Coroner's Finding: O'Shea, Amie 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 Amie Maree O'Shea Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Amie Maree O'Shea (Ms O’Shea); b) Mrs O'Shea died in the circumstances set out below; c) Mrs O'Shea’s cause of death was mixed prescription drug toxicity; and d) Mrs O'Shea died between 19 and 20 May 2019 at Glenorchy, Tasmania.

Introduction In making the findings set out above I have had regard to the evidence gained in the comprehensive investigation into Ms O'Shea’s death. That evidence comprises:  The Police Report of Death for the Coroner;  Affidavits establishing identity and life extinct;  Affidavit of Dr Donald Ritchey State Forensic Pathologist;  Forensic Science Service Tasmania – toxicological and analytical report of Mr Neil McLachlan-Troup;  Affidavit of Ms Anita Clay;  Affidavit of Mrs Melissa Simpson;  Affidavits of Ms Lauren Clifford;  Affidavit of Mr Darren Simpson;  Affidavit of Sergeant Andrea Richardson;  Affidavits of First-Class Constable Nicholas Cooper;  Affidavit of Senior Constable Lauren Haines;  Affidavit of Detective Senior Constable Kirby – Rae Direen;  Affidavit of Constable Tania Curtis;  Ms O’Shea’s medical records obtained from the Royal Hobart Hospital (RHH);

 Ms O’Shea’s medical records obtained from the Princess Alexandra Hospital in Brisbane, Queensland. These records contained records of treatment Ms O’Shea received at the Logan Hospital in Brisbane;  Ms O’Shea’s medical records obtained from the Browns Plains Family Practice.

Browns Plains is a southern suburb of Brisbane; and  Photographs and forensic evidence.

Background Ms O’Shea was 39 years of age (DOB 19 April 1980), single and she ordinarily resided with her mother in Queensland at the date of her death. Ms O’Shea was born in Tasmania and went to school in this State. She formed a close friendship group during her school years of about 9 people which included Mrs Simpson, Ms Clifford and Ms Clay.

When she died she was married to Mr Karl Grissell for a period of about 10 years. They had one daughter together who at the date of her mother’s death was 13 years of age. Although they were married they were estranged and Mr Grissell had not spoken to Ms O’Shea for at least 12 months. He says he had been trying to get a divorce from Ms O’Shea but she would not sign the papers. He has custody of their daughter who lives with him in Brisbane. It appears from what he has said in an unsworn affidavit they had separated and resumed their relationship on a number of occasions. Shortly after they were married they moved to Tasmania and lived here for approximately 2 years before returning to Queensland. The medical records, referred to below, indicate after returning to Queensland and after she ceased living with Mr Grissell Ms O’Shea would visit Tasmania from time to time. Prior to her marriage to Mr Grissell Ms O’Shea was in a relationship with Matthew Bester and they had 2 daughters together who were aged 21 and 17 at the date of their mother’s death. Ms O’Shea was estranged from Mr Bester. Her daughters lived independently from her in Tasmania.

Health I have examined over 3500 pages of medical records. The GP records cover a period of almost 15 years to 5 April 2019. The medical records indicate Ms O’Shea suffered from a number of very debilitating conditions during her lifetime. These conditions included juvenile rheumatoid arthritis, sarcoidosis, psoriasis, anxiety and major depression, migraines and an ice addiction which lasted for about 5 years up until about 2016. In April of that year she entered a rehabilitation program. In October 2017, Ms O’Shea was diagnosed with breast cancer after which she underwent chemotherapy until February 2018. On 8 March 2018 she underwent a mastectomy and she remained in hospital until she was discharged on 15 March

2018. She re-presented on 24 March 2018 with septic shock which arose out of an infection

to the mastectomy wound. This required an ICU admission and a debridement. She was not discharged until 5 April 2018. Thereafter Ms O’Shea underwent radiation therapy over the next few months.

In October 2018 Ms O’Shea was readmitted to hospital for a period of 5 days during which time she was suffering from lymphoedema of both arms and hands. There was also a lump in the mastectomy scar from which a biopsy was taken. The results of that biopsy were negative for a recurrence of cancer. There were subsequent assessments for lymphoedema between that admission and March 2019. In none of those records or in any GP records is there any evidence her cancer recurred.1 The records in Queensland reveal Ms O’Shea overdosed on prescribed medications and alcohol in June 2015 and August 2016. There was also an admission in October 2010 and November 2011 for alcohol intoxication. The sarcoidosis developed in 2007 with interstitial pulmonary disease and widespread polyarthritis. This was treated initially by inpatient hospital treatment and then subsequently with methotrexate for a period and also corticosteroids. In 2009 Ms O’Shea ceased taking methotrexate. In addition she was being followed up at the Logan respiratory clinic, immunology clinic and eye clinic. She attended a number of appointments but was discharged from each of those clinics when she failed to continue her treatment. There was a further admission in July 2011 due to ongoing symptoms and subsequent outpatient reviews in that year which again ended because of Ms O’Shea’s failure to engage in treatment.

The Tasmanian records indicate there were 4 admissions to hospital for treatment one of the which concerned a medication and alcohol overdose in May 2012.

The circumstances leading to Ms O’Shea’s death Ms O’Shea usually resides with her mother in Queensland. She travelled to Tasmania on 11 April 2019 for her daughter’s 21st birthday. After her daughter’s birthday Ms O’Shea stayed with Ms Clifford at her home.2 On Saturday 18 May 2019 Ms O’Shea went to a girls’ night at Mrs Simpson’s house. She was driven to Mrs Simpson’s home by Ms Clifford and they arrived just prior to 6.00pm. Ms Clay 1 This is to be compared to the evidence of Mrs Simpson in her statement where she says Ms O'Shea “said the cancer had gone to her spine, however she didn't say anything like the cancer was terminal, but mentioned that she had to have another breast removed in August up in Queensland.” There is no sign of this procedure being planned for in the medical records.

2The medical records reveal she last saw her general practitioner on 5 April 2019 and treatment providers at the Princess Alexandra Hospital on 10 April 2019. Those providers had a phone consultation with Ms O’Shea while she was in Tasmania on 17 April 2019. The records suggest she was coming to Tasmania for 9 weeks or thereabouts.

arrived shortly thereafter. Ms Clifford and Ms Clay both describe Ms O’Shea as generally in good spirits at the party. There was no indication given by Ms O’Shea she intended to commit suicide. Ms Clay says Ms O’Shea was usually casual and distant about organising parties however in the lead up to this party, she was insistent that everybody from their friendship group attend so that she could see them. The evidence of the witnesses with respect to Ms O’Shea’s alcohol consumption is consistent in that she consumed beer and premixed alcoholic drinks. There is no evidence she consumed any drugs at the party.

At 2.00am on 19 May 2019 Ms O’Shea and Mr and Mrs Simpson were the last people at the party. Mr Simpson had been in and out that evening given it was a girls’ night at his home. At that time Ms O’Shea is described as being in a good mood. Mrs Simpson says Ms O’Shea did open up about her health problems, that she was a burden on her children and because she was unwell she was not able to provide for them. This did not ring any alarm bells in Mrs Simpson because Ms O’Shea was confiding in her and her general mood seemed to Mrs Simpson to be fine. In addition she was future focused and talking about Mr Simpson’s upcoming birthday in June. Her subsequent death was sudden and unexpected from Mrs Simpson’s point of view. Mr Simpson offered to take her home; an offer which she eventually accepted after she insisted on getting an Uber home. Mr Simpson dropped her off and watched her walk inside. Ms O’Shea was alone that weekend because Ms Clifford was staying with her partner at his home. A Facebook group including Ms Clay, Ms Clifford and Mrs Simpson received a message from Ms O’Shea which said “last man standing” at 2.25am on 19 May 2019. Ms O’Shea received a number of calls and messages throughout 19 May 2019 but she did not answer those.

At 7.00am on 20 May 2019 Ms Clifford arrived home because she needed to take her child there to get ready for school. When she arrived the house was secure and she subsequently located Ms O’Shea deceased in the guest bedroom. She then called for an ambulance with paramedics arriving a short time later. They confirmed Ms O’Shea’s death through the use of monitors and therefore they did not attempt CPR or administer any medication.

Investigation

(i) Police Sergeant Richardson was advised of this matter at 9.45am on 20 May 2019 and she arrived at Ms Clifford’s home at 10.20 am. She was led to Ms O’Shea’s location within the home and Ms O’Shea was observed by Sergeant Richardson laying on her right side on the left side of a double bed. The right side of the bed was undisturbed and most of Ms O’Shea’s belongings were packed in a suitcase on that side of the bed. There was a cordial bottle with fluid in it sitting on the table next to her. Otherwise, the room did not appear disturbed. A forensics

officer was tasked to attend and the mortuary ambulance was notified. Sergeant Richardson was advised Ms O’Shea kept her medication in a small rectangular leopard print makeup case. Sergeant Richardson searched the room and the rest of the house but was unable to locate the makeup case.

Subsequently the forensics officer, Constable Curtis, and Detective Constable Direen attended. It was after this Sergeant Richardson located the makeup case in a bin in the kitchen/laundry area and upon opening it she established there was a quantity of medication unaccounted for. A number of medications, empty blister packs and prescriptions were located in the bin.

First Class Constable Cooper and Senior Constable Haines also attended. First Class Constable Cooper spoke to two paramedics who advised they had been called to the address by one of Ms O’Shea’s friends. He then spoke to Ms Clifford and Ms Clay who were present. A search of the premises was then conducted. Subsequently First Class Constable Cooper spoke to Mr Grissell who identified himself as being Ms O’Shea’s spouse but there were divorce proceedings on foot between the two of them. Over the ensuing months First Class Constable Cooper assisted Mr Grissell in preparing a coroner’s affidavit which was finalised and sent to Mr Grissell with instructions to take the affidavit to a police station in Queensland so that it could be sworn. Mr Grissell acknowledged the email. However, despite multiple emails and attempts to call him First Class Constable Cooper was unable to speak to Mr Grissell again and the draft affidavit was never sworn and/or returned.

Investigations revealed the home was secure when Ms Clifford returned home at approximately 7.00am on the morning of 20 May 2019. A message Ms O’Shea sent in the early hours of 19 May 2019 indicated Ms O’Shea was awake at that time. There were no signs of injury to Ms O’Shea, signs of violence or a struggle in the room. There was no forced entry to the home and Ms O’Shea’s wallet and phone were located at the residence.

As a result of the police examination of the scene and of Ms O’Shea there was nothing found to suggest any other person was involved in Ms O’Shea’s death.

(ii) Post Mortem and Toxicological Testing Dr Donald Ritchey performed the post-mortem examination on 21 May 2019. It was noted Ms O’Shea had a body mass index of 37.6. Her weight was 106 kg.3 He found no evidence of violent injury specifically no scalp contusions, skull fractures or intracranial collections of 3 The medical records disclose that in July 2005 Ms O'Shea weighed 72 kg. In May 2015 her weight was 107 kg and she advised her doctor that 2 years earlier it had reached 130 kg. This was apparently due to the medications she was prescribed for her various conditions.

blood. There were no soft tissue injuries of the neck. Toxicology was positive for a number of prescribed medications and for alcohol.

As a result of his examination and consideration of the histology and toxicology Dr Ritchey concluded Ms O’Shea’s cause of death was mixed prescription drug and alcohol toxicity (ethanol, tapentadol, promethazine, tramadol, diazepam and propranolol). He says significant contributing factors were aspiration of gastric contents and depression and previous suicidal ideation.

The toxicology report indicates multiple central nervous system (CNS) depressants were identified namely alcohol, tapentadol and promethazine, all at elevated levels, as well as tramadol and diazepam. CNS depression can cause many symptoms which may include feeling sleepy and uncoordinated, staggering, blurred vision, impaired thinking, slurred speech, impaired perception of time and space, slowed reflexes and breathing, decreased heart rate, reduced sensitivity to pain, and loss of consciousness possibly leading to coma or death. In addition tapentadol was identified at a concentration that has been associated with toxicity and fatalities when combined with other CNS depressants which was the case here.

While the concentration of each individual drug and alcohol was not sufficient to cause Ms O’Shea’s death I find the combination of the drugs and alcohol did cause her death by causing aspiration of gastric contents, respiratory depression and finally death.

Comments and Recommendations On balance I agree with the investigating officer’s conclusion that Ms O’Shea overdosed on prescription drugs after consuming an excessive quantity of alcohol with the intention of taking her own life. I have come to this conclusion because Ms O’Shea suffered from very poor health for in excess of 10 years, there is evidence she believed she was a burden to her children and she was unable to provide for them. She suffered from anxiety and major depression and had previously attempted suicide.4 She had also, unusually, insisted on the attendance of all of her friends in her friendship group at the party at Mrs Simpson’s home as if this was her last opportunity to say farewell. There is no evidence that any of her friends at the party were aware of her intention and therefore there was nothing that anyone could have done to change the course of events.

4 The medical records disclose there are at least 5 admissions to hospital for a drug overdose and/or excessive alcohol consumption. Some studies have suggested the most commonly identified risk factor for suicide in males and females in all age groups except those 65 and over is a personal history of self-harm.

The circumstances of Ms O'Shea’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 extend my appreciation to investigating officer Constable Nicholas Cooper for his investigation and report.

I convey my sincere condolences to the family and loved ones of Ms O'Shea.

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

Robert Webster Coroner