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Geddis, Re inquest into the death of [2019] NICoroner 8 (7 June 2019)

Ref: 2019NICORONER8

Neutral Citation No: [2019] NICoroner 8

Judgment: approved by the Court for handing down

(subject to editorial corrections)*

Delivered: 07/06/19

IN THE CORONERS COURT FOR NORTHERN IRELAND

____________

IN THE MATTER OF AN INQUEST INTO THE DEATH OF

PETER FRANCIS GEDDIS

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Before: Coroner Mr Patrick McGurgan

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The deceased, Peter Francis Geddis, born on 25th August 1971, of 12 Templemore Avenue, Belfast, died on 20th April 2016.

I received evidence from a number of witnesses, including the State Pathologist, Dr James Lyness, the daughter of the deceased, Laura Geddis, a civilian who was present in and around the time of death, Peter McIlroy, and a number of police officers. I also considered a large number of statements admitted under Rule 17 and a number of exhibits.

It is not possible to recite all of the evidence in these findings although all of the evidence received by me has been considered before arriving at these findings.

The oral evidence and medical records confirmed that the deceased had a history of alcoholism, polysubstance abuse, dissocial personality traits, depression and schizophrenia. His GP also confirmed that he also had a history of Hepatitis C related to intravenous drug abuse.

During her evidence the deceased's daughter, Laura Geddis, said that whilst her father had used for many years, she felt that his problems with drugs had escalated in the last number of years and I find that, sadly, to be an accurate observation based on the evidence I received.

It is clear from the evidence that the deceased was taken from Great Victoria Street to the Accident and Emergency Department of the Royal Victoria Hospital, Belfast, by ambulance at around 8.45am on the 20th April 2016. When triaged, he complained of low mood thoughts of self-harm, visual and auditory hallucinations. He stated that he had taken 18 x 200 milligram Lyrica tablets, 14 Diazepam and 3-4 Xanax tablets the previous day. He also claimed to have injected himself with 2ml of bleach and consumed vodka and herbal highs that morning. A preliminary mental health assessment was started but a full assessment could not be completed as the deceased was under the influence of drugs. As a result he was admitted to the Clinical Assessment Unit in order to allow him time to become medically fit for the assessment to take place but the deceased left the hospital. Hospital staff were concerned for his safety and contacted the police at around 10.15am to report that he had left hospital. The PSNI engaged the missing persons protocols and various efforts were made to locate the deceased, although they were unsuccessful.

The evidence of what happened after he left hospital is less clear. I received what I consider to be reliable evidence from a number of students, police officers and paramedics who were present in one capacity or another at the scene where the deceased lost his life. However, all of those witnesses describe what happened in the period after he lost his life. The evidence of what happened in the hours between him leaving hospital and dying in and around the alleyway to the rear of Lawrence Street in the Botanic Avenue area of Belfast is less clear. It comes from persons who were all at the time self-confessed heroin addicts. Of the three witnesses who speak to that time, namely Peter McIlroy, Michelle Gill-Hamner and Maria Brady, only one gave oral evidence that is Mr McIlroy.

Mr McIlroy cooperated with the inquest, although he gave evidence three years after the events without the benefit of a memory refreshing written statement made contemporaneous to the events in question.

Ms Gill-Hamner refused to attend and communicated through her Solicitor that she wished to rely upon her earlier statements. We were also unable to secure the attendance of Maria Brady despite her attendance being requested through her Solicitor.

In her witness statement to the police, made the day after this tragedy and admitted by me under Rule 17, Michelle Gill-Hamner stated that she was a friend of the deceased. She met the deceased sitting outside the Grand Opera House on the 20th April 2016. The deceased was also her sister's boyfriend at this time. After speaking to the deceased for a period of time, Ms Gill-Hamner then met up with her boyfriend, Mr Peter McIlroy. Sometime later she noticed a crowd had gathered around the Grand Opera House and on walking closer she witnessed the deceased taking a seizure. An ambulance arrived and took the deceased to hospital. Sometime later she again found the deceased outside the Grand Opera House and she was surprised to see him out of hospital so soon. According to Ms Gill-Hamner, she and the deceased left and went to a "drug den" that her group frequently used. On the way to this area she described how he was sick and when the two were in the "drug den" the deceased apparently fell asleep and was snoring. Ms Gill-Hamner said that Maria Brady was present at the den and that Mr McIlroy arrived later, accompanied by others she did not name. She said that later Mr McIlroy noticed that the deceased's lips were blue, which led to an ambulance being called and the assistance of some nearby students being engaged and CPR was attempted.

Ms Gill-Hamner described how the deceased had made comments about wanting to end his life and that he hadn't long to live owing to his Hepatitis C, although there is no support whatsoever in any of his medical records for the suggestion that he didn't have long to live.

In early May 2016 Ms Gill-Hamner revealed to a Project Worker with Extern that she knew more about the circumstances of the deceased's death namely that she was involved in 'pinning' (injecting) the deceased with heroin, as she alleged he had begged her to help him die. She later distanced herself from the comments she made to the support workers, which she said she had no memory of and was under the influence at the time allegedly making them. The support workers confirmed that she was under the influence at the time of making these comments.

In her evidence to the Inquest, admitted under Rule 17 as she also refused to attend the Inquest, Maria Brady said that on 20th April she made her way into town on foot at around 7am as was her usual routine. As she was outside Tesco's in Great Victoria Street, she was approached by Ms Gill-Hamner and a male she now knows to have been the deceased. The deceased asked Ms Brady if she could get him two bags of "brown" which is heroin. Ms Brady declined and the two left. Ms Brady remained outside Tesco's begging for around 1 ½ hours until she had enough money to purchase heroin. Ms Brady made her way to the drug den. Ms Brady then left to purchase heroin and on return approximately 5 minutes later she noted that the deceased's lips were blue.

Ms Brady went on to describe how she and Ms Gill-Hamner attempted to gain the attention of a group of students living above the scene. Two of these students attended and Ms Brady phoned the emergency services handing the phone to one of the students while the other attended to the deceased. The deceased was moved into the nearby entry and CPR was commenced by one of the students.

Ms Brady describes in her statement how the deceased's left arm was bleeding from a needle injection and that Ms Gill-Hamner told her not to call the ambulance because Ms Gill-Hamner had injected him. However I bear in mind that other reliable witnesses, such as the medical student, described Ms Gill-Hamner trying to get them to call an ambulance, which doesn't lend any support to Maria Brady's latter comments.

I have noted that Ms Gill-Hamner mentions that there was a written suicide note when she was later discussing the deceased's alleged suicidal comments with a support worker. She didn't mention the note previously or subsequently. The police, who were interested in finding such a note, were unable to locate one.

I am not convinced that either Ms Brady or Ms Gill-Hamner are reliable historians.

Ms Gill-Hamner's accounts are inconsistent with each other. Ms Brady's account is inconsistent with Ms Gill-Hamner's and also with Mr McIlroy.

Mr Peter McIlroy gave evidence to the Inquest. He stated that he had known the deceased for a few months prior to his death as the deceased was the boyfriend of Ms Gill-Hamner's sister and he was Ms Gill-Hamner's partner.

Mr McIlroy stated that he did not see the deceased the morning of the 20th April but first encountered him at the drug den in the afternoon. Mr McIlroy had his own issues at the time with drugs and he had gone to this den in order to take heroin. When he arrived he described seeing the deceased in a yard area off an alleyway to the rear of a property in Lawrence Street, Belfast. The deceased was sitting on a sports bag sleeping. He did not see anyone administer drugs to the deceased nor did the deceased take any drugs himself. He described Ms Brady and Ms Gill-Hamner both being present also and that he believed that Ms Gill-Hamner had had a hit of heroin prior to his arrival. Mr McIlroy explained how he then left the area in order to purchase drugs for himself and on return to the area within 5 -10 minutes he noticed that the deceased's breathing was heavier and his lips were blue. Mr McIlroy described the noise emanating from the deceased as a death rattle.

He described how the deceased was then moved into an adjacent alleyway so that CPR could be attempted and Mr McIlroy waited at the scene until the arrival of police and emergency services.

According to Mr McIlroy, whilst he knew the deceased used drugs, he had never seen the deceased take heroin or methadone before and that the deceased had discussed low mood at times and that he understood that he had fallen out with his partner that morning.

On questioning by Counsel for the next of kin, Mr McIlroy described how Ms Gill-Hamner had previously administered heroin to him at his request in the past when he was unable to do so himself.

On arrival of paramedics CPR was continued but unfortunately same proved futile and life was pronounced extinct at 5.11pm at the scene.

Detective Sergeant Mason noted needle marks to the deceased's arms at the scene. The Pathologist also noticed needle marks to his left arm and to his left hand, although it looks likely that the mark on his left hand was as a result of giving bloods at the hospital that morning, owing to what appears to be green medical gauze taped over the wound with what appears to be surgical tape, judging by the photographs.

I find on the balance of probabilities that the deceased had at some time in the past taken intravenous drugs but that in the period immediately prior to his death he had not been engaged in this type of drug use and therefore his tolerance levels to intravenous drugs were low.

A toxicological analysis of a sample of the deceased's blood revealed the presence of a large number of drugs. On balance I find that the deceased drank methadone earlier in the day after being released from hospital and that he later injected himself with heroin, in addition to the other drugs he consumed.

The Pathologist described how the amount of methadone ingested was of itself dangerous. Similarly, the level of pregabalin he consumed was of itself dangerous. The level of other drugs, including heroin, were lower, but the combined effects of the various drugs were dangerous and ultimately fatal.

I find on the balance of probabilities that, particularly given the deceased's low tolerance levels to intravenous drugs, he did not intend to take his own life and he failed to appreciate the danger associated with the quantity of drugs he was taking. In particular, he failed to understand the toxic effects of the combination of drugs taken.

There was no toxicology test available that could test for the presence of bleach in the deceased's blood or urine, although the evidence from the Pathologist, which I accept, suggests it played no role in his death, if in fact it was injected in the first place, which I think is unlikely.

A post mortem was performed and it records and I find that death was due to:

I(a) Heroin, Methadone, Pregabalin, Diazepam and Alprazolam Toxicity.