Coroner's Finding: Godwin, Chantal Maree

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of Chantal Maree Godwin Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Chantal Maree Godwin (Ms Godwin); b) Ms Godwin died in the circumstances set out below; c) Ms Godwin’s cause of death is Sudden Unexpected Death in Epilepsy (SUDEP); and d) Ms Godwin died between 10 and 11 February 2020 at Devonport, Tasmania.

Introduction In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Ms Godwin’s death. The evidence includes:  The Police Report of Death for the Coroner;  Affidavits confirming identification and life extinct;  Affidavit of the pathologist Dr Brain who conducted the autopsy;  Affidavit of Mr Neil McLachlan-Troup, forensic scientist of Forensic Science Service Tasmania;  Affidavit of Bronwyn Chilcott, friend of Ms Godwin;  Information from her family;  Medical reports and records relating to Ms Godwin obtained from Smartclinics Family Medical Centre, Devonport; and  Report of the coronial medical advisor Dr Anthony Bell MB BS MD FRACP FCICM.

Background Ms Godwin was born in Footscray, Victoria on 16 December 1981. At the time of her death, she was aged 38 years and was living alone in Devonport, Tasmania.

Ms Godwin was born to William and Maria Godwin and she had four siblings. She lived her early years in Braybrook, Victoria where she attended two primary schools before moving with her family to Tasmania in or about 1991. In Tasmania Ms Godwin attended Herdsman’s Cove Primary School and then Bridgewater High School. Ms Godwin was never able to work because she was diagnosed with epilepsy as a young child. At the time of her death she was in receipt of a disability support pension because of her epilepsy.

Ms Godwin never married but had 2 sons the firstborn in 2001 and the second in 2009 as a result of a relationship with Daniel Brown.

Medical history Ms Godwin was diagnosed with epilepsy as a young child, had regular seizures and was prescribed numerous different medications in an attempt to control this condition. The formal diagnosis was left temporal lobe epilepsy. Her mother also had epilepsy and she suffered a fatal seizure in 1987.

Ms Godwin regularly attended her local general practitioner. In 2019, she told her GP on a number of occasions of recent epileptic seizures. She also had other minor medical issues which suggest she did not to have a healthy lifestyle. Ms Godwin also suffered from depression for which she saw a psychiatrist. She was subsequently advised on 5 September 2019 to stop taking antidepressant medication as that had the effect of reducing her seizure threshold. Her epileptic medication was changed and the medication prescribed also had a mood stabiliser.

Restarting antidepressant medication was to be considered if she was seizure free for 4 months and if she still had low mood. Her last visit to her GP was on 23 December 2019 at which time there was some discussion about one of her friends1 becoming Ms Godwin’s carer.

The records also disclose a visit to the Mersey Community Hospital (MCH) on 12 March 2019 due to lethargy and an increase in appetite. There was then a referral, on 6 May 2019, to the neurologist Dr de Souza at the Launceston General Hospital (LGH). Ms Godwin was reviewed 1 I infer this is Ms Chilcott.

by him on 27 June 2019 and advice was provided to the general practitioner with respect to Ms Godwin’s future management. Next there was an admission to the MCH on 25 August 2019 after being brought in by ambulance where the history was Ms Godwin had suffered 6 seizures in the last 18 hours; the last one taking place in the emergency department. She was reported to be compliant with her medications. Generally she suffered from a seizure every 3 months or so but their frequency had been increasing in more recent times. Because of treatment she had received at the LGH Ms Godwin was transferred to that hospital on that day where she remained an inpatient and was treated until being discharged on 27 August 2019. Next there was a visit to the MCH on 30 September 2019 because Ms Godwin had hurt her right foot after a fall caused by a seizure. Finally Ms Godwin was taken to the MCH by ambulance on 12 October 2019 after suffering from 3 seizures. She suffered another seizure whilst being reviewed. She was treated and discharged.

Circumstances of Death Ms Chilcott had known Ms Godwin for approximately 2 years. Prior to Ms Godwin’s death she and Ms Chilcott were going through the process of Ms Chilcott becoming her carer due to Ms Godwin being prone to epileptic fits. Ms Chilcott would assist Ms Godwin take her medication on a daily basis. Ms Godwin would stay at Ms Chilcott’s home from time to time and towards the end of her life Ms Godwin would stay with Ms Chilcott and be present at her address for approximately 80% of her time.

On 10 February 2020, Ms Godwin spent the day with Ms Chilcott, at her address in Devonport. Ms Godwin left to go home at about 3.15pm. They planned to meet up again at Ms Chilcott’s house the next morning and go shopping together.

On 11 February 2020, Ms Godwin did not arrive at Ms Chilcott’s home so Ms Chilcott unsuccessfully attempted to contact Ms Godwin via her mobile telephone on a number of occasions. Ms Chilcott then arranged for her daughter and granddaughter to walk to Ms Godwin’s unit. They attended Ms Godwin’s address but were not able to raise her. Ms Godwin’s home was entered and she was found to be unresponsive and lying on the bathroom floor. Emergency services were contacted.

Investigation Ambulance Tasmania personnel were present at the scene upon the arrival of police and they notified police of the location of Ms Godwin within her home and advised police Ms Godwin had passed away. Police entered the property and examined the scene and Ms Godwin. Police officers from the Criminal Investigation Branch and forensics were contacted and they attended

and inspected the scene. Although the home appeared to be unlocked police located Ms Godwin’s purse in clear view in the lounge room which contained a number of personal cards, bank cards and a quantity of cash. In addition a set of keys and 2 mobile phones were located.

One phone was on the TV cabinet in the lounge room and the other was found in Ms Godwin’s handbag which was also located in the lounge room. As a result of a thorough police search and examination of the scene and of Ms Goodwin police determined there were no suspicious circumstances surrounding Ms Godwin’s death.

Ms Chilcott formally identified Ms Godwin to police.

A post-mortem examination was conducted by the forensic pathologist Dr Terry Brain on 13 February 2020. He noted Ms Godwin’s medical history and observed a bruise that could only be seen when the scalp was reflected on the left forehead region. There was also a significant bruise and some blood about the nose slightly to the right. Toxicology testing revealed no alcohol or illicit drugs. Three medications for epilepsy were detected 2 of them at therapeutic levels and the third at a sub therapeutic level. As a result of his examination and after considering the histology and toxicology Dr Brain determined there was no overt cause of death and no natural disease was identified. The death appeared to him to be natural and it was noted Ms Godwin had a history of epilepsy. He therefore concluded in all the circumstances that epilepsy was the likely cause of death. I accept Dr Brain’s opinion.

Dr Bell, the coronial medical advisor, has reviewed the investigation and medical records and notes Ms Godwin was under the care of a neurologist and also managed by her general practitioner. Changes in her medication were made after advice from her neurologist. Dr Bell says: ‘Patients with epilepsy have a small risk of sudden unexpected death, a condition referred to as sudden unexpected death in epilepsy (SUDEP). SUDEP is defined specifically as the sudden, unexpected, witnessed or unwitnessed, non-traumatic and non-drowning death in patients with epilepsy with or without evidence of a seizure, and excluding documented status epilepticus, in which post mortem examination does not reveal a structural or toxicological cause for death.” Dr Bell concludes by saying the cause of death in this case was SUDEP2 and Ms Godwin’s medical care was of good quality. I accept Dr Bell’s opinion.

2 Which is consistent with Dr Brain’s opinion.

Comments and Recommendations Given the opinions of Dr Brain and Dr Bell I find Ms Godwin’s cause of death was natural.

The circumstances of Ms Godwin’s death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of Ms Godwin.

Dated: 28 November 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner