believed she was trying to run away.27 She was described as behaving aggressively but not capable of moving very fast and more ‘sort of lunging past’ the police officers. Merttens was concerned she was going towards Hall and attempted to distract her. This enabled Hall to catch hold of the deceased as she turned towards Merttens.

Hall managed to catch the deceased’s hair with one hand and direct her to the ground with his other hand on her shoulder. She was taken to the ground, rather than thrown to the ground, and Hall went down with her.28 He was then in the vicinity of her head stopping her head from coming into contact with the ground and attempting to control her, while Merttens held her legs in an attempt to stop her from kicking.

27 t.17.8.16, p.128 28 t.29.8.16, p.140 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 16.

The two police officers could feel the deceased was still attempting to move and Hall directed Perhavec to cuff her in an attempt to restrain her and keep her calm.29 Perhavec was concerned about her, but it became obvious that was the easiest course of action.

Perhavec first caught hold of her left arm, which was free and carefully placed the handcuffs around her wrist because he was concerned about a large open gash on the underside of her left forearm which was still oozing blood.

He placed the cuff so it was very loose and managed to free her right arm, which had been underneath her, and again loosely placed the cuff around her right wrist. In evidence Perhavec said he also had hold of her hands and maintained a hold on her hands so she would not hurt her wrists against the cuffs.30 The police officers then placed the deceased fully on her side with Perhavec reminding them they needed to ensure she could breathe and avoid positional asphyxia.31 This was in accordance with both their training as police officers and Perhavec’s training as a life saver.32 Mr Steer confirmed the police had been as gentle with the deceased as was possible in all the circumstances confronting them. Mr Steer’s perception was the deceased was not struggling once she was on the ground, but he did 29 t.29.8.16, p.141 30 t.16.8.16, p.24 31 t.16.8.16, p.46 32 t.16.8.16, p.25 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 17.

not recall the presence of the third officer holding her legs which was preventing her from kicking.33 Hall stated he was kneeling on his right knee, alongside the deceased and while they were securing her, had his left leg across the top of her body, but not in contact with her body to stop her from being able to rise without compressing her chest. It was Mr Steer’s view that as soon as the police had secured the deceased she ceased to struggle. He considered the police to have behaved very professionally and to have been very mindful of the deceased and the condition she was in.

As soon as the deceased was on the ground in the recovery position, Merttens recontacted POC to request an ambulance, but this time on a priority one.34 Perhavec tried to talk to the deceased and asked her name but she did not respond to questions.

While the police were trying to contain the situation the occupant of 7 Kyogle Place was shouting at the police, but they were focused on what they were doing. Eventually Hall asked him to stop because they could not concentrate on trying to assist the deceased.

Perhavec, due to his additional first aid training, monitored the deceased’s condition while Hall remained in the vicinity of her head protecting it from the ground. Perhavec noticed several small cuts all over the deceased’s head but none 33 t.17.8.16, p.25 34 t.16.8.16, p.46 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 18.

which required immediate pressure.35 He continued to hold her hands to ensure she did not struggle against the cuffs and further damage herself.36 The deceased began to struggle less and Merttens went to get the first aid kit from the police vehicle as they were concerned her condition may deteriorate. Perhavec stopped holding the deceased’s hands to monitor her breathing and as he did so he noticed she deteriorated to a semi-conscious state and stopped breathing.

Mr Steer advised he also noticed her breathing to become very shallow and the police officers responded by removing her cuffs and turning her onto her back so they could commence cardiopulmonary resuscitation (CPR) as soon as the breathing mask became available. Merttens returned with the first aid kit but had been unable to find a breathing mask. Hall noticed one in the bottom of the kit and they were in the process of preparing the deceased for CPR when she again began to breath. She was placed back in the recovery position on her right side with Hall supporting her head and ensuring her airway remained open.

Additional police officers arrived from Armadale Police Station and Constable Shianne Morrison (Morrison) identified the deceased to the police officers as someone with whom she had prior contact. The ambulance officers 35 Exhibit 2, Tab 27 36 Exhibit 2, Tab 27 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 19.

arrived and began to assess the deceased as she deteriorated and again stopped breathing. The police officers commenced CPR while the ambulance officers set up their equipment. The police officers maintained compressions while the ambulance officers established an airway for the deceased.

The occupant of 7 Kyogle Place continued abusing both the police and the ambulance officers and was eventually told to go away or he would be arrested.37 He returned to 7 Kyogle Place.

Perhavec placed his handcuffs in a clip bag and left them with the first aid kit because they were covered in blood and he understood the scene would become a protected forensic area and all items needed to be left in place.

The police officers present rotated compressions between them until the ambulance officers stated the deceased could be moved. She was placed into the rear of the ambulance with police officers still maintaining CPR and the paramedics maintaining her airway. Perhavec went in the ambulance to assist the paramedics with the deceased’s care.

37 t.16.8.16, p.49 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 20.

The St John Ambulance Patient Care Records indicate the ambulance paramedics were notified at approximately 9.15 pm to attend at Kyogle Place, and they arrived at the scene at 9.34 pm. They left the scene at 9.58 pm having attempted to stabilise the deceased, and reached hospital at 10.07 pm.38 In their narrative they recorded that they were dealing with a 33 year old female in cardiac arrest whilst breaking into a house. They indicated that on route to the scene they were upgraded to a priority one.

On their arrival they record the deceased as lying face down, however, I am confident this is not the case, both on the evidence of the police officers and the independent evidence of Mr Steer. The ambulance paramedics also noted CPR was not being conducted, however, again I am satisfied this was because until very shortly after their arrival the deceased was still breathing.

On their examination of the deceased the paramedics noted she had a radial pulse, beats of 60bpm with shallow respirations and that she was making movement. They noticed the injury to her head and wrist with lots of contusions, and noted she was covered in purplish bruises with her pupils dilated and fixed. They were initially unsuccessful in placing an airway, but the deceased was then placed on a scoop and taken priority one to AKMH with the police on board for assistance. They prepared 38 Exhibit 1, Tab 7 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 21.

adrenaline but it was discarded as it did not need to be used.

Perhavec remained at the hospital and was notified by doctors at 10.30 pm the deceased had not survived. He communicated this to POC. The scene at Kyogle Place was maintained as a protected forensic area and the police officers involved in the incident separated so they could not communicate with one another pending being interviewed by independent police officers as to the circumstances of the incident.

POST MORTEM REPORT39 The post mortem examination of the deceased was undertaken on 7 May 2012 by Dr G A Cadden, Forensic Pathologist, at the State Mortuary. The post mortem examination was extensive and extremely thorough due to the circumstances of the death. A death in which police have been involved always requires meticulous investigation. In addition there were also charges against others involved in the incident earlier on the evening of 27 April 2012 which needed to be clarified.

Dr Cadden’s examination resulted in an interim cause of death as ‘head injury’ with further investigations pending.

Those further investigations related to neuropathology to 39 Exhibit 1, Tab 8 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 22.

establish if there was a traumatic head injury which would account for the death, and toxicology in an attempt to ascertain an explanation for the deceased’s apparent intoxication.

Dr Cadden commented on the fact the deceased was covered in numerous fresh bruises, lacerations and abrasions. In addition Dr Cadden noted a fractured skull, a comminuted fracturing of the left scapula and fracturing of the left ulna with bony rib cage fracturing. There was no evidence the rib fracturing had penetrated the pleural cavity and caused a pneumothorax.40 The head injury was above the left ear on the side of the head and had a U shape appearance with the base of the U towards the lower part of the wound. In evidence Dr Cadden described the U shape as being more consistent with a crutch or bar, but not as a result of the striking of the head on a large object such a pole or the ground. The damage would have been caused as a result of considerable force.41 Dr Cadden noted that in the area of the U shaped injury the underlining muscle was exposed and the skin could be repositioned within the overall U shape from which it appeared to have been displaced.

40 t.17.8.16, p.112 41 t. 17.8.16, p.104 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 23.

In his police interview, it was noted by Merttens that although they had not found a knife in the vicinity of the deceased, after her removal by ambulance, the forensic police did find a small metal pole close to where the deceased had been sitting.42 Hall believed that may have been the object the deceased was searching for when she appeared to be feeling behind her and there was concern she might produce a knife.43 Dr Cadden noted some of the bruising on the deceased appeared yellowish in colour consistent with the police officers description of apparently old bruising, but that the majority of the deceased’s injuries were recent. They were purplish or red and he put them as ‘recent to the time of death’.

In view of the events of the evening prior to police arrival at Kyogle Place the injuries on the deceased would appear to be consistent with that history from the various eye witnesses.

Dr Cadden could see no underlying pathology which would account for the deceased’s death, other than the head injury which needed to be further examined. None of the injuries appeared to account for the deceased’s death on their own.

42 Exhibit 1, Tab 26 43 Exhibit 2, Tab 28 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 24.

Dr Cadden also commented on the concept of positional asphyxia and its relationship to the death of the deceased.

Dr Cadden was adamant there was no evidence of asphyxia at post mortem examination. He stated there was no evidence for impaired oxygen delivery as a result of positional asphyxia. He elaborated that in his view the restraint described by the police provided no basis for a consideration of positional asphyxia in that the deceased had not been placed in a position which would provide mechanical or physical obstruction of her airways so as to induce cardiorespiratory arrest as the result of a lack of oxygen.44 Dr Cadden was anxious to distinguish cardiorespiratory arrest as a result of positional asphyxia leading to hypoxia and creating a medical emergency, as opposed to a pre-existing medical emergency as a result of methylamphetamine toxicity inducing agitated delirium and resulting in a cardiac arrest.

Toxicology revealed methylamphetamine and amphetamine in the deceased’s blood at the time of death, with a methylamphetamine level at 2.4mg/L and amphetamine at 0.44mg/L. There were also therapeutic quantities of venlafaxine, desmethylvenlafaxine and quetiapine.

Dr Cadden noted the level of amphetamines in the deceased’s blood were in the range of what would be considered a high recreational usage, and within the range quoted as being related to fatalities from 44 t. 17.8.16, pp.113-114 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 25.

methylamphetamine intoxication. Dr Cadden specified the cause of death of the deceased as unascertained (consistent with acute methylamphetamine toxicity).45 Dr Fabian Evidence was heard from Dr Vicki Fabian, neuropathologist, who examined the deceased’s brain for evidence of brain injury.46 Dr Fabian noted bleeding on the surface of the brain which was as a result of traumatic injury, but not of significance to the cause of death.

In addition, Dr Fabian noticed changes within the brain stem relating to consciousness. She described that as a concussive injury, which she dated as occurring between 2 ½ hours and up to 3 days before the time of death. While those changes may have accounted for a period of unconsciousness or appearing dazed, Dr Fabian did not consider they were sufficient for a cause of death, nor a contributor to death in and of themselves.47 Professor Joyce Evidence was called from Professor David Joyce, Clinical Toxicologist, to further expand upon the 45 Exhibit 1, Tab 8 46 Exhibit 1, Tab 9 47 t. 17.8.2016, pp.94, 96, 97 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 26.

methylamphetamine results and their relationship to the death of the deceased.

Professor Joyce explained the contribution of drug intoxication to the cause of death and the deceased’s clinical state prior to death. Professor Joyce noted the deceased had one prior incidence of methylamphetamine induced agitated delirium in her presentation to hospital on 11 March 2012. He advised that agitated delirium is a consequence of acute intoxication with methylamphetamine, usually from high doses.

He also noted there seemed to have been other incidents of psychostimulant disorders prior to that period of agitated delirium, which he called paranoia and acute stimulant intoxication. Professor Joyce noted there did not appear to be a history of spontaneously occurring psychotic disorders with the deceased, outside drug intoxication.48 Professor Joyce also noted the deceased did not appear to have any pre-existing cardiac conditions which might predispose her to a sudden cardiac death with or without stimulants, despite her prior history of heavy methylamphetamine use.

Professor Joyce described acute stimulant intoxication as a state of being overly active with heightened arousal which sometimes accompanies recreational doses of methylamphetamine or amphetamine type drugs. These are 48 Exhibit 1, Tab 12 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 27.

often the effects which those abusing the drug desire because they produce increased confidence, a sense of wellbeing, euphoria and a sense of invulnerability with a subjective feeling of increased alertness.

Undesirable side effects can be over activity, agitation and trembling with picking or scratching of the skin, and risk taking behaviours, including recklessness, paranoia, aggression and violence and are early consequences of intoxication with amphetamines. Those indicators can merge into reported agitated delirium at higher doses.

Professor Joyce outlined that after a period of acute stimulation passes, users often become slower, inattentive and have impaired reactions with lower moods. Later on it is quite frequent for a person to become very sleepy or even fall asleep without warning. Professor Joyce considered the deceased’s presentations to hospital49 on 11 March, 1 April, 2 April and 14 April all were evidence of acute stimulant intoxication, probably amphetamines, with only that on the 11 March falling into the agitated delirium diagnosis.

With respect to paranoia Professor Joyce considered that usually occurs during acute methylamphetamine/ amphetamine intoxication and may be a delusional state. It is more difficult where that paranoia may be grounded in reality. It is also possible for that state of paranoia to be 49 Exhibit 1, Tab 19 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 28.

elevated even though intoxication may have passed.

Although Professor Joyce did not specifically mention a delusional state, it would seem the deceased’s behaviour prior to the arrival of police, and even following their arrival, would support some delusional aspects due to her alleging her son, for whom she was looking, was in some of the homes which led to her bizarre behaviour. We know the deceased’s son was in Tasmania.

Generally, the history of the deceased’s presentations to hospital with psychostimulant intoxication appear to reveal a tendency to violence and aggression when intoxicated.

It was also confirmed from her medical records the deceased had hepatitis C. Professor Joyce indicated the condition is most commonly acquired through the re-using of another person’s intravenous injection equipment and would support, that on occasion, the deceased had been involved in intravenous methylamphetamine ingestion.

With respect to the levels of methylamphetamine found in the deceased’s body at death, Professor Joyce referred to those as very high levels, but not generally consistent with lethality in an experienced user, without some other factor present. The levels were high enough for Professor Joyce to say the method of ingestion was irrelevant in the case of the deceased. The levels were high enough to account for a direct toxic death arising out of methylamphetamine use Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 29.

alone due to a disturbance of the cardiac rhythm of the heart.

Professor Joyce pointed out a single very large dose of methylamphetamine can cause almost immediate death by inducing severe heart rhythm disturbance, although in the case of the deceased this was clearly not the case. She survived for some time after administration of the drug.

Therefore, it was likely there was another factor involved, which would appear to be related to a late sudden death following methylamphetamine toxicity in combination with a period of intense physical exertion.

Professor Joyce did not consider the deceased’s physical position at any stage, as described in the evidence, would carry a special risk of ongoing respiratory compromise during restraint. He did consider it likely death resulted from the period of intense exertion while intoxicated as described prior to the arrival of the police.

Professor Joyce explained that during intense exertion the sympathetic nervous system delivers additional stimulants to the heart to increase heart performance.

Methylamphetamine accentuates that increase in heart performance beyond that which the heart can withstand and beyond which the body can compensate.50 In this way a lethal disturbance of the heart rhythm and possibly 50 t.17.8.16, p.74 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 30.

constriction of the coronary arteries supplying blood to the heart occurs and pre-disposes to rhythm disturbances or other abnormalities.

In the case of the deceased there was no evidence of cardiac disease which may pre-dispose her to sudden death as a result of cardiac arrhythmia but there was evidence in this case of extreme exertion. This, in conjunction with other factors relating to the events before her death, such as her blood loss which from the description of witnesses at the scene was reasonably significant, inclined Professor Joyce to state the circumstances of the deceased’s death were “consistent with an amphetamine and exertion induced cardiac arrhythmia in a woman involved in intense exertion”.51 The deceased’s collapse appeared to occur in a very short time frame prior to and around the time of the arrival of the ambulance staff. Professor Joyce pointed out the deceased still had a cardiac output, but it was abnormally low which would imply that a cardiac arrhythmia was already present.

Professor Joyce considered the transition from an arrhythmia to cardiac arrest was rapid and that the rhythm encountered by the ambulance officers on the first ECG, and at the hospital, was asystole. He stated this was the usual consequence of ventricular fibrillation, when it cannot be reversed quickly enough to allow return of effective 51 Exhibit 1, Tab 12 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 31.

cardiac pumping. It was Professor Joyce’s view the deceased had died as a result of methylamphetamine toxicity inducing a state of agitated delirium which led to cardiac arrest and death.

Professor Joyce pointed out that the process of restraining a violent person can compromise breathing and there are some postures which compromise respiratory function in a restrained person, but the witnesses’ evidence in this case did not suggest the deceased had been restrained in a way which would threaten her breathing and compromise her from that perspective.

Professor Joyce concluded the evidence indicated the deceased had been intoxicated with methylamphetamine at the time of her death and that was probably through a sustained high level of methylamphetamine use. He described her behaviour as entirely consistent with a methylampetamine induced agitated delirium. He could not rule out a delusional state but said the evidence was not sufficient, although there was the issue of the deceased insisting her son was in the various houses to which she demanded access.

Although Professor Joyce did not have the statements of the police at the time he reviewed the matter, he did have the witness statements as to events both before and after police arrival. The evidence of the police officers was described to Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 32.

Professor Joyce and he agreed the presence of methylamphetamine in her system at the level at which it was, and her manner of death, was entirely consistent with a methylamphetamine induced lethal cardiac rhythm disturbance during extreme exertion.

The extreme exertion related to events before police arrival as well as her attempts to evade police. Although the witness, Mr Steer, did not consider the deceased struggled once the police had restrained her, the evidence of Merttens and Hall makes it clear this was because they were holding her and preventing her from moving in an attempt to reduce her injuries.

The earliest ECG in the ambulance records shows the deceased was already in asystole (no cardiac electrical activity). Professor Joyce explained that typically methylamphetamine caused ventricular fibrillation, but would progress to asystole if effective circulation could not be re-established. Methylamphetamine can also cause sudden cardiac arrest in the absence of severe exertion but that is rare and in this case there is evidence of exertion. In the cases Professor Joyce was referring to without exertion, the levels of methylamphetamine were generally much higher.

Professor Joyce considered the deceased’s venlafaxine and its metabolite, desmethylvenlafaxine, may have increased Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 33.

the toxic potential of methylamphetamine, but that was only a theoretical proposition. He did not consider the pharmacological evidence added anything to understanding the complete circumstances, and although blood loss, tension pneumothorax or position during restraint could contribute to death through impaired oxygen delivery this was not as significant as the degree of exertion described.

Each could be an additional stressor to oxygen delivery.

Professor Joyce indicated contributions to an arrhythmia risk from a head injury or venlafaxine could not be excluded, however, there was no evidence those factors could cause sudden death, without the presence of methylamphetamine intoxication.

Professor Joyce considered the circumstances and outcomes of the evidence in this case are typical of methylamphetamine and exertion induced cardiac arrhythmia. Without the exertion, activity, pain and distress, he believed the methylamphetamine and amphetamine would probably not have directly threatened the deceased’s life. However, the presence of agitated delirium sets in train a number of consequences which means the presence of methylamphetamine intoxication was an indispensable contribution to her death in this case.

Professor Joyce confirmed the deceased’s death resulted from a medical emergency, which was in existence before Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 34.

the police arrived. The police were faced with the prospect of a sudden death due to methylamphetamine and exertion induced cardiac arrhythmia from the time they arrived at the scene.

It was necessary to restrain the deceased in the circumstances, to bring her under control, and once the cardiac arrhythmia commenced the more rapidly her electrical impulses were brought under control and stabilised the better her outcomes. In this case the deceased was provided with cardiopulmonary resuscitation from the moment she stopped breathing and as such her downtime was minimal. This gave her the best chance for survival, if that was to be the outcome.

CONCLUSION AS THE DEATH OF THE DECEASED I am satisfied the deceased was a 33 year old female who was a regular amphetamine user. At the time of her death she was living in a defacto relationship in Armadale and her son was being cared for by her mother in Tasmania.

During the months leading up to the deceased’s death she was experiencing some increased signs of pronounced responses to her methylamphetamine intoxication. This resulted in what was probably agitated delirium on the 11 March 2012. She was admitted to hospital on that date and it was concluded her responses were consistent with Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 35.

methylamphetamine intoxication rather than a psychiatric condition.

On 27 April 2012 the deceased experienced a relatively normal day and at some point consumed methylamphetamine. Following this she appears to have become mildly delusional. She became fixated on the fact her son was somehow in one of the houses within walking distance in Armadale.

The deceased attempted to enter a number of properties, some of which contained young children, in a fairly violent and aggressive manner. This provoked extreme responses from some of the householders. One in particular, in attempting to control her behaviour, inflicted considerable injury to the deceased on more than one occasion.

The deceased attempted to enter one property through a window she smashed and the attempts of the occupants and others to remove her from that situation caused her extensive lacerations, one on her forearm left her bleeding quite heavily. During the course of the various struggles she suffered a smashed scapula, forearm, and a fractured skull.

Although the deceased appeared to collapse as a result of the events, she ultimately always came to her feet and eventually, using one of the weapons which had been used Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 36.

against her, continued to rampage. A number of calls were put through to police and the context of those caused the police who attended to believe they would be dealing with a burglary in progress.

Officers Hall, Merttens and Perhavec attended, in two separate vehicles, and were confronted with a collapsed deceased, and a number of bystanders observing, and advising the police she was very strong and aggressive. The police on seeing the deceased and her state immediately asked for an ambulance. When she attempted to continue her activities they made the decision they needed to restrain her for her own safety, the safety of others, and to ensure she received medical treatment. It was obvious to them they were dealing with a medical emergency.

The presence of the police appears to have agitated the deceased further. She attempted to get to her feet and either accost, or run away from them. It is not clear which.

Certainly some of the bystanders believed she was intending to attack various people. Once on her feet and moving Hall was able to catch hold of her and bring her to the ground.

All three police officers then surrounded her in an effort to:

(a) restrain her,

(b) keep her as injury free as possible and

(c) ensure she was in a position in which she was able to breath.

Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 37.

One of the bystanders believed one of the police officers had his knee on her back. However, I am satisfied from the description of that police officer his weight was on his right knee which was on the ground, and his left leg was over her body, but without any compressive force. It was an attempt to prevent excessive movement and an ability to stand.

Unless the deceased struggled her body would not have come into contact with that shielding leg. This would not have been obvious to bystanders who, nevertheless, were all adamant the police behaved professionally, calmly, and certainly in the deceased’s best interests as far as they could see.

The police officers were very conscious of the potential for agitated (excited) delirium and two of them believed they were dealing with that situation prior to their attempts to restrain her. Once she was restrained Perhavec was very mindful of positional asphyxia and all three officers concentrated on attempting to calm her without causing further injury or impairment to her oxygen intake.

Unfortunately the deceased stopped breathing and the police officers immediately turned her onto her back to begin cardiopulmonary resuscitation. However, placing her on her back appears to have jolted her into breathing and as she recommenced to take shallow breaths, so she was again placed on her side and maintained in that position. The police officers monitored her closely pending the arrival of Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 38.

an ambulance which had already been requested to attend, priority one.

Before the ambulance arrived the deceased again stopped breathing and the police officers turned her onto her back and commenced cardiopulmonary resuscitation as the ambulance officers arrived and set up their equipment.

I am satisfied, despite the process of restraining the deceased, the deceased was in a less vulnerable situation on the arrival of the police than she had been before.

In the event the police had not arrived when they did, it is highly likely the deceased would have roused and again commenced her search for her son. She would have suffered further extreme confrontation with the residents of Kyogle Place. She was already in a condition where she was likely to experience a sudden death event as a result of her intoxication, agitated delirium and the extreme exertion of the previous hour.

The arrival of police prepared to undertake competent resuscitation gave the deceased the best chance of survival she had at that point in time.

Manner and Cause of Death Unfortunately despite prompt medical attention from the police officers and paramedics the deceased could no longer Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 39.

compensate for her extremely agitated state and she died shortly after arrival in AKMH as the result of a fatal cardiac arrhythmia induced by methylamphetamine intoxication and extreme exertion.

I find death occurred by way of misadventure.

ACTIONS OF THE POLICE Review of the police training manuals and modules indicates the training and education of police in the areas of ‘use of force in effecting control of individuals’ and their understanding of the difficulties surrounding dealing with individuals ‘suffering the effects of psychostimulants’ has been updated. The training now received by police officers at the Academy is comprehensive concerning the uncontrollable risk factors, such as agitated delirium, and the controllable risk factors, such as the methods of restraint and their effect on a person’s wellbeing.

That training now covers the risk police may be dealing with a medical emergency prior to the issue of restraint, and the fact of sudden cardiac death needs to be understood along with the concepts of the effects of restraint.

In this case the police officers certainly understood they were dealing with a medical emergency and acted in the deceased’s best interest in attempting to calm her and place Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 40.

her in a situation where she was no longer exposed to extreme physical exertion. While two of the police officers were quite clear they were facing a situation of excited (agitated) delirium, the third was also extremely mindful of the effects of positional asphyxia.

It was apparent in evidence there may have been some difficulty with the police officers’ ability to articulate their conceptual understanding of the situation with which they were faced. However, the practical outcome was their training had taught them to respond appropriately.

Whether they were dealing with a situation of excited delirium or were just avoiding the very real dangers of positional asphyxia did not matter in the practical outcome in the circumstances of this case.

Dr Cadden clarified that positional asphyxia is a mechanical or physical obstruction of the ability to breathe freely and so oxygenate the blood effectively. This can result from obstruction of the airways, compression of the lungs, diaphragm, or compression which may affect the beating of the heart. Any of these mechanical or physical obstructions to the process of respiration, can cause death by asphyxia.

Agitated delirium is a physiological/chemical response of the body to psychostimulant intoxication which affects the chemistry of the body and so prevents effective oxygenation Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 41.

of the system which works beyond its capacity in an attempt to deliver oxygen to the vital organs and brain.

While the effect of the reduced ability to respire effectively will result in cardiac arrest, the pathways are different. One is physical, the other physiological.

I am unable to say whether that definition of positional asphyxia makes the theory any easier in police officer training, however, I am satisfied that despite there being some difficulty with the concepts, the practical outcome of the police training they received is that all three officers clearly understood their training, both at the original level and at the refresher courses.

I am satisfied the three officers in this particular set of circumstances well understood the fact the deceased was faced with a medical emergency and acted in the deceased’s best interests when they attempted to restrain and then monitor her pending the arrival of the ambulance.

Effectively the police were the deceased’s best chances of survival in the circumstances in which she found herself at approximately 9pm on the 27 April 2012.

I note all three police officers indicated they had been confronted with methylamphetamine intoxication difficulties a number of times in their careers. Prior to 2004-2006 most police officers found themselves confronting the issue of Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 42.

methylamphetamine intoxication without having prior experience, or comprehensive education, other than the fact of positional asphyxia, which was only one of the risk factors of which police needed to be aware when dealing with persons suffering psychostimulant intoxication and the need to restrain them.

I do not feel there are useful recommendations I can make.

It is clear that with the increased prevalence of methylamphetamine intoxication in the community, the training of police to confront these situations has moved with the times.

E F VICKER Deputy State Coroner 17 November 2016 Inquest into the death of Shannon Elizabeth MURPHY (429/2012) page 43.