CORONER'S REPORT REASONS FOR DISPENSING WITH INQUEST DEATH OF ANNA VICTORIA WOOD NUMBER 2094 OF 1995 Reasons for dispensing with the holding of an inquest The manner and cause of Anna Wood's death is now clear to me to the standard required by law. Because of this and as the death involves no indictable offence against any known person, I have decided to dispense with the holding of an inquest. This case has generated a great deal of public debate and interest. Pronouncements have been made by a number of sources and some of those have been found to be manifestly inaccurate. Whilst often in a case such as this one, the public interest may dictate that an inquest be held, in deciding to dispense with the holding of one I have taken into account the wishes of Anna's family, and my own view that the manner an cause of death is now clear. I feel that the public interest can best be served by giving reasons for dispensing with an inquest and also giving in some small detail, my conclusions as to the cause of Anna Wood's death. It is the wish of the parents of Anna Wood that I state publicly and clearly my findings as to the probable cause of Anna's death, so as to allay the rumours and misconceptions which have arisen since Anna died. Manner and cause of death Anna Wood, a 15 year old girl presented to Royal North Shore Hospital on the morning of 22 October, 1995 with a clinical history of respiratory arrest, following alleged ingestion of methylenedioxymethamphetamine (MDMA \ ecstasy) late the previous evening. She had apparently remained relatively well for some time after ingestion of the drug, and continued dancing strenuously. She periodically ingested water, and had been vomiting before 5 am. She was apparently taken to the home of a friend and placed in bed. Apparently there were continued episodes of dry retching, intermittent sleep, confusion and possible convulsion-like movements. By about 10 am, Anna had lapsed into unconsciousness at her friend's place. There was a period of hypoxia, possibly up to 12 minutes. On arrival, ambulance staff commenced resuscitative treatment for respiratory arrest. Anna was transported to Royal North Shore Hospital and treatment for suspected overdose was continued. She was quickly admitted to Intensive Care. On 23 October, 1995 there was evidence of absent cerebral blood flow, which was confirmed the next day. "Brain death" was pronounced at 2.45 pm on 24 October, 1995. I must stress that whilst urine analysis on admission confirmed the presence of MDMA, no other substances were demonstrated. Dr Paul Botterill, a Forensic Pathologist at the N.S.W. Institute of Forensic Medicine, conducted an exhaustive post mortem. He described the cause of Anna's death as being hypoxic encephalopathy. He reiterated in detail in his post mortem report his opinion as to how Anna came to suffer this cerebral oedema. I shall quote from aspects of Dr Botterill's report:- "The cause of death was hypoxic encephalopathy following the protracted period of respiratory arrest which has followed the ingestion of MDMA. The precipitant event is not clearly established. It is not clear whether the respiratory arrest represented a direct toxic effect of MDMA or other unidentified contaminant substances (particularly in association with exertion and/or water ingestion), an idiosyncratic response to those substances or some other pathological process ... coincidentally associated with the substance ingestion. The possible roles of airway compromise prior to resuscitation and or aspiration of vomitus are also difficult to assess. Death following ingestion of MDMA is uncommon .... Some features in this case (the history of drug taking with protracted dancing, subsequent vomiting, possible convulsions and semi-comatose state) are consistent with the reported cases, but other features are not typical of the reported cases from the early 1990's. I have discussed this case with Dr J.A. Henry of the National Poisons Unit, Guy's Hospital, London, who is aware of a number of recent British cases with similar features. Those reported cases, and other very recent deaths followed ingestion of relatively small doses of MDMA and large quantities of water, and were associated with hyponatraemia (low sodium level) and water intoxication. Advanced hyponatraemia can be associated with hallucinations, inappropriate behaviour, altered temperature regulation (including hypothermia), seizures, coma, diabetes insipidus and respiratory arrest. The exact mechanism of this effect is not clear, but appears to involve both water intoxication and ingestion of MDMA .... It is conceivable that the features in this case, including the development of a syndrome of inappropriate ADH secretion may have been modified by the period of hypoxia associated with the respiratory arrest" Dr Botterill was quite confident as to his findings and took a great deal of time and care with his research into death following MDMA ingestion. This phenomenon is quite rare in this country. As I have indicated he spoke to Dr John Henry, a consultant Physician with the Medical Toxicology Unit at Guy's Hospital, London. I requested Dr Henry to carry out a review of the case. In view of the rarity of this phenomenon, no one person can claim real expertise. However Dr Henry has seen comparatively more cases than his colleague in Australia. Dr Henry's review has now been completed and was forwarded to me on 30 May, 1996. Dr Henry states:- "It is clear that Miss Wood had ingested ecstasy (MDMA), had been dancing intermittently and had drunk large amounts of fluid. Her illness and death bore all the hallmarks of cerebral oedema, and it can be concluded that she died of acute water intoxication, secondary to MDMA ingestion. Her case closely parallels a widely publicised case which occurred in Britain recently .... I am aware of at least two other fatalities. There have also been a number of non-fatal cases .... It may be asked why the drug is associated with the complication of potentially fatal cerebral oedema, and whether this complication should be regarded as ecstasy toxicity or acute water intoxication .... Ecstasy is a drug which combines most of the pharmacological effects of amphetamine sulphate with an alert euphoric empathic state in which all inputs are heightened, giving it the combination of pharmacological properties which have lead to its widespread use as a dance drug. Prolonged dancing has led to a number of deaths due to hyperthermic collapse. People continue dancing for many hours without replacing fluids (because of the appetite suppressant effects of amphetamines) and this led to the harm limitation messages that it would be good to drink fluids if one was using ecstasy as a dance drug. This information may well have saved a number of lives, but it may also have induced many people to drink large amounts of fluids without any understanding of the reasons for so doing. As long as one is replacing lost fluid, there is no problem. However if excess fluid is drunk, there is a potential problem, because in a proportion of people the drug reduces the kidney's ability to rid the body of excess water (the so-called syndrome of inappropriate anti-diuretic hormone secretion - SIADH). Thus, drinking several litres of water over and above the body's requirements over a short space of time, may cause hyponatraemia due to dilution of the body's sodium content, and cerebral oedema (swelling of the brain) due to this dilution. This swelling can force pressure on vital centres at the base of the brain, which in extreme cases may cause breathing to cease. Some people may wish to label this death as a case of water intoxication in an attempt to exonerate the drug as a cause of death. However, although water intoxication was the mode of death the excess fluid ingestion would not have occurred if the drug had not been taken, and secondly the drug aggravates excessive water ingestion by causing SIADH. I thus conclude that the cause of death must be given as ecstasy ingestion." Conclusions It can be seen, therefore, that Drs Botterill and Henry have jointly reached the same conclusion as to the cause of Anna Wood's death. In effect, Dr Henry discards several possible scenarios postulated by Dr Botterill and agrees with his probable cause. The message given by Drs Botterill and Henry, particularly as to the non-exoneration of MDMA as a cause of death is a sobering one, and one which ought to be noted by all those who use this drug, particularly in a dance party setting. Dr Henry concludes his opinion by saying this:- "The Department of Health in this country has included in its publicity the words 'water is an antidote to dancing, not an antidote to ecstasy.' People are recommended now to drink one pint of water or isotonic fluid per hour if they are dancing vigorously and not more than one cup of fluid per hour if they are not dancing vigorously. This modification of the original harm limitation message may help to avoid the two potentially fatal extremes of hyperthermic collapse (heatstroke) and hyponatraemia (water intoxication)." It is not unlikely that a tragedy such as this will occur again in N.S.W. In an effort to reduce the chance of that happening, I propose to recommend that the N.S.W. Health Department publishes a pamphlet, which will have the twofold effect of educating those who use the drug as to its dangers, and also educating the community as to the appropriate care of the individual who becomes ill following ingestion of the drug. I would like to see the pamphlet disseminated as widely as possible. The Department deferred the publishing of such a pamphlet until this case is finalised. The pamphlet's message will have to be carefully considered and worded. I thank those who have assisted me in finalising this matter, particularly Drs Paul Botterill and John Henry. To the members of Anna's family I extend my sympathy on their loss. FINDING That Anna Victoria WOOD died on 24 October, 1995 at Royal North Shore Hospital, St. Leonards, N.S.W. of hypoxic encephalopathy, following acute water intoxication secondary to ingestion of MDMA (methylenedioxymethamphetamine). RECOMMENDATION That the Health Department of N.S.W. publishes a pamphlet aimed at those who use MDMA (ecstasy), which clearly indicates the possible consequences of MDMA ingestion, and the action to be taken by any person who becomes ill or who may be with a person who becomes ill following ingestion of MDMA. (John Abernathy) N.S.W. Deputy State Coroner, Glebe, N.S.W. _________________________________________________________________ Note: these footnotes do not form part of the original report; they have been added where necessary to explain medical terms with which laypersons may not be familiar. 1. hypoxia: a state where inadequate amounts of oxygen are available. 2. hypoxic encephalopathy: lack of oxygen supply to the brain. 3. oedema: effusion of fluid into the interstices of cells or body tissues. 4. aspiration: breathing in. 5. ADH: anti-diuretic hormone. 6. pint: about 600 ml. [ this file found at: http://www.houseoflove.com.au/stuff/annawood.html ] ------------------------------------------------------------------------------- The Daily Telegraph, Sydney, Australia - Wednesday, June 19, 1996. "Hug Ends Anguish for Woods" - by Brad Clifton It was a simple gesture that yesterday marked the end of months of anguish for the family of ecstasy victim Anna Wood. As he concluded his findings into her daughter's death, NSW Deputy State Coroner John Abernethy left his bench, approached Angela Wood and hugged her. The spontaneous embrace represented a union of hope, that through his official recommendations on drug education and her continued fight in Anna's memory, the pair could jointly prevent a repeat of the tragedy. Mr. Abernethy, who has formed a close friendship with the family since the 15-year-old's death, yesterday officially concluded she died from a lethal combination of water and ecstasy, which she consumed at a dance party last October. He also outlined his steps to ensure the community was better educated about the potentially fatal qualities of the drug. "It is not unlikely that a tragedy such as this will occur again in NSW", Mr. Abernethy said. "In an effort to reduce the chance of that happening, I propose to recommend that the NSW Health Department publishes a pamphlet, which will have the twofold ef fect of educating those who use the drug as to its dangers, and also educating the community as to the appropriate care of the individual who becomes ill following ingestion of the drug. I would like to see the pamphlet disseminated as widely as possible". Mr. Abernethy dispensed with holding an inquest into Anna's death after consulting with her parents, but said the family wished him to publicly state his findings to "allay the rumours and misconceptions which have arisen since Anna died". He enlisted the aid of consultant physician Dr. John Henry, from London's Guy Hospital, who has studied similar recent deaths in Britain. Dr. Henry reported Anna died from the combined effects of water and ecstasy. "It is clear that Miss Wood had ingested ecstasy... and had drunk large amounts of fluid," he said. "Her illness and death bore all the hallmarks of cerebral oedema [brain swelling], and it can be concluded that she died of acute water intoxication, secondary to [ecstasy] ingestion." In simple terms, Dr. Henry said the drug Anna had taken enabled her to dance with a heightened level of energy. This extended physical activity then made her thirsty and she drank more water. But the drug had caused a reaction in her body known as SIADH - the Syndrome of Inappropriate Anti-Diuretic Hormone secretion. The condition reduced the ability of Anna's kidneys to rid her body of the excess water, leading to hyponatraemia - also known as "water intoxication" - which in turn led to brain swelling and death. Mr. Abernethy said Dr. Henry's conclusions should serve as a warning to those considering experimenting with ecstasy. "The message given by [Dr. Henry], particularly as to the non-exoneration of [ecstasy] as a cause of death, is a sobering one, and one which ought to be noted by all those who use this drug, especially in the dance party setting," he said. Outside the court, Mr and Mrs Wood said they were relieved at the coroner's decision. ------------------------------------------------------------------------------- See also: http://www.crimestoppers.net.au/anna.html (The Anna Wood Drug and Alcohol Education Project - includes Anna's photo) ------------------------------------------------------------------------------- The Daily Telegraph, Sydney, Australia - Friday, May 24, 1996. "The Ecstasy and the Agony" - Mike Gibson For all the kids in this city who are going out for a rave this weekend, this is how 15-year-old Anna Wood died last October. She took an ecstasy tablet, and went dancing with friends at a club in George Street, Broadway. I could try putting what happened in my own words. A traditional review. But nothing could be more graphic than the words of journalist Bronwyn Donaghy. Bronwyn has written a book called Anna's Story. It will be published next week. "I'm having the best night of my life," repeated Anna to her friends. "I'm having the best night of my life." Alexia thinks it was about 5AM when she noticed Anna sitting on a boy's lap at the edge of the dance floor. "I went up to talk to her and I could see from her face that she was really drugged out. Her face was everywhere, her eyes were rolling around in her head, she was sweating. Her jaw was wobbling. She was clenching and unclenching her fists. Her facial movements kept changing." Anna's face was pale and waxy. She vomited, splashing the boy she was with and the other people beside him. Horrified, she leapt up and ran towards the toilets. "I ran in after her," said Chloe. "I got there just as she collapsed. I caught her and sat her down on the floor, so she could heave into the toilet bowl. I started to scream." It was a 45-minute drive to Belrose. "On the way, she said she couldn't feel her lips or her legs," said Chloe. "I asked her if she thought we should take her to see a doctor, but she didn't answer." Chloe and Jeff pushed Anna through the front door and up the stairs to Chloe's bedroom. She vomited on the way. "We left her in bed and tried to clean up the mess on the stairs," said Chloe. "Then we heard this big thump and went up to see what happened. She was lying against the door and we couldn't get it open. I could hear her vomiting. I finally pushed the door open far enough to get in. She'd thrown up on the floor. I put her back into bed. She wasn't talking any more, just retching and throwing up and rolling around on the bed." "We weren't scared for ourselves," said Alexia, sounding terrified. "We were very scared for Anna. We knew that if Anna's Mum found out what she'd been doing that she would never let us see Anna again." So they woke up Chloe's mother, Judy, and said Anna was sick in Chloe's bed and that someone had spiked her Coke, possibly with drugs. "She was curled up in a ball on the bed, facing the doorway," said Judy, "covered in vomit." "You'd better come," said Judy to Angela, Anna's mother. "Anna's ill. There's something wrong." It was 10AM. Angela swept through the front door and upstairs into the bedroom where her daughter lay. She saw a clammy, cramping waif, sweating and smelling of sick, delirious and out of control. Her hair was matted with vomit and she had wet herself - her jeans were stained with urine. "What have you done to her?" screamed Angela. "Where have you been?" "It was a drink she had at the Go-Kart club," they gabbled. "Someone must have spiked her drink." Anna's father Tony was attempting to keep Anna conscious. "Don't die, darling," he whispered. "You have to keep breathing". In the distance, they all heard the siren. Anna was taken to the Royal North Shore hospital. "They told us then they were pretty sure that her brain was gone," said Tony. "They had a little cemetery at the hospital. Angie was there, crying and screaming." Angela watched the people come and say goodbye to her daughter in a haze of grief and exhaustion. Tears ran down their faces. How could this still, white child be that lovely, bouncing talking, lively, vividly smiling Anna Wood? On Tuesday afternoon Angela and Tony agreed that their daughter's vital organs - heart, lungs, pancreas, liver and kidneys were to be removed for donation. At 8PM the family left the intensive care unit after Anna had been wheeled away for the final oper ation. In the early hours of the morning they saw their daughter again, but she was no longer the Anna they remembered. "She lay there like stone," said her father. Anna Wood, a girl as golden and warm as a sun-ripened peach, was cold. Ecstasy is a drug which causes stimulation and hallucination to a highly abnormal degree. Its real name is MDMA - the name of the chemical from which it is made. There is no doubt that the poisonous chemical, MDMA, would have changed the way messages were carried to and from Anna's brain. Anna's brain swelled so much that the lower end or stem was forced down through the hole in the base of the skull where the spinal cord joins the brain. This hole is called the foramen magnum. [Ed Note: If MDMA is a "poisonous chemical" then so is Aspirin -- lamont] The brain stem contains the body's respiratory drive. Once it was pushed down through the foramen magnum, the mechanics of respiration would have stopped working. Normal breathing would have stopped. "Anna didn't do drugs like we did," said Chloe. "She smoked some pot over the last nine months or so but apart from that she might have had one trip, at a fireworks night - she didn't like it - and I think she tried speed once. She took half an ecstasy tablet about a month before she passed away. We were at a local rave party. Her parents didn't know and it wasn't far from home so she would have just said she was staying with one of us for the night". Anna Wood was a lovely girl. Everybody said so. She died on October 24, 1995.
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