Coroner's Finding: GRAEFE Phillip Brian

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 21st day of May and the 16th day of July 2020, by the Coroner’s Court of the said State, constituted of Paul Marvin Foley, Deputy State Coroner, into the death of Phillip Brian Graefe.

The said Court finds that Phillip Brian Graefe aged 62 years, late of 5143 Old Eyre Highway, Caralue, South Australia died at the Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, South Australia on the 19th day of November 2017 as a result of multi-organ failure due to Paraquat ingestion. The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Philip Brian Graefe was born on 17 June 1955. He died on 19 November 2017 aged 62 years at the Queen Elizabeth Hospital in Woodville South.

1.2. Dr Iain McIntyre of Forensic Science South Australia performed a pathology review of Mr Graefe’s medical case notes and clinical history and concluded that the cause of his death was multi-organ failure due to the ingestion of paraquat1, and I so find.

1.3. A sample of Mr Graefe's blood was taken at the Queen Elizabeth Hospital at 5:30pm on 19 November 2017. A toxicological analysis of that blood sample found it contained approximately 160mg of paraquat per litre of blood.2 A blood concentrate of paraquat greater than about 2mg per litre of blood four hours after ingestion, and a concentration 1 Exhibit C2a 2 Exhibit C3a

of 0.1mg per litre at 24 hours after ingestion, is likely to be lethal in most persons. The blood concentration of paraquat in Mr Graefe's system meant his ingestion was fatal.

2. Reason for inquest 2.1. This is a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mr Graefe had been on an Inpatient Treatment Order (ITO) at the time of his death, and his death is therefore regarded as a death in custody. A Level 1 ITO was made pursuant to section 21 of the Mental Health Act on 19 November 2017 at 12pm by Dr Daniel Claughton at the Kimba Hospital after Mr Graefe presented in an ambulance.3 Following Mr Graefe’s admission he advised that he had taken a small amount of paraquat. The doctor sighted a suicide note written by Mr Graefe and in a conversation with him he confirmed that he wanted to end his life. Dr Claughton made the ITO as he deemed Mr Graefe to be a risk of further harm to himself if he was to recover, and he would require inpatient care until he could be assessed by a psychiatrist.

3. Background and medical history 3.1. Mr Graefe lived with his parents June and Mervyn on the family farm in Caralue for his whole life. He had no children or partner. His mother carried out the domestic duties at the farm. He had one sibling, a younger sister Beverley.4 On 26 September 2017 Mr Graefe's father was admitted to the Kimba Hospital as a permanent resident due to his poor health, and when this occurred Mr Graefe took on the sole responsibility for the running of the family farm. His mother had moved to be with her husband.

3.2. Mr Graefe had a medical history that included hypertension, chronic stage 2 renal failure and insulant dependent diabetes, with retinopathy, which was managed through laser treatment.

4. The circumstances surrounding Mr Graefe’s death 4.1. At approximately 8:23am on Sunday 19 November 2017, Mr Graefe telephoned his brother-in-law, Dean Berg.5 Mr Graefe said that he felt crook and said that he felt like dying, or words to that effect. Mr Berg alerted his wife Beverley and then travelled the few kilometres to Mr Graefe's house. Mr Berg arrived approximately five minutes after 3 Exhibit C6 4 Exhibit C5a 5 Exhibit C4

he had received the phone call from Mr Graefe. Upon arrival he saw his brother-in-law lying on the lounge room floor with blue on his mouth and his singlet and in a semiconscious state. Mr Berg contacted triple zero. Beverley Berg, her son and his wife attended at the house shortly afterward. Mr Berg's daughter-in-law, Angela Maunder, was a registered nurse and she rendered assistance to Mr Graefe while awaiting the ambulance.

4.2. Upon questioning, Mr Graefe told Mr Berg that he had taken spray seed. Mr Berg, who was also a farmer, believed that Mr Graefe had probably taken paraquat based on the blue colouring around Mr Graefe's mouth and singlet. Mr Berg went to the chemical shed on Mr Graefe's property and found a container on the floor with a label 'spray 250 SL' with an active constituent of 250gm per litre of paraquat. There was also a plastic measuring cup on a metal tin next to the container which had a blue/green residue in the base, consistent with the liquid in the spray top container.

4.3. Dr Claughton was employed at the Kimba Hospital at the time and he received a telephone call from the South Australian Ambulance Service advising they were en route to Mr Graefe in relation to a suspected paraquat overdose. Dr Claughton telephoned the poisons information line and sought advice from the on-call toxicologist, Dr Darren Roberts, who advised that Mr Graefe would need urgent transfer for dialysis and earth treatment en route to hospital as activated charcoal was not available to the paramedics.6 The ambulance arrived at Mr Graefe's property at 9:22am and he was conveyed to Kimba Hospital arriving at 10:26am. The SAAS paramedics obtained a history from Mr Graefe who indicated he had intentionally consumed about 100-150mls of paraquat at approximately 7:45am.7

4.4. Mr Graefe told paramedics he contacted his brother-in-law shortly after consuming the paraquat. Paramedics noted an irregular heart rate with laboured breathing. The SAAS notes detail that, consistent with the advice from the toxicologist, Darren Roberts, earth therapy was provided en route to hospital which consisted of a slurry of dirt and water being consumed by Mr Graefe.

6 Exhibit C6 7 SAAS Attendance Record

4.5. Beverley Berg later that day located a note on the kitchen bench authored by Mr Graefe saying that he could not go on and wanted to die.8

4.6. When Mr Graefe attended at the Kimba Hospital he was still conscious. Mr Graefe told Dr Claughton that he had taken a small amount of paraquat and had vomited shortly afterwards. Dr Claughton was shown the suicide note and questioned Mr Graefe about why he wanted to die. Mr Graefe responded with words to the effect of 'the farm and my dad's poor health'.9

4.7. A MedSTAR retrieval team arrived near Kimba at 11am and they intubated, sedated and ventilated Mr Graefe. A naso-gastric tube was inserted to allow charcoal administration in an attempt to neutralise the paraquat. Mr Graefe was airlifted to the Queen Elizabeth Hospital, arriving at 2:28pm.10

4.8. Staff at the Queen Elizabeth Hospital sought advice from the poisons hotline prior to Mr Graefe's arrival. They were advised that 2ml of ingested paraquat is usually a fatal dose and the dose that Mr Graefe stated that he had taken (100-150ml) would be terminal. There were no known specific therapies for the treatment of paraquat poisoning.

4.9. Medical staff continued to ventilate Mr Graefe and provided him with medication to support his extremely low blood pressure. Dialysis was not an option for Mr Graefe due to his low blood pressure.

4.10. Medical staff spoke to Mr Graefe's sister, Beverley Berg, over the telephone and advised of her brother's deterioration and poor prognosis. She provided instructions that Mr Graefe was not for resuscitation in the event of him suffering a cardiac arrest.

4.11. Mr Graefe's suffered an asystolic arrest at 9:20pm on 19 November 2017 and was formally certified deceased by Dr Mark Harris at that time.11 8 Exhibit C5 9 Exhibit C15 10 Exhibit C14 11 Exhibit C14

5. Coronial investigation 5.1. Detective Brevet Sergeant Douglas Monks of the Port Lincoln Criminal Investigation Branch was tasked with investigating Mr Graefe’s death in custody.12

5.2. Detective Monks did not identify any issues of concern regarding the treatment of Mr Graefe either at the Kimba Hospital or the Queen Elizabeth Hospital.

6. Conclusions and recommendations 6.1. I find that Mr Graefe took his own life by ingestion of the chemical paraquat. The quantity of paraquat ingested by Mr Graefe was a fatal dose and no medical intervention could have prevented his death.

6.2. I find that Mr Graefe was in lawful detention at the time of his death and that the detention had no bearing on his death.

6.3. I further find that Mr Graefe received an appropriate level of care and treatment both at the Kimba Hospital and the Queen Elizabeth Hospital.

6.4. I have no recommendations to make in this matter.

Key Words: Death in Custody; Paraquat Poisoning; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 16th day of July, 2020.

Deputy State Coroner Inquest Number 46/2020 (2381/2017) 12 Exhibit C12