CORONERS ACT, 2003
SOUTH
AUSTRALIA
FINDING OF INQUEST
An Inquest taken on behalf of our Sovereign Lady the Queen at
Adelaide in the State of South Australia, on the 28th, 29th and 30th June 2006, and the 3rd
January 2007, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns,
State Coroner, into the death of Brodie Sian Foot.
The said Court finds that Brodie Sian Foot aged 23 years, late of Unit
6, 31 Parkmore Avenue, Sturt died at Somerton Park, South Australia on the 24th day of
March 2004 as a result of drowning and citalopram overdose. The said Court finds that the
circumstances of her death were as follows:
1.
Introduction
1.1.
Brodie Sian Foot was a twenty-three year old woman who was found deceased in the
sea near Somerton Park on 24 March 2004. She was single, and lived with her five
year old son in rented accommodation. She was a second year at Flinders University,
being enrolled in the Occupational Therapy course at that institution. She was in
receipt of a supporting parents benefit. She had recently seen a doctor, and had been
commenced on anti-depressant medication.
A post mortem examination was
conducted on 25 March 2004, and the cause of death was given as follows:
‘1A) Drowning.
1B) Citalopram overdose.’
(Exhibit C2a)
1.2.
The focus of the Inquest was on the events of 17 March 2004. On that day, Ms Foot
made a number of efforts to obtain medical assistance for herself. She presented to a
general practitioner who referred her to the Flinders Medical Centre, which after some
assessment discharged her, after which she finally visited a second general
practitioner who worked at the same practice as the general practitioner she had seen
earlier that day. She was very distressed, apparently as a result of a relationship
2
break-up with her partner some time before, and, according to expert evidence
provided to the Court, was suffering from a significant depressive condition and
almost certainly that of a major depressive disorder.
1.3.
The movements and activities of Ms Foot between 17 March 2004 and 24 March
2004 when she was found in the ocean off Somerton beach were not examined in
detail at the Inquest. Inquiries were made Detective Senior Constable McLean in an
effort to establish what, if any, other contacts Ms Foot may have had with the health
system during that period.
In particular, inquiries were made with the Health
Insurance Commission (Commonwealth).
That Commission provided Detective
Senior Constable McLean with certain information which was not produced to the
Inquest by reason of secrecy provisions contained in the Health Insurance Act 1973
(section 130(3A)) and the National Health Act 1953 (section 135A(3)).
Those
provisions prevented disclosure of the information beyond Detective Senior Constable
McLean and persons involved in the investigation. However, had the material elicited
from the Health Insurance Commission opened any lines of inquiries there is no doubt
that Detective Senior Constable McLean would have pursued them.
2.
Dr Chew – Ms Foot’s first medical appointment on 17 March 2004
2.1.
Dr Angela Chew gave evidence at the Inquest. She also provided a very short written
statement to Detective Senior Constable McLean by letter dated 8 April 2005 which
was admitted as evidence as Exhibit C13 in these proceedings. Ms Foot attended at
the Marion Domain Medical and Dental Centre where Dr Angela Chew practiced.
Dr Chew had not seen Ms Foot before that day, and according to records of the
Marion Domain Medical and Dental Centre which were put before the Court, she had
only attended at the centre on one previous occasion on 6 January 2004 for an
unrelated purpose.
2.2.
Dr Chew made a brief computer record of the consultation as follows:
‘distressed crying – depression – several months – not on Rx (meaning no treatment)
worse last night – suicidal ideation
no family support
Rx – ref FMC
Outbox: Referral Letter’ (The words in parenthesis are mine).
(Exhibit C15)
3
2.3.
Dr Chew did write a letter to the Flinders Medical Centre Emergency Department
doctor, a copy of which was admitted as Exhibit C14. The letter is extremely brief
and is as follows:
‘Thank you for your advice and help with the continuing management of this patient who
presented today with depression & suicidal ideation & distressed.’
2.4.
Dr Chew stated in evidence that her reason for the referral to Flinders Medical Centre
was that Ms Foot was depressed and had suicidal thoughts and therefore she needed
immediate treatment because she was at risk of harming herself. Dr Chew stated that
she herself could not manage Ms Foot that morning and therefore referred her to
Flinders Medical Centre (T26-27).
2.5.
Dr Chew never saw Ms Foot again.
She was shown a copy of a facsimile
transmission from the Flinders Medical Centre Emergency Department addressed
herself and apparently sent on 18 March 2004 at 0604. The facsimile records that
Ms Foot did indeed attend at the Flinders Medical Centre Emergency Department on
Wednesday 17 March 2004 at 10:08 am. It recorded that her presenting condition
was “suicidal ideation, depression, not coping”.
depressive disorder, single episode”.
It gave a diagnosis of “major
It then stated “Not Admitted to FMC –
Discharged to home”. Dr Chew acknowledged that the facsimile was received by her
practice.
It was admitted as Exhibit C16 in these proceedings.
It appears that
Dr Chew was consulting with Ms Foot at approximately 9:49 am that morning (T23)
therefore Ms Foot wasted no time in proceeding to the Flinders Medical Centre with
the referral letter from Dr Chew.
3.
Ms Foot attends Flinders Medical Centre
3.1.
Dr Ching
Dr Peter Chi-Ming Ching gave evidence at the Inquest. He also provided at statement
to Detective Senior Constable McLean which was admitted and marked Exhibit C17.
He is now an anaesthetic registrar at the Women’s and Children’s Hospital. In March
2004 he was a second year registered medical officer in the Emergency Department at
Flinders Medical Centre. On 17 March 2004 he was working on the day shift. He did
not recall Ms Foot and had to resort to the Flinders Medical Centre notes. Those
notes showed that Ms Foot was seen by a triage nurse who made some initial
observations of temperature, pulse, breathing and blood pressure at 11:15 am.
Dr Ching stated he would have seen Ms Foot after that initial assessment. He took a
4
history which identified Ms Foot’s age and living arrangements and recorded that she
presented with suicidal ideation and depression. She had no significant past medical
history and was not taking medication. She told him that she had a long history of
depression which had never been treated, but which had become acutely worse in the
last few days. She referred to relationship problems with her partner or friends but
would not reveal more about that to him. She stated that she was constantly crying
and had increased alcohol use. She stated that she had occasional suicidal thoughts.
She told him that she had plans but she would not reveal them. She told him that she
did not have any close family or friends for support, had not obtained any psychiatric
services in the past, and that her general heath was good.
3.2.
Dr Ching did a screening physical examination and did not find any significant.
3.3.
Dr Ching stated that the fact that Ms Foot had told him that she had suicidal plans but
that she would not reveal to him what her plans were “is a sign of high risk” (T44).
He decided to refer her for further psychiatric assessment in the Emergency
Department. He stated that during the day shift there is always a mental health nurse
who is attached to the Emergency Department and the Emergency Department
registered medical officer (RMO) usually refers psychiatric patients for assessment by
the mental health nurse.
The mental health nurse then communicates with the
psychiatric registrar or consultant.
3.4.
He stated that he would have done a direct verbal handover of Ms Foot to the mental
health nurse who was on duty. He stated that he would have also handed over the
Emergency Department progress notes and the general practitioner referral letter. He
stated that he had expected that Ms Foot would have been seen by a psychiatric
registrar at some point because on his assessment she had “high risk suicidal signs”
(T46). He did stated that not all patients are necessarily seen by the psychiatric
registrar. He stated that if a patient had presented on multiple occasions with non life
threatening complaints and simply needed reassurance, the patient might be seen by a
mental heath nurse but not a psychiatric registrar. However, he stated that “my
expectation would be that the psychiatric registrar would see all patients who
presented for the first time” (T48). He stated that his expectation was that Ms Foot
would be seen by a psychiatric registrar.
5
3.5.
Dr Ching stated that he would have considered other possible explanations of a nonpsychiatric nature for Ms Foot’s presenting condition. He stated that he would have
ruled out hyperthyroidism, for example, on her physical examination as her presenting
condition did not indicate it.
3.6.
Dr Ching stated that when he made his handover to the mental health nurse, the nurse
in question was Michael Hawkins. Dr Ching stated the would have brought his
documentation to Mr Hawkins and told Mr Hawkins about Ms Foot’s depressive
condition, her suicidal ideation, and “I would have emphasised the point that she
would have had plans but didn’t reveal them” (T57). He stated that he would have
done that because it was something which he considered to be quite significant.
3.7.
Dr Ching stated that he was not the author of the facsimile advise of discharge
(Exhibit C16).
3.8.
Dr Ching stated that he did not have any expectations as to whether Ms Foot would be
admitted or not because it was up to the psychiatric services within Flinders Medical
Centre to determine whether the patient needs to be admitted or can be managed as an
outpatient or in the community (T58).
3.9.
Mental Health Nurse Michael Hawkins
Mr Michael Hawkins, Registered General Nurse and Mental Health Nurse gave
evidence at the Inquest. He holds a Batchelor of Nursing and a Graduate Diploma of
Mental Health Nursing both awarded by Flinders University.
He provided a
statement to Detective Senior Constable McLean which was admitted as Exhibit C19
in these proceedings.
3.10. Mr Hawkins stated that he works with the Southern Assessment and Crisis
Intervention Service (Southern ACIS) and from time to time relieves in the
Emergency Department at Flinders Medical Centre as the ACIS nurse.
3.11. He provided an account of the role of the ACIS nurse at the Emergency Department at
Flinders Medical Centre which corresponded largely with that of Dr Ching. He stated
that the patient would be seen by the triage nurse, and if assessed as being a
psychiatric patient, would then be seen by the registered medical officer on duty. If
the registered medical officer confirmed the view that there was a psychiatric issue,
then the registered medical officer would refer the patient to the mental health team.
6
At that point the Mental Health Nurse would become involved. He stated that the
Mental Health Nurse might send the patient to the psychiatric registrar or consultant,
but added that it was his understanding of the practice at the time, which I took to be
March 2004, that the Mental Health Nurse might also decide upon a management plan
for a patient. He said that in that case the plan would be discussed with the registrar
or consultant and if agreed the Mental Health Nurse would implement the plan. The
implication of this was that he had an understanding that not all patients would
necessarily be referred to the psychiatric registrar or consultant by the Mental Health
Nurse. The relevance of this will become more apparent in due course.
3.12. Mr Hawkins stated that he could not recall now but that it was most likely that he
would have had the documentary material which had been gathered to that point in
relation to Ms Foot, namely the progress notes of Dr Ching, and Dr Chew’s note of
referral. Mr Hawkins recorded his own history and assessment on a document headed
“Community Assessment Record”. He stated that the assessment would have taken
approximately forty-five minutes. He assessed Ms Foot as a young person of high
alibility to carry out daily living. He noted that she was enrolled in Occupational
Therapy and had completed her first year and was therefore a highly functioning
person who was able to overcome disadvantages in her life. He did not think she was
chronically depressed but was depressed by her recent break-up. He rated her risk of
self-harm to be moderate. He noted that she had a good relationship with her family
and particularly her younger brother. He did not think her stated plan of overdosing
on “whatever I can get” was a specific plan against the context of her relationship
break-up.
3.13. He assessed that she had situational crisis leading to a depressive episode.
He
recorded that he had discussed the matter with the psychiatric registrar who, on
Mr Hawkins recommendation, provided four Diazepam 5 mg tablets to help with
sleep over the next two or three days. He stated that this would have been approved
by the psychiatric registrar but he could not remember who the registrar was. He
acknowledged a photograph of an envelope bearing the words “Diazepam 5 mg” as a
depiction of the envelope he would of provided to Ms Foot containing the four
Diazepam tablets and that the handwriting was his.
3.14. The second aspect of his management plan was to request Southern ACIS to make
contact with Ms Foot between 1600 and 1800 hours that day for short-term support
7
and referral as determined. He stated that he would have gathered together all of the
relevant documents and then written a covering note on a facsimile cover sheet and
faxed the information to Southern ACIS. He then would have rung the triage worker
at Southern ACIS to confirm that the papers had arrived. He said that Southern ACIS
would then have opened an interim file while awaiting contact with Ms Foot.
3.15. He also stated that the triage worker at Southern ACIS would have discussed the case
with the Southern ACIS consultant. A copy of the bundle of documents which was
provided by Mr Hawkins to Southern ACIS was admitted as Exhibit C20 in these
proceedings. The facsimile transmission was dated 17 March 2004 and was sent at
1315 hours on that day.
3.16. Finally, Mr Hawkins provided details of a general practitioner – Dr Helen Sage –
because of the importance of having a regular general practitioner. He stated that
would not have done this if he had obtained the impression that Ms Foot would return
to Dr Chew. He stated that it was important to stress the need for a patient in
Ms Foot’s circumstances to have a regular general practitioner:
‘It's critical, I believe, because if someone is to be given medication to assist with their
depression it is critical that the person who prescribed it follows it up.’ (T75)
3.17. He stated that, as at 17 March 2004, he was not aware of any protocol within the
Emergency Department at Flinders Medical Centre that a patient presenting with
psychiatric symptoms who had never been seen before by the department, should be
seen by a psychiatric registrar.
3.18. Mr Hawkins was not represented by Counsel for the Flinders Medical Centre in these
proceedings. He was represented by his own Counsel. Counsel for the Flinders
Medical Centre asked Mr Hawkins questions about the orientation which he would
have received when he first went to work in the Flinders Medical Centre Emergency
Department. He was asked particularly about guidelines as to when a patient needed
to be seen by the psychiatric registrar. Mr Hawkins could not recall specifically, but
stated that he recalled that the criteria were much the same as they would have been in
Southern ACIS where, if a nurse felt that it was important for one of the doctors to
start the patient on a course of medication then the patient would be referred to the
doctor, or if the patient was thought by the nurse to be detainable then the patient
would be referred to the doctor. However, if the decision was made that the person’s
condition did not warrant admission, it was possible for the nurse to make that
8
decision. When questioned by Counsel for the Flinders Medical Centre whether he
understood in March 2004 that a patient such as Ms Foot who had not previously been
seen by the psychiatric team at Flinders Medical Centre and was presenting with a
psychiatric condition should be seen by a psychiatric registrar he stated “I understand
after the event that that is the current protocol. At the time I did not know that.”
3.19. Mr Hawkins stated that he thought it was unlikely that he would have recommended
to the psychiatric registrar that the registrar not see the patient, but he believed that he
would have had a discussion with the psychiatric registrar about his proposed course
of action, and that the psychiatric registrar would have agreed with it. Strangely,
Counsel for the Flinders Medical Centre asked him why he did not recommend to the
psychiatric registrar that the patient be examined by that registrar. This seems to me
to be an unusual proposition to put to a mental heath nurse working within the
Flinders Medical Centre Emergency Department; I would have thought it more
consistent with the hierarchical relationship between registrar and nurse that the nurse
would take his or her cue from the registrar in these matters.
3.20. It was put to Mr Hawkins by Counsel for the Flinders Medical Centre that the
Diazepam should not have been provided to Ms Foot without her having been seen by
a doctor. He stated that he is now well aware that a medical practitioner should not
authorise the provision of medication to a patient without actually seeing the patient
but could not remember what his knowledge was at the time.
3.21. It will be noted that according to Mr Hawkins account of his dealings with Ms Foot,
there were at least two significant differences between her account to him and her
account to Dr Ching and Dr Chew. In particular, Dr Ching was concerned that
Ms Foot had a suicidal plan but would not reveal it to him. Dr Ching regarded that as
particularly significant. However, by the time Ms Foot saw Mr Hawkins, her account
had changed; to Mr Hawkins she was saying that her plan was to overdose on
whatever she could get. Secondly, she had told both doctors Chew and Ching that she
did not have good family support; to Mr Hawkins, she stated the opposite.
Mr Hawkins was questioned extensively about the significance of these differences.
It appears that he did not attach any great significance to these differences and
accepted the account given to him by Ms Foot as an accurate representation of her
state of mind and beliefs when he saw her. He acknowledged that psychiatric patients
9
sometimes conceal the truth or even lie. He simply stated that his assessment of her
was at the time she was speaking to him she was truthful.
3.22. In my view, this approach by Mr Hawkins is altogether too glib. By the time Ms Foot
saw Mr Hawkins, she had already had contact with doctors Chew and Ching to whom
she had provided histories, and at least one, possibly two nurses at the Flinders
Medical Centre to whom she had also provided details. It is very likely by the time
she saw Mr Hawkins that she may have been impatient, and altering her account to
move through the system more quickly. In my view, Mr Hawkins should have been
alerted to a possible problem with the differing accounts. He agreed that given the
differences in presentation it would have been prudent in hindsight to ask the
psychiatric registrar to assess her (T99).
4.
The position of Flinders Medical Centre in the Inquest – Statement of Professor
Ross Kalucy
4.1.
After the commencement of the Inquest on the first day of hearing, the solicitors for
Flinders Medical Centre forwarded to the Court a statement of Professor Ross Kalucy.
That statement was subsequently verified by affidavit made on 29 June 2006 and
admitted in evidence as Exhibit C23.
4.2.
The statement identifies Professor Kalucy as the Head of the Department of
Psychiatry at the Flinders Medical Centre and the Director of Emergency Mental
Health at Flinders Medical Centre. Professor Kalucy states that he is familiar with the
facts of this Inquest and has read the statements of doctors Ching and Morris and
Registered Mental Health Nurse Hawkins and a report provided to the Court by
Professor Goldney. I will quote from the statement because it is significant:
‘5.
The mental health service supplied to the Emergency Department (ED) of FMC
should operate in the following way:
5.1 There are senior ACIS nurses who are available in the ED to review patients
who attend with psychiatric symptoms or conditions. There is also a
Psychiatric Registrar and myself available to review patients.
5.2 Between 8.00 to 8.30 each morning, 10.00 to 10.30 a.m., 12.00 to 12.30 p.m.
and then again at mid-afternoon, there is a handover between the ACIS
nurses, the Psychiatric Registrar and myself. All cases are reviewed. During
the morning I review all detention orders and the Psychiatric Registrar will
review patients referred by the ACIS nurses.
10
5.3 All patients should be referred by the ACIS nurses to either the Psychiatric
Registrar or myself unless the patients are extremely well known to us so long
standing management plans can be put in place by the ACIS nurses.
4.3.
6.
I am uncertain as to why Mick Hawkins was on duty as an ACIS nurse. He is not
the usual ACIS replacement nurse who comes to the ED. It is possible that he did
not receive proper orientation as to the system that operates in the ED with respect
to providing mental health nursing and psychiatric assistance.
7.
I have no understanding from the documents I have reviewed why Ms. Foot was
only reviewed by Mr Hawkins without any follow-up by the Psychiatric Registrar.
In my experience, this was an extremely rare event.
8.
From my experience and understanding of how the mental health services operate
with the ED when a patient presents as Ms. Foot did, she was dealt with in what I
can only say is an extremely anomalous fashion.
9.
It is not the policy of the psychiatric team working within ED to provide drugs
without the patient being reviewed by either the Registrar or myself. It is also the
policy of the department that any patient who presents with a specific problem,
such as depression and suicidal ideation, is to be referred to a Psychiatrist for
review.
10.
(Omitted)
11.
(Omitted)
12.
(Omitted)
13.
In summary, Ms. Foot should have been reviewed by the Psychiatric Registrar
given her presentation to the ED and most importantly because she was not known
to the team.
14.
(Omitted)
15.
(Omitted)
16.
The department is in the process of committing to writing some guidelines for the
ACIS nurses and all staff who make up the psychiatric team operating in the ED. I
understand also that ACIS is general1y developing a new system whereby there
will be services offered to patients who need acute intervention and alternative
services to patients who :may need long term fol1ow-up care in the community,
say for a period of twelve months.’
(Exhibit C23)
The omitted passages are to the effect that it is unusual for Diazepam to be provided
in the manner that it was to Ms Foot, that Professor Kalucy is unable to say whether
Mr Foot should have been detained but that she could certainly have had an overnight
stay in the Extended Emergency Care Unit at Flinders Medical Centre, and that
voluntary admission could have been considered. He stated that it would also have
been possible to arrange a more intensive community care program, including to
Dr Chew as distinct from a new general practitioner.
He also states that he is
concerned that Mr Hawkins not be entirely blamed for the problems that have arisen
11
and that he had little experience of the Emergency Department and the policies of the
psychiatric team but is known to have a long history of a mature and professional
attitude.
4.4.
The provision of this statement on the first day of the Inquest shows a belated
acceptance by Flinders Medical Centre of deficiencies in the handling of Ms Foot’s
case. It would have been far more useful if these acknowledgements of shortcomings
had been made at a much earlier stage. Flinders Medical Centre has been well aware
of these proceedings for a considerable amount of time. Counsel for Flinders Medical
Centre had no proper explanation of why the concessions were not forthcoming much
earlier. She was only able to say that the Inquest material was provided to the
hospital at some time previously.
4.5.
It is disappointing that significant concessions of shortcomings in the treatment of a
patient should only be made by a public hospital on the first day of an Inquest into the
death of that patient. Earlier advice of a concession such as this matter might have the
potential to refocus the direction of the Inquest in a way that might produce more
useful outcomes.
5.
Mr Hawkins level of understanding of Flinders Medical Centre’s stated policies
as at March 2004
5.1.
At T106 Mr Hawkins made it plain that it was not his understanding as at March 2004
that a patient who presented with a specific problem such as depression or suicidal
ideation was to be referred to a psychiatrist for review. He stated that a nurse could
not offer medication without discussing the matter with the registrar or consultant
first. It will be noted this contrasts quite starkly with the policy as stated by Professor
Kalucy in his statement. Mr Hawkins acknowledged that it would be unusual for
medication to be provided without the patient having been seen by the doctor, but not
“very unusual”.
5.2.
At T112 Mr Hawkins stated that he did not advise Ms Foot to go to a general
practitioner to obtain antidepressant medication (T112). He stated however that it
was probably likely that he would have discussed antidepressants with her.
6.
Dr David Morris – the events of the evening of 17 March 2004
12
6.1.
Dr David Morris gave evidence at the Inquest. He stated that he practices as a general
practitioner at the Marion Domain Medical Centre. He was interviewed by Detective
Senior Constable McLean and a record of that interview was admitted as Exhibit C21
in these proceedings.
6.2.
Dr Morris gave evidence that Ms Foot attended at the practice at 7:22 pm on
17 March 2004. She waited until 8:10 pm when she was assigned to Dr Morris.
Dr Morris started to enter a record of the consultation into the computer system at
8:32 pm. He stated that Ms Foot was the last patient he saw on that day and that he
had never seen her before.
He stated that he would have accessed Ms Foot’s
computerised notes, and that Dr Chew’s record of consultation was available to him
on the computer and he accessed it at the time of his consultation with Ms Foot.
6.3.
Dr Morris stated that Ms Foot was very reserved and withdrawn and that it was
difficult to take a history from her. He thought that she had been assessed by a
psychiatric registrar at Flinders Medical Centre and did not know that she had only
been seen by a psychiatric nurse. Ms Foot told him that she had been given a small
supply of Diazepam to assist her to sleep. She taken some that afternoon to help her
sleep but they had been ineffective. He said that her opening remark to him was that
she had come to see him at Flinders Medical Centre’s request to obtain
antidepressants. He stated that this is a little unusual because a patient usually would
be provided with antidepressant medication at the Flinders Medical Centre pharmacy
in those circumstances. However, in some situations a patient may not want to wait
for medication to be dispensed at the hospital and they come back to a general
practitioner. This also assists to forge a link with the general practitioner.
6.4.
He stated that he made no physical examination of Ms Foot. He said that she was
initially reluctant to talk but gradually opened up. She mentioned her boyfriend and
her break-up. Dr Morris was concerned about the suicidal thoughts expressed to
Dr Chew earlier, but Ms Foot reassured him that she had become happier over the
course of the day. Dr Morris formed the view that she would not be an immediate
risk to herself at that time. He stated that he gave her antidepressants but not just
because she asked for them, but as a result of his consideration of her circumstances
and history. He did not recall her mentioning the referral to Southern ACIS.
13
6.5.
He stated that he gave Ms Foot two “starter packs” of the antidepressant Cipramil. He
stated that the starter packs are supplied to general practitioners by pharmaceutical
representatives and can be useful to provide a patient with a small supply to get
started.
If the patient tolerates the medication well, then the doctor can give a
prescription later.
6.6.
Dr Morris stated that he gave Ms Foot two packs of Cipramil with seven tablets in
each pack, which is how they are provided to him by the drug company. He provided
her with two packs because there is a delay in the onset of benefit from the
antidepressant of up to ten to fourteen days, and it was his policy to give enough
medication to get the patient to start to feel some benefit, get through any troublesome
side effects, and then review the patient’s progress at the end of the ten to fourteen
day period to see how they were managing (T130).
6.7.
Dr Morris stated that he would have made Ms Foot aware of the potential side effects
of Cipramil which he stated can include nausea, dizziness and insomnia.
He
suggested to Ms Foot that she should start with half a tablet for a few days until she
became used to the medication and then move up to a full tablet daily. He also
provided her with the sleeping medication Stilnox in a starter pack form to assist her
with her sleep. He stated that it was his understanding that even if Ms Foot had taken
all of the Cipramil and Stilnox which he provided to her that evening in one dose it
would not have been lethal.
6.8.
He stated that when he provides a patient with an antidepressant medication such as
Cipramil he likes to take responsibility for the seeing the patient at follow-up. He
believed that he would have offered Ms Foot the choice of coming back to see him at
ten days or possibly Dr Chew if she wanted. He would have told her what days and
hours he worked and told her how to register to see him again.
6.9.
Dr Morris stated that he was of the understanding that Ms Foot would come back to
see either himself or Dr Chew at the follow-up at which time he hoped that the
medication he provided would have become effective (T135-136).
6.10. Dr Morris stated that his next contact was when Ms Foot’s sister Kylies contacted him
to inform him of Ms Foot’s death. He then had some meetings and discussions with
Ms Foot’s family and has generally made himself available to the family at all times.
Dr Morris was asked whether he was aware in March 2004 of any risk factors peculiar
14
to any age group in the prescription of Cipramil. He stated that in March 2004 he
believed that the provision of antidepressants such as Cipramil to young children was
not recommended but that in people of Ms Foot’s age group he had prescribed it for
many years with no problems. He stated that Ms Foot’s sister Kylies had pointed out
to him that there was some evidence even at that time that there may be some
increased risk of suicidality with users of SSRI’s (Selective Serotonin Reuptake
Inhibitor) such as Cipramil but that he had not been aware of it at that time.
6.11. At T142 Dr Morris states that he has changed his approach to the prescription of
antidepressants in that he now ensures that he raises with patient’s the possibility of
increased thoughts of suicide and tries to establish that there is a support system that
the patient’s can use during the time they are in the early stages of antidepressant
therapy or withdrawal.
6.12. Dr Morris pointed out that an appointment to see a psychiatrist in private practice can
take two months from arrangement to the first visit. He also said that to see a general
practitioner frequently in the first ten days of commencement on an antidepressant
medication can be problematic for some general practitioners who are booked out for
a week in advance.
7.
Toxicology results – Peter Felgate
7.1.
Mr Peter Felgate is the Manager of the Toxicology Group at the Forensic Science
Centre of South Australia. He has worked in that capacity since 1974.
7.2.
Mr Felgate identified two toxicology reports which were admitted and marked Exhibit
C3a and C24 respectively. Exhibit C3a was a report dated 27 May 2004. It reported
that the drugs detected in the peripheral blood of Ms Foot were:
7.3.
‘(1)
2.1 mg citalopram per L.
(lethal concentration)
(2)
63 mg ibuprofen per L.
(excess but probably not toxic)
(3)
0.13 mg zolpidem per L.
(therapeutic concentration)
(4)
approximately 0.1 mg diazepam per L.
(therapeutic concentration)’
Exhibit C24 was a second report dated 31 August 2005 which was specifically testing
for citalopram. That report returned a result for the peripheral blood of 2.2 mg of
citalopram per litre (potentially lethal).
15
7.4.
At T185 Mr Felgate explained the difference between the two reports in their
description of the citalopram concentrations as lethal on the one hand and potentially
lethal on the other.
He stated that the description “potentially lethal” was his
preference because it took into account the findings of the pathologist who gave
drowning as another cause of death. He acknowledged that the concentration could
cause the death of a person but because there is another cause, namely drowning, it
was preferable to use the expression “potentially’”. I do not think much turns on this,
because Dr Gilbert did indeed find drowning to be a cause of death. The very high
concentration of citalopram in Ms Foot’s blood stream may well have caused her to
be drowsy with the result that she was more likely to drown. However, it appears that
the mechanism of death was more likely to be drowning than toxicity. However, it is
certainly correct to say that citalopram toxicity was a cause of death in the sense that
it was contributory.
7.5.
Mr Felgate stated that two phials of blood were taken from the peripheral regions of
Ms Foot’s body at autopsy. From these, two sets of tests were carried out, one in
2004 and the second in 2005 on the dates recorded above. The first test gave a
recording of 2.1 mg per litre and the second gave a recording of 2.2 mg per litre.
Mr Felgate explained that the difference between these two is purely an analytical
error and within the accepted variation of plus or minus twelve percent on the mean of
the results. He stated that there was no possibility of there being any laboratory error
and that the Forensic Science Centre is accredited by NATA.
7.6.
Mr Felgate that he would not expect a concentration of 2.2 mg per litre from fourteen
Cipramil tablets (T176).
7.7.
Mr Felgate stated that post mortem redistribution can affect post mortem blood
concentrations. He stated that it may therefore be that prior to death Ms Foot’s
Cipramil concentration may have been as little as 1.1 mg per litre taking account of
post mortem redistribution (T177). However, at T177 Mr Felgate stated that fourteen
Cipramil tablets would be “very unlikely” to account for a concentration of 1.1 mg
per litre of Cipramil in Ms Foot’s blood stream. He also stated that Ms Foot’s low
weight of 57 kilograms would be unlikely to provide an explanation either.
Mr Felgate also expressed the view that he thought it unlikely that the presence of
water in Ms Foot’s lungs or otherwise from her having been in the water for an
16
extended period before being found, would be likely to result in an increased
concentration of Cipramil in her blood stream.
7.8.
At T191 Mr Felgate gave evidence that in order to achieve a toxicology result of
1.1 mg per litre (this being a result assuming that post mortem redistribution had its
full effect) Ms Foot would have had to have taken fifty of the 20 mg tablets to achieve
such a concentration.
To achieve a concentration of 2.2 mg (which would be
necessary if there had been no post mortem redistribution effect) the required dosage
would have been one hundred 20 mg tablets. It will be recalled that Ms Foot was
provided with fourteen 20 mg tablets by Dr Morris (T14).
7.9.
There is no evidence before the Court to demonstrate that Ms Foot obtained any more
than fourteen Cipramil tablets in the period between 17 March 2004 and 24 March
2004. However, Mr Felgate’s evidence shows that in order to achieve the lethal
concentration of Cipramil that was found to be in her blood, she would have had to
have consumed between fifty and one hundred Cipramil tablets. Unfortunately, there
is no explanation for this apparent anomaly. I can only conclude that Ms Foot
obtained further Cipramil medication from a person or persons unknown.
8.
Flinders Medical Centre – the identity of the Psychiatric Registrar to whom
Mental Health Nurse Hawkins spoke
8.1.
Shortly before this Inquest started it came to the attention of the Court that Ms Foot’s
mother received a letter from Flinders Medical Centre dated 5 April 2004 which was
sent in response to an application made under the Freedom of Information Act 1991
for access to documents relating to Ms Foot. The letter was admitted as Exhibit C27
in these proceedings. It contains the following sentence:
‘With regard to the name of the Psychiatric Registrar with whom Brodie’s case was
discussed, I understand that it was Dr Spick.’
The letter is signed by Mr P Edwards, Manager, Freedom of Information.
8.2.
This letter was made available to Counsel Assisting me shortly before the
commencement of the Inquest. Accordingly, a summons was issued requiring the
attendance of Dr Spick at the Inquest. Dr Spick was available at short notice and
attended in response to the summons and gave evidence at the Inquest.
17
8.3.
Dr Spick said that he was working as a psychiatric registrar at Flinders Medical
Centre in early 2004, and would have been working on 17 March 2004. He stated that
at that time there were four psychiatric registrars in the department (T194).
8.4.
At T202, Dr Spick stated that it was his practice that he would always see a patient if
an ACIS nurse requested that he do so unless he was busy with some other patient or
task and was unable to see the patient in which case the nurse would be referred to
another psychiatric registrar. Dr Spick stated that if he had been the registrar and had
been handed the paperwork prepared by Nurse Hawkins he would have gone and seen
Ms Foot. He stated at T203 that he would have done this “Because I believe that firstly, from this paperwork it's not clear that she's known to the service…”
8.5.
At T205 Dr Spick was asked whether he had any recall of whether he saw Ms Foot on
17 March 2004. He replied “I definitely did not see her. I don't have any recollection
of seeing her at all.” He was asked if he recalled Nurse Hawkins discussing Ms Foot
with him on 17 March 2004 and he replied that he did not.
8.6.
At T210 Dr Spick was asked, having reviewed the Flinders Medical Centre notes
whether there were any entries or signatures entered by him and he replied in the
negative. At T212 he repeated that his position would have been that he would have
seen Ms Foot if requested to do so or informed Mr Hawkins, if Mr Hawkins had
discussed the matter with him, that he was not available and could not see her until
later and that if he needed her to be seen immediately he would have to get somebody
else to see her.
8.7.
Thus far I have summarised Dr Spick’s evidence in chief. He completed his evidence
in chief at the end of an afternoon. As matters then stood, Dr Spick had been
identified as the Registrar concerned in a letter provided by the Flinders Medical
Centre to Ms Foot’s mother but Dr Spick’s evidence to that point was that he denied
that he had been properly identified. The Flinders Medical Centre was requested to
carry out inquiries overnight with a view to determining how Dr Spick came to be
identified. When Court resumed the following morning, Counsel for the Flinders
Medical Centre advised that she had made arrangements for the Freedom of
Information Officer, Mr Edwards, to be present in Court. I decided to interpose Mr
Edwards.
I asked counsel for the Flinders Medical Centre if she had obtained
instructions in relation to the matter and she responded that she had and that Mr
18
Edwards was ready to give evidence to explain what enquiries he had carried out,
referring to appropriate documentation. Accordingly, Mr Edwards was interposed.
8.8.
Mr Edwards gave evidence that he had been contacted by Ms Foot’s sister Kylies
shortly after Ms Foot’s death. He had attempted to provide her with information as to
what had occurred when Ms Foot attended at the Flinders Medical Centre on 17
March 2004. At T227 Mr Edwards stated that he had spoken to Mr Hawkins and
established that he was the Mental Health Nurse who saw Ms Foot. He could not
recall if he asked Mr Hawkins who the psychiatric registrar was. If he had made such
an inquiry he had made no record of it in his notes. I think it is unlikely that Mr
Hawkins identified Dr Spick as the psychiatric registrar to Mr Edwards. Had Mr
Hawkins identified him, I believe that Mr Edwards would have made an entry to that
effect in the notes that he was making contemporaneously with that contact.
Significantly, Mr Hawkins was asked by his own Counsel at T72 whether he recalled
who the psychiatric registrar was and he replied “I’m sorry I have no recollection”.
He could not recall if the psychiatric registrar was male or female. At T241 Mr
Edwards was asked whether if Mr Hawkins had identified the name of the psychiatric
registrar he would have written it down. He replied:
‘Absolutely, I wouldn't have had any reason not to write it in there.’
8.9.
Mr Edwards gave evidence that he advised the Clinical Risk Manager, Ms Gail
McBain, of the contact he had had with Ms Foot’s family. He also passed this
information on to the Clinical Governance Division. He said that he believed that the
Director of Clinical Governance at that time would have been either Annette Ferris or
Professor David Ben-Tovim.
8.10. At T231 Mr Edwards was asked if he could explain how he identified Dr Spick in the
letter to Ms Foot’s mother. He was unable to give any explanation. However, he did
explain that it was his custom and practice to attempt to assist grieving families. At
T232 he said he had no recollection of how he tried to identify the psychiatric
registrar. He said that he assumed that he would have spoken to staff within the
Emergency Department and possibly spoken to some doctors. However he had no
recollection of how he identified Dr Spick as the psychiatric registrar, and stated that
this was something which he deeply regretted “now that I’m sitting here” (T233). At
T234 he stated that he may have spoken to the doctor whom he named, but he could
not be certain of it.
19
8.11. At T244 Mr Edwards stated that despite inquiries he had made he was unable to
explain how he formed the belief that Dr Spick was the psychiatric registrar to whom
Mr Hawkins spoke. In summary, Mr Edwards was unable to provide any useful
assistance to the Court about the reliability of his identification of Dr Spick. At this
stage of proceedings, Dr Spick himself had denied any involvement in examination in
chief, and Mr Edwards was unable to provide any satisfactory explanation as to his
identification of Dr Spick. Flinders Medical Centre provided the Court with no
explanation of its own position, despite having been afforded an opportunity
overnight to do so. Flinders Medical Centre was aware that Dr Spick suffered from a
serious illness that I need not identify.
8.12. When Dr Spick’s evidence resumed, counsel for the Flinders Medical Centre
exercised her right to cross-examine Dr Spick. In answer to questions from counsel
from the Flinders Medical Centre, Dr Spick conceded that he may have been the
psychiatric registrar to whom Mr Hawkins spoke but that he simply did not have any
recollection of the matter.
8.13. In the end, it became apparent that Dr Spick had no recollection of seeing Ms Foot
and that no one else was in a position definitively to assert that he did. Dr Spick very
forthrightly conceded that there was a possibility that he may have been the
psychiatric registrar to whom Mr Hawkins spoke, but it is by no means certain that he
was the registrar, and there were a number of other psychiatric registrars in the
department at that time who may have been the person concerned.
8.14. Flinders Medical Centre had knowledge through the Clinical Risk Manager,
Ms McBain, and the Director of Clinical Governance who was then either Annette
Ferris or Professor David Ben-Tovim, that Ms Foot had died, and the circumstances
in which she had died, and the fact that her family were concerned. They had this
knowledge from late March 2004. These people were also aware that Mr Edwards
had some knowledge of the matter. They were always in a position to have examined
the Flinders Medical Centre notes and to make their own efforts to identify the
psychiatric registrar to whom Mr Hawkins spoke. By the time the Inquest was heard
it was impossible to reach any conclusion about that. No doubt it would have been a
relatively simple task to have established the identity of the psychiatric registrar in
late March or early April 2004 if either the Clinical Risk Manager or the Director of
Clinical Governance had bothered to do so after being informed by Mr Edwards of the
20
issue. Instead nothing was done, and Flinders Medical Centre allowed a situation to
develop in which Dr Spick was subjected to the distress of having to give evidence
and be subjected to cross-examination, including by Counsel for the Flinders Medical
Centre. I note that Dr Spick ceased to work the Flinders Medical Centre in August
2004.
8.15. It is disappointing that the Flinders Medical Centre did not carry out, through the
Clinical Risk Manager, or the Director of Clinical Governance, some better
investigation of the identity of the psychiatric registrar than that which Mr Edwards
was able to carry out.
Had they done so, Dr Spick may have been spared the
discomfort of having to give evidence if, indeed, he were not the psychiatric registrar
concerned. If he had been identified as the psychiatric registrar concerned, then no
doubt he would have been informed of the matter much sooner, and he would have
had a proper recollection of events and, presumably, would have been provided
representation by Flinders Medical Centre rather than having been subjected to crossexamination by Flinders Medical Centre’s own Counsel.
8.16. The result was that the Court spent more than half a day pursuing a line of inquiry that
went nowhere. Furthermore, because of the delay involved in the interposition of Mr
Edwards, and the fruitless cross-examination of Dr Spick, Professor Goldney, who
had been warned as a witness for the last afternoon of the Inquest, had to be put off
until another day. This resulted in considerable inconvenience and expense to the
Court, to Professor Goldney and to Ms Foot’s family.
9.
Professor Goldney
9.1.
Professor Robert Goldney provided a report to the Court in relation to the treatment of
Ms Foot. The report is dated 20 August 2005. Professor Goldney is a distinguished
psychiatrist. He has provided many medico legal opinions in the field of psychiatry,
he is a Professor of Psychiatry (part time) at the University of Adelaide and also
conducts a private practice in general psychiatry. Professor Goldney’s report was
admitted as Exhibit C.29 in these proceedings. He also gave evidence at the Inquest.
9.2.
In Exhibit C.29 Professor Goldney stated that it is evident that Ms Foot had a
significant depressive condition and almost certainly a major depressive disorder. He
was critical of the management of Ms Foot at the Flinders Medical Centre. He
considered that her assessment and management was not adequate. He pointed out
21
that she was not seen by a Psychiatric Registrar and he considered that the importance
of a major depressive diagnosis was not properly recognised, or at the very least, not
properly documented.
Professor Goldney was highly critical of Mr Hawkins’
suggestion to Ms Foot that she consult a different General Practitioner from the
General Practitioner who had referred her to Flinders Medical Centre (Dr Chew). I
agree with Professor Goldney.
Mr Hawkins was no doubt well intentioned in
suggesting that Ms Foot consult a particular General Practitioner. However, it is
inappropriate and unprofessional for a clinician to refer a patient to a General
Practitioner other than the referring General Practitioner in these circumstances. I
note that Mr Hawkins recommended the other General Practitioner because he was a
patient of that General Practitioner. This exacerbates the problem. Mr Hawkins
allowed his personal experiences and knowledge to interfere with his professional
judgement. It goes without saying that it is inappropriate for a Psychiatric Nurse at a
public hospital to suggest that patients at that hospital should consult the nurse’s own
General Practitioner.
9.3.
Professor Goldney was also critical of the decision to provide Ms Foot with diazepam
when she had not been seen by a Psychiatric Registrar or other Medical Practitioner.
Once again, it need hardly be stated that the provision of psychotropic medication
such as diazepam to a patient who has not been seen by a Medical Practitioner by a
member of the non medical staff at a public hospital is extraordinary. It clearly
should not have happened and this was conceded by Flinders medical centre through
its counsel.
9.4.
Professor Goldney could not account for the reported blood concentration of
Citalopram in Ms Foot at autopsy. This must remain one of the mysteries of this case.
As I have already stated, it appears that Ms Foot was able to obtain supplies of
Citalopram in addition to those that were given to her by way of the sample packs
from Dr Morris. The evidence available to me simply does not cast any light upon
where she obtained that additional Citalopram.
9.5.
Ms Foot’s family was concerned about the provision of Citalopram to Ms Foot.
Citalopram is an antidepressant medication and is one of the class of drug known as
an SSRI or Selective Serotonin Re-uptake Inhibiter. Their concern was based upon
reports of suicidal behaviour in association with SSRI antidepressants. Professor
Goldney has written an article on this topic which was published in the Australian and
22
New Zealand Journal of Psychiatry 2006; 40: 381-385. A copy of the article was
admitted as Exhibit C.29a in these proceedings. In that article, Professor Goldney
refers to “increasing media scrutiny and criticism about the use of antidepressant
drugs and their possible association with suicidal behaviours”.
The import of the article Exhibit C.29a and Professor Goldney’s report Exhibit C.29 is
that
''The best available evidence is that at the population level there is no convincing
evidence that SSRIs are associated with suicidal behaviour.”
“However, whilst such studies at the population level are reassuring in regard to
the use of SSRIs in depressed persons, one can never exclude the possibility that
there may be an idiosyncratic response of an individual to a drug ….. just as there
can be to any other medication. However, the data, at the population level, do not
support the assertion that SSRIs such as Citalopram are causally related to
suicidal behaviour”.
9.6.
Professor Goldney informed the Court both in his report, and his oral evidence, that
he sits on an advisory panel of the pharmaceutical company Lundbeck Australia,
which is the manufacturer of the drug Citalopram. He made this disclosure lest it be
thought that his evidence might be coloured by his association with that company. I
am grateful to Professor Goldney for disclosing this involvement, but I have no
hesitation in accepting his evidence upon this topic. Citalopram is only one of many
SSRI antidepressants available on the market. The concerns raised in media reports
about SSRIs are not confined to Citalopram. There is an extremely wide base of
manufacturers producing SSRI antidepressants on the market. It would be most
unlikely that a distinguished academic and clinical practitioner such as Professor
Goldney would allow his independent judgement to be compromised by his role as an
advisor to one of the companies in that market.
9.7.
There seems to be little doubt that the majority of psychiatric opinion supports the
conclusion that, at the population level, antidepressants provide significant relief to
many in the community who suffer from depression. I do not consider that there is
any basis to conclude that Ms Foot’s tragic death was induced by her consumption of
the medication Citalopram.
9.8.
Professor Goldney had no criticisms to make of Doctors Chew, Ching or Morris in
their treatment of Ms Foot. He had no criticism of Dr Morris in providing the sample
23
packs of Citalopram to Ms Foot.
He noted that patients can have reactions to
particular antidepressants and the provision of starter packs is a useful aid in
determining whether a patient can tolerate a particular antidepressant without the
patient having to incur the expense of paying for a full prescription in the first
instance. This appears to be a sensible approach and I have no disagreement with
Professor Goldney’s opinion.
9.9.
As I have already noted, Professor Goldney is of the opinion that Ms Foot did not
receive optimum psychiatric care at Flinders Medical Centre. He considered that it
was not adequate that Mr Hawkins simply spoke with a Psychiatric Registrar and that
Ms Foot was not actually assessed by the Psychiatric Registrar. Professor Goldney
was critical of the fact that the psychotropic medication diazepam was provided to Ms
Foot when she had not been seen by a Medical Practitioner. With great respect to
Professor Goldney I consider that he may be understating the inadequacy of the
service provided by Flinders Medical Centre in this matter. The inadequacies speak
for themselves. The fact that Ms Foot was not seen by a Psychiatric Registrar has
been acknowledged by the Flinders Medical Centre as a failure of its own policies
and procedures at the relevant time. This is a appropriate concession that could not
have been avoided. It is unfortunate that it was not made at an earlier time. In my
opinion it is obvious that Ms Foot should have been seen by a Psychiatric Registrar.
9.10. Professor Goldney commented on the observation of Mr Hawkins that Ms Foot
appeared to be less distressed towards the end of his consultation with her and he
considered that she was improving. Professor Goldney stated that this overlooks the
fact that symptoms of depression can fluctuate within as short a period as one day.
He also referred to the so-called diurnal mood variation as a result of which people
with depression are often worse in the morning than in the afternoon. Thus when Dr
Chew saw Ms Foot in the morning, she may have appeared more depressed than she
did that afternoon. Professor Goldney gave evidence that:
''The important thing is to believe one’s colleagues”1.
He stated that if one Clinician has said that a person was severely depressed, another
Practitioner should not dismiss that lightly.
1
Transcript, page 293
24
9.11. Professor Goldney was concerned about the number of Practitioners that Ms Foot saw
on the day in question. It will be recalled that she saw Dr Chew in the morning and
Dr Ching at the Flinders Medical Centre Emergency Department. She was then
referred to Mr Hawkins who then referred her to Southern ACIS. She then returned to
the Domain Medical Practice but instead of seeing Dr Chew again, she saw Dr
Morris. As Professor Goldney said, Dr Morris was
''the fourth helping person that she’s seen in one day”
He added:
''That’s not the way to treat somebody. Really there has to be some sort of sense of
ongoing responsibility”2.
9.12. It is most unfortunate that Ms Foot was not cared for by one or perhaps two
Practitioners on that day. I can well imagine that she must have felt that she was
being referred from one person to another without being provided with definitive
treatment until she finally saw Dr Morris. I agree with Professor Goldney that this
case shows that persons in Ms Foot’s situation need to have a sense that a particular
Medical Practitioner or Psychiatrist has assumed continuing responsibility for their
care.
9.13. Professor Goldney said that Dr Morris should have recorded in his notes the number
of Citalopram tablets he provided by way of sample medication to Ms Foot.
Although Dr Morris was able to reconstruct the number from memory - and I accept
his evidence in relation to the number he provided - it was not satisfactory that he did
not make a clear record of the number provided in his notes.
10.
Conclusion
10.1. Unfortunately, the source of the additional Citalopram which Ms Foot must have
consumed remains a mystery. There is no doubt that it was most unfortunate that Ms
Foot was passed from practitioner to practitioner on the day on which she sought
treatment, culminating with the provision of the sample packs of Citalopram by Dr
Morris. If she had been able to obtain continuing care from one of the practitioners
she saw on that day, she may have been more reassured, and better able to overcome
her sense of hopelessness. It goes without saying that the Flinders Medical Centre
2
Transcript, page 327
25
failed in its responsibility to Ms Foot by failing to ensure that she saw a Psychiatric
Registrar on the day in question, and in providing her with diazepam medication when
she was not seen by a Medical Practitioner. However, the provision of the diazepam
cannot be shown, of itself, to have been causative of her death. The Flinders Medical
Centre has acknowledged the failures of that day. It asserts that they were anomalous
and were contrary to Flinders Medial Centre’s own policies and procedures.
Unfortunately, Flinders Medical Centre’s inadequacies were exacerbated by the
baseless identification of Dr Spick as the Psychiatric Registrar in question when there
was no evidence to support this contention. There was evidence to show that Dr
Spick saw two other patients referred to the Emergency department on that day.
However, this says nothing about whether or not he saw Ms Foot. On the one hand,
the fact that he was recorded as seeing two other patients, and not Ms Foot, could be
taken to suggest that he did not see Ms Foot. On the other hand, it does appear that he
was on duty on that day. However, his own evidence at the Inquest was that he had
no recollection of having been consulted about Ms Foot by Mr Hawkins. Nor did Mr
Hawkins have any recollection of the Psychiatric Registrar consulted. There the
matter must rest.
Key Words: Citalopram, continuity of care, depression.
In witness whereof the said Coroner has hereunto set and subscribed his hand and
Seal the 3rd day of January, 2007.
State Coroner
Inquest Number 13/2006 (0842/04)