Kevin Meagher was an involuntary patient at a mental health facility. He had a history of significant psychiatric episodes. He was found dead in the facility on 15 December 2014.

It was subsequently revealed that he died as a result of alcohol toxicity. An investigation into the source of the alcohol revealed that the deceased likely consumed a substantial quantity of Listerine mouthwash over a short period of time. The inquest into his death examined the circumstances in which he died and the knowledge in the facility, about his use of Listerine.

Background Facts

At the age of 12, the deceased was diagnosed with minor cerebral palsy which mainly affected his right side. He required physical, and later speech therapy until early primary school. At the age of 20, his behaviour deteriorated, with complaints that he had a breakdown and acute onset psychosis. He was subsequently diagnosed with schizoaffective disorder with manic element. Over the years, he continued to have major mental health-related episodes and required a number of involuntary admissions to the hospital.

On 20 April 2014, the deceased was admitted to the hospital as an involuntary patient after repeated refusal to take his medication. In the morning of 15 December 2014, the deceased was found by nursing staff, unresponsive in his room. Nurses performed CPR until emergency support team arrived. Mr Meagher was confirmed dead shortly after, aged 36. An autopsy showed that the cause of death was alcohol toxicity with lethal levels of alcohol shown on a blood test. It was not possible to 'reliably postulate a time of death in the … circumstances.'

Circumstances of Death

Prior to the death of Mr Meagher, he had been placed on two-hourly observations. These were completed by nursing staff throughout the night before his death. When his body was discovered, the stiffness in his body which were signs of rigor mortis, made it difficult to determine the time of his death.

The only alcohol substance within the deceased's reach was a Listerine mouthwash. The inquest heard, and accepted, that the level of alcohol found in his body could have only resulted from a rapid consumption of a full 1 litre bottle of Listerine, containing 21% alcohol. The inquest also heard, that in this case, the claimant's death could have therefore, occurred within thirty minutes. There was no direct evidence of the deceased consuming any Listerine the day before his death nor the morning of his death. However, an empty bottle of Listerine mouthwash was observed in his wardrobe.

There was evidence from progress notes, that the deceased was 'obsessed with Listerine' and that due to his delusion, he had a conviction that he was allergic to normal toothpaste and used Listerine frequently. There was further evidence that nurses had intervened at some point, by removing a bottle of Listerine from his room after he referred to it as 'his wine'. The inquest also heard that the claimant had Hashimoto Thyroiditis. The autopsy did not explore the likely contribution of this, if any, to the way his body metabolised alcohol.

Findings

The Deputy State Coroner, Magistrate Teresa O'Sullivan accepted the opinion by experts that the deceased passed away as a result of having consumed a substantial quantity of alcohol in the form of Listerine mouthwash. She found that this was not because the deceased was an abuser of alcohol. Rather, it was because of his delusional thoughts. The Deputy State Coroner acknowledged that there was some knowledge amongst the nursing staff that the deceased liked Listerine. However, she could not find any evidence indicating that they thought that this was a life-threatening problem, especially considering that the deceased was not known to be an alcohol abuser. The Deputy State Coroner offered his condolences to Mr Meagher's family.