Finding into death of Mark Clinton Edwards

IN THE CORONERS COURT Court Reference: COR 2020 6721

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Caitlin English, Deputy State Coroner Deceased: Mark Clinton Edwards Date of birth: 1 May 1968 Date of death: 11 December 2020 Cause of death: 1(a) Stab injuries to the chest Place of death: 108/320 Point Cook Road, Point Cook, Victoria

INTRODUCTION

1. On 11 December 2020, Mark Clinton Edwards was 52 years old when he took his own life.

At the time of his death, Mr Edwards lived at Point Cook with his mother.

THE CORONIAL INVESTIGATION

2. Mr Edwards’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent, or result from accident or injury.

3. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

4. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.

5. The Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Mr Edwards’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

6. This finding draws on the totality of the coronial investigation into Mr Edwards’s death, including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1 1 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased

7. On 11 December 2020, Mark Clinton Edwards, born 1 May 1968, was visually identified by his mother, Joan Edwards.

8. Identity is not in dispute and requires no further investigation.

Medical cause of death

9. Senior Forensic Pathologist, Dr Michael Burke, from the Victorian Institute of Forensic Medicine (VIFM), conducted an inspection on 14 December 2020 and provided a written report of his findings dated 16 December 2020.

10. Toxicological analysis of post-mortem samples identified the presence of amitriptyline2 and nortriptyline, and temazepam.3

11. Dr Burke provided an opinion that the medical cause of death was “1(a) Stab injuries to the chest”.

12. I accept Dr Burke’s opinion.

Circumstances in which the death occurred

13. Mr Edwards had worked in warehousing when, in 2007, he suffered a workplace injury that affected his legs, back, and shoulders. Over the following years, he underwent multiple surgeries, including the amputation of his right leg in 2017.

14. At the end of 2019, Mr Edwards contracted an infection in his left leg, which required a months-long hospital admission. He was discharged in September 2020 at which time he moved in with his mother, Joan Edwards, at a retirement village.

15. According to his general practitioner, Dr Alan Reid, Mr Edwards had previously been in significant pain and had issues with pain management. But by November 2020, he was stable in terms of pain medication and was using less medication. However, at that time Mr Edwards did mention his pain was increasing, but not distressing, and Dr Reid adjusted his dose of Lyrica (a pain medication). Dr Reid did not mention whether Mr Edwards had experienced 2 Amitriptyline is an antidepressant.

3 Temazepam is a sedative/hypnotic drug of the benzodiazepine class.

any mental health issues but included amitriptyline and temazepam in the list of Mr Edwards’s current medications.

16. Mrs Edwards said that in the days before his death, her son complained of painful gout to his left foot and was concerned that it would lead to another amputation.

17. On the morning of 11 December 2020, Mr Edwards and his mother spoke about their plans for the day. Mr Edwards had an appointment with his orthopaedic surgeon at 1.00pm and had booked a taxi to pick him up about at 12.00pm; Mrs Edwards planned to go shopping and planned to return home at about 1.00pm.

18. Mrs Edwards subsequently left home at approximately 10.00am.

19. When she returned home at approximately 1.30pm, Mrs Edwards found her son on the floor in the bathroom covered in blood. She activated the emergency button in the house and sought help from her sister. The village nurse subsequently attended and confirmed Mr Edwards was deceased. Emergency services also attended and confirmed the same.

20. From the evidence, it appears that while his mother was gone, Mr Edwards took a knife from the kitchen which he then used to take his own life in the bathroom.

21. Mr Edwards had received a significant compensation payment after his workplace injury. It appears that by the time of his death, the payout had been depleted due to Mr Edwards’s gambling addiction. He had also borrowed a significant amount from his cousin, which he was unable to repay.

22. Although a suicide note was not found, police members later discovered Mr Edwards’s journal, which revealed previous suicidal attempts and suicidal ideation. It also detailed his gambling addiction. Mrs Edwards noted that her son had always seemed happy but had made comments about not wanting to go to functions and problems with his legs. She did not otherwise indicate he had experienced any mental health issues.

FINDINGS AND CONCLUSION

23. Pursuant to section 67(1) of the Act I make the following findings:

(a) the identity of the deceased was Mark Clinton Edwards, born 1 May 1968;

(b) the death occurred on 11 December 2020 at 108/320 Point Cook Road, Point Cook, Victoria, from stab injuries to the chest; and

(c) the death occurred in the circumstances described above.

24. Having considered all of the evidence, I am satisfied that Mr Edwards intentionally took his own life.

COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.

1. As part of my investigation, I sought data from the Coroners Prevention Unit (CPU) about the link between suicide and workplace injuries.

2. The CPU noted that men and women who experienced a work-related injury have been shown to be at greater risk of suicide.4 There are several physical and social consequences of occupational injuries.5 A decline in mental health is commonly seen among individuals who are recovering from an occupational injury or illness.6

3. Research conducted in New Mexico examined suicide and drug-related death subsequent to a work-related injury. The study found that depression is a common long-term health consequence of an occupational injury and often resulted from subsequent stressors, such as financial concerns, loss of employment, chronic pain, and a lengthy recovery period.7 This was further consolidated in a Korean study where the risk of depression was found to be greater among occupationally injured workers when compared to non-work-related injured workers.8 A Canadian study found that poor communication between the employee and the workers compensation case manager subsequent to a work-place injury contributed to a decline in the individual’s mental health.9 A decline in mental health due to several stressors 4 Lee, H. E., Kim, I., Kim, M. H., & Kawachi, I. (2021). Increased risk of suicide after occupational injury in Korea. Occupational and environmental medicine, 78(1), 43–45.

5 Dembe A. E. (2001). The social consequences of occupational injuries and illnesses. American journal of industrial medicine, 40(4), 403–417.

6 Orchard, C., Carnide, N., Smith, P., & Mustard, C. (2021). The Association Between Case Manager Interactions and Serious Mental Illness Following a Physical Workplace Injury or Illness: A Cross-Sectional Analysis of Workers' Compensation Claimants in Ontario. Journal of occupational rehabilitation, 10.1007/s10926-021-09974-7. Advance online publication.

7 Applebaum, K. M., Asfaw, A., O'Leary, P. K., Busey, A., Tripodis, Y., & Boden, L. I. (2019). Suicide and drug-related mortality following occupational injury. American journal of industrial medicine, 62(9), 733–741.

8 Lee, H. E., Kim, I., Kim, M. H., & Kawachi, I. (2021). Increased risk of suicide after occupational injury in Korea. Occupational and environmental medicine, 78(1), 43–45.

9 Orchard, C., Carnide, N., Smith, P., & Mustard, C. (2021). The Association Between Case Manager Interactions and Serious Mental Illness Following a Physical Workplace Injury or Illness: A Cross-Sectional Analysis of Workers' Compensation Claimants in Ontario. Journal of occupational rehabilitation, 10.1007/s10926-021-09974-7. Advance online publication.

following a work-related injury therefore provides an explanation for the link between suicide and work-related injury.10

4. Many occupational injuries have shown to cause chronic pain. This often results in heavy prescription medication use to manage the pain, which has been shown to potentially lead to drug misuse.11 One study concluded that work related injuries have contributed to an increase in both drug related deaths and suicides over a 10-year period.12

5. A Victorian study found similar recurring themes where suicide followed a workplace musculoskeletal injury. These included an inability to return to work, chronic pain or disability and a decline in mental health, resulting in suicidal ideation in the context of chronic pain.

Further factors linked to the relationship of the workplace injury and the suicide event included a greater time elapsed from the injury to returning to work, lack of support from employers and unsatisfactory health care.13 A study conducted in Korea revealed that only half of employees injured in the work force returned to the workplace within a one-year period and approximately 20% were unemployed within three years of their injury.14

6. Employment in the construction industry at the time of the workplace injury was found to be a recurring theme in a previous study.15 An Australian study specifically examined male suicide among construction workers, finding occupational injuries among many middle-aged and older employees; these injuries impacted on the individual’s mobility and were accompanied by pain symptoms. This study revealed that both pain and restricted mobility were correlated with loss of employment, long term injury and depression in this cohort.16 10 Lee, H. E., Kim, I., Kim, M. H., & Kawachi, I. (2021). Increased risk of suicide after occupational injury in Korea. Occupational and environmental medicine, 78(1), 43–45.

11 Applebaum, K. M., Asfaw, A., O’Leary, P. K., Busey, A., Tripodis, Y., & Boden, L. I. (2019). Suicide and drug-related mortality following occupational injury. American journal of industrial medicine, 62(9), 733–741.

12 Applebaum, K. M., Asfaw, A., O'Leary, P. K., Busey, A., Tripodis, Y., & Boden, L. I. (2019). Suicide and drug-related mortality following occupational injury. American journal of industrial medicine, 62(9), 733–741.

13 Davis, M. C., Ibrahim, J. E., Ranson, D., Ozanne-Smith, J., & Routley, V. (2013). Work-related musculoskeletal injury and suicide: opportunities for intervention and therapeutic jurisprudence. Journal of law and medicine, 21(1), 110–121.

14 Lee, H. E., Kim, I., Kim, M. H., & Kawachi, I. (2021). Increased risk of suicide after occupational injury in Korea.

Occupational and environmental medicine, 78(1), 43–45.

15 Davis, M. C., Ibrahim, J. E., Ranson, D., Ozanne-Smith, J., & Routley, V. (2013). Work-related musculoskeletal injury and suicide: opportunities for intervention and therapeutic jurisprudence. Journal of law and medicine, 21(1), 110–121.

16 Milner, A., Maheen, H., Currier, D., & LaMontagne, A. D. (2017). Male suicide among construction workers in Australia: a qualitative analysis of the major stressors precipitating death. BMC public health, 17(1), 584.

Victorian Suicide Register

7. The Victorian Suicide Register (VSR) is a database containing detailed information on suicides that have been reported to and investigated by Victorian Coroners between 1 January 2000 and the present.

8. The primary purpose of gathering suicide data in the VSR is to assist Coroners with prevention-oriented aspects of their suicide death investigations. VSR data is often used to contextualise an individual suicide with respect to other similar suicides; this can generate insights into broader patterns and trends and themes not immediately apparent from the individual death, which in turn can lead to recommendations to reduce the risk that further such suicides will occur in the future.

9. So much is still unknown about suicide and, given that every suicide occurs in unique circumstances to a person with a unique history and life experience, possibly there is much we will never be able to quantify and understand. But through recording information about each individual suicide in the VSR, particularly information about the health and other services with whom the person had contact, and then looking at what has happened across time and across people, we hope the VSR can at least lead us to new understandings of how people who are suicidal might better be supported in our community.

10. The VSR indicates the annual frequency of suicides occurring in the state of Victoria has been steadily increasing for the past decade, from 550 deaths in 2011 to a peak of 713 deaths in 2020.17

11. The annual Victorian suicide rate for the period 2011 to 2019 ranged from 9.9 suicides per 100,000 people in 2011 to 11.0 suicides per 100,000 people in 2017.18 Victorian suicides following workplace injury

12. From the VSR statistics, the CPU identified 169 suicides between 1 January 2009 to 31 December 2016 which occurred following workplace injury.

17 Coroners Court Monthly Suicide Data report, October 2021 update. Published 15 November 2021.

18 The annual suicide rate is the annual suicide frequency expressed as a proportion of the population in which the suicides occurred. The most common calculation for a crude rate is to divide the frequency of Victorian suicides by the overall population of Victoria in that year, then multiple by 100,000 (to produce the suicide rate per 100,000 people). For example, in 2011 there were 550 Victorian suicides and the population of Victoria at that time was estimated to be 5,537,817 people, so the rate was (550 ÷ 5,537,817) × 100,000 = 9.9 suicides per 100,000 people.

13. Most deceased were male (n=144, 85.2%), with the highest frequency of suicides following workplace injury occurring in the 45 to 54 age group (n=43, 29.9%).

14. The occupation with the highest suicide frequency was technicians and trade workers with 51 deaths (30.2%), 48 of whom were male.

15. The most common workplace incidents were falls and lifting-related, with each type identified in 18 deaths (10.6%). Of those with fall-related injury, six (33.3%) were technicians and trades workers.

16. The most dominant workplace injury identified was back/spinal injuries, accounting for nearly 40% (n=67) of all injuries. Approximately 30% (n=20) of all back/spinal injuries, occurred among the technicians and trade workers. Similar to Mr Edwards, several of the deceased experienced multiple workplace injuries (n=32, 18.9%).

17. Among the 169 deaths identified, the largest group comprised those who experienced a workplace injury one to five years prior to their suicide (n=46, 27.2%). There was a similar distribution of deaths where the deceased had experienced the workplace injury less than one year prior to their suicide (n=31, 18.3%) and between six and 10 years prior to the suicide (n=29, 17.2%). In the case of Mr Edwards, he experienced his work-related injury 13 years prior to his suicide. The data demonstrates that there is a smaller cohort of deceased present in this group where the injury occurred 11 to 15 years prior to the suicide (n=10, 5.9%).

18. The three most prevalent themes in the identified deaths were a decline in mental health subsequent to the workplace injury (38.5%), reduced or no capacity to work (59.8%), and experience of chronic pain (58%).

19. These statistics illustrate the profound impact that a workplace injury can have on a person.

Prevention developments in Victoria

20. During the period 2009 to 2016 there were approximately 21 suicides annually following workplace injury. These were not counted in workplace death statistics at the time, and if they were, they may have substantially inflated the statistics. For example, in financial year 20152016 WorkSafe reported that 31 people lost their lives at work; an extra 21 deaths is a greater than 60% increase on this official reported figure.

21. Commencing 1 July 2020, WorkSafe now counts suicides attributable to work as workplace fatalities in its statistics. These include suicides that are caused by unsafe working conditions

and suicides where occupation was a significant causative factor and that are compensable under the Workplace Injury Rehabilitation and Compensation Act 2013.19

22. Having a greater awareness of the risk of suicide following workplace injury has only recently been recognised by WorkSafe Victoria. Greater awareness of this risk among the workforce may better prepare workplaces for such incidents and encourage improved responses and support for staff following a workplace injury.

I convey my sincere condolences to Mr Edwards’s family for their loss.

In accordance with section 73(1A) of the Coroners Act 2008, I direct this finding be published on the Internet.

I direct that a copy of this finding be provided to the following: Joan Edwards, senior next of kin Chief Executive Officer, WorkSafe The Secretary, Victorian Trades Hall Council First Constable Amber Kessler, Victoria Police, Coroner’s Investigator Signature: ___________________________________ Caitlin English, Deputy State Coroner Date : 08 December 2021 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.

19 WorkSafe Victoria. (2020). Workplace fatalities. www.worksafe.vic.gov.au/resources/workplace-fatalities/.