Inquest Findings in the Death of Rosemary Haldane — (Victoria Coroner’s Court, Melbourne)

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Court Reference: COR 2012 2267

Hearing Dates:                               19 April 2013

Findings of:                                   JOHN OLLE, CORONER

Police Coronial Support Unit        Leading Senior Constable K. Taylor

I, JOHN OLLE, Coroner having investigated the death of ROSEMARY HALDANE

AND having held an inquest in relation to this death on 19 April 2013 at MELBOURNE

find that the identity of the deceased was ROSEMARY KAYE HALDANE born on 30 September 1955 / aged 56

and the death occurred on 16 June 2012

at Room 4, Burwo.od Unit, Delmont Private Hospital, 298 Warrigal Road, Glen Iris 3146



in the following circumstances:

 Rosemary Haldane was aged 56 years at the time of her death. She lived alone at Unit 2, 27 Fairholm Grove Camberwell. At the time of her death, Rosemary was an inpatient at the Delmont Private Hospital Glen Iris.

  1. A mandatory inquest was held. The summary of .evidence read into evidence, accurately reflects the comprehensive coronial brief. 1

Summary of Evidence

 Rosemary Haldane was a mother of two children, and grandmother of She was a widow whose husband passed away unexpectedly in 2006 from a heart attack.

  1. Since the passing of her husband, Rosemary struggled with depression and had constant suicidal thoughts. She saw her local medical practitioner, Dr Anne Money, approximately weekly for supportive psychotherapy. Rosemary was prescribed antidepressants to help manage her suicidal thoughts.
  2. In September 2008, Rosemary attempted suicide by taking an overdose of her

She was subsequently admitted to Delmont Private Hospital (‘Delmont’) where she recovered. Her second suicide attempt was in May 2010 where she was once again admitted to Delmont. Her third attempt led to her admission to Box Hill Intensive Care Unit.

  1. Rosemary was then transferred to the St Vincent’s Mental Health Service as an involuntary

1 A copy of the brief will r main in court file.

  1. Rosemary’s son, David Haidane, noted that each suicide attempt came just before the birth of a grandchild. He believed her reasoning was a birth would ease the family’s pain of having to cope with her loss.
  1. Rosemary had the following admissions to Delmont under. the care of Dr Justin Lewis, Consultant Psychiatrist:
    1. 29 June2011 to 8 July2011
  2. 15 October 2011 to November 2011
  3. 22 November 2011 to 20 December 2011
  4. 25 April 2012 to 10 May 2012; and finally
  5. 23 May 2012 to 16 June 2012
  6. I note the consistent, dedicated, professional care and attention, Rosemary received from Dr Money and Dr Lewis, together with nursing staff at Delmont.
  7. On her final admission to hospital, Rosemary told Dr Lewis she “had a plan”. Due to this she was placed on hourly observations and not authorised to leave the
  8. Following improvement, Rosemary was permitted accompanied leave on the 28th of May
  9. For the next few weeks Rosemary fluctuated from having periods of feeling settled, to periods of feeling suicidal.
  10. On 15 June 2012, Rosemary was reviewed by Dr Lewis, who noted that she was feeling settled and reactive. Rosemary denied any intent to self
  11. Rosemary accepted accompanied day leave from 8 am and returned at 10.30 am on 15 June 2012. She stated that she had coffee with a few friends. In hindsight, it appears Rosemary obtained prescription medication from a local pharmacy whilst on leave. At all times throughout that day, Rosemary appeared to nursing staff to be settled.
  12. It appears at some time during the night, Rosemary ingested a fatal dose of prescription medication. When checked at 6 am on 16 June 2012, Rosemary was At approximately 7.30 am, Rosemary made a feint response to the nurse consistent with Rosemary sleeping.
  13. Rosemary was sadly unresponsive at a subsequent nursing check at about 9am. CPR was commenced and a Code Blue called. Ambulance personnel attended but were unable to revive
  14. There was a white cup found near her body with some remnants of pills Also found was a recent entry in her journal which talks about her struggles and makes reference to her making another attempt on her life.

Final review by Dr Lewis

 On 15 June 2012, Dr Lewis reviewed Rosemary:

“At that time, her presentation was noted to be “settled and reactive” although Mrs Haldane continued to report a mild lowering in mood and intermittent suicidal ideation. A discussion was had at that time with respect to the advantages and disadvantages of a more prolonged admission. Mrs Haldane denied any intent to self hann and on the basis that she felt increasingly confident seeking support if she felt suicidal, she was given approval for day leave”.2

  1. David Haldane concluded:

“On the 16th of June 2012 I was notified of mum’s death. I attended at Delmont Hospital and spoke to the staff there. I was very saddened by the events of that day, but it did not come as a shock to me. I knew that mum had neyer got over Dad’s death and deep down I feared that she would take her own life one day”.3

Post mortem medical examination

 On 20 June 2012 Dr Malcolm Dodd, Forensic Pathologist at the Victorian Institute of

Forensic Medicine examined the body of Rosemary Kaye Haldane.

  1. Dr Dodd found the cause of death to be combined drng toxicity
  2. Dr Dodd commented:

“Overnight toxicological analysis discloses a multiplicity of drugs.  The medications Alprazolam, 7-aminoclonazepam, Citalopram, Clonazepam, Diazepam, Nordiazepam, Paracetamol, Quetiapine and Zolpidem were identified in blood.