Coroner's Court of Western Australia

Inquest into the Death of Elia WANI

Inquest into the Death of Elia WANI

Delivered on : 3 December 2021

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

Recommendation No. 1

The Therapeutic goods Administration should consider whether products containing sodium nitrate should be the subject of similar restrictions as those about to imposed in relation to sodium nitrite, given the similar effect on the human body of both substances.

Recommendation No. 2

The Therapeutic Goods Administration should consider advising suppliers of products containing sodium nitrite that these products have been widely promoted as capable of causing death in the context of euthanasia and suicide, and suggesting that suppliers take all possible steps to ensure that the sodium nitrite products they sell are intended for legitimate purposes.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Wani died on 21 May 2019, from methaemoglobinaemia in association with sodium nitrite toxicity after he ingested a product containing sodium nitrite with the intention of taking his own life.  He was 29 years old.

At the time of his death Mr Wani was subject to a Community Treatment Order (CTO) under the Mental Health Act 2014.  He was placed on the CTO because of issues with non-compliance with medication and because he lacked insight into the need for treatment for his mental health condition.

In 2013, Mr Wani diagnosed with bipolar affective disorder in 2013.  Although he was treated with medication, he experienced a number manic relapses requiring hospitalisation, and these relapses were predominantly related to his non-compliance with his medication regime.  Mr Wani last admission to hospital was in October 2018.  He was discharged home on a CTO on 8 October 2018 and managed by his local community mental health team.  Mr Wani’s treatment plan involved monthly reviews with his consultant psychiatrist and fortnightly meetings with his care coordinator.  As a result of side-effects, Mr Wani had been tried on several different medications and by February 2019, he was receiving monthly injections of antipsychotic medication reported feeling much better.  He was last reviewed by his consultant psychiatrist on 7 May 2019 at which time he seemed to “doing well”.  On 17 May 2019, the Mental Health Tribunal extended Mr Wani’s CTO for a further three months.

On 10 May 2019 Mr Wani made an online purchase of a product containing sodium nitrite from a food ingredient supplier in Melbourne.  It is unclear when the package arrived at his home.  When ingested, sodium nitrite causes the iron in the haemoglobin continued in red blood cells to oxdise.  This interferes with the normal transport of oxygen around the body and if causes death when a sufficient amount of sodium nitrite is ingested.  Sodium nitrite and a related substance, sodium nitrate are both used as meat preservatives (amongst other things) and are widely available.

On 20 May 2019, Mr Wani received his regular depot injection and his next appointment was scheduled for 5 June 2019.  Mr Wani went to bed at about 9.15 pm and was heard snoring at about 11.20 pm.  This was unusual and family members checked on him, they found Mr Wani lying unresponsive in bed.  Emergency services when ambulance officers arrived, his respiration and heart rate were very slow and his oxygen saturation was only 73%.  Mr Wani was taken to the Armadale Kelmscott District Memorial Hospital, but despite the efforts of his family, ambulance officers and hospital staff, Mr Wani could not be revived.

Prior to Mr Wani being taken to hospital ambulance officers found a box of sodium valproate tablets under a desk in his bedroom and a handwritten note in which he indicated his intention ot take his life by ingesting sodium nitrite.

The Coroner was satisfied that the decision to place Mr Wani on a CTO was appropriate because of his non-compliance with medication and his lack of insight into the need for treatment for his mental health condition.  The Coroner was also satisfied that the supervision, treatment and care that Mr Wani received whilst he was the subject of a CTO was of a good standard.

The Coroner made two recommendations aimed directed to minimise the risks associated with the misuse of products containing both sodium nitrite and sodium nitrate.

Catch Words : Sodium nitrite : CTO : Supervision, Treatment and Care : Suicide

Last updated: 5-Jan-2022

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