Inquest into the death of Basilio Alesandro Petsas

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Basilio Alesandro Petsas Hearing dates: 16 October 2018 Date of findings: 16 October 2018 Place of findings: State Coroners Court, Glebe Findings of: Magistrate Russell Deputy State Coroner Catchwords: CORONIAL LAW – Cause and manner of death, compromised immune system, possible drug use, delay in post-mortem analysis File number: 2017/00012181 Representation: Assisting the Coroner: Sgt. Benjamin Hart Coronial Advocate Mr El Mostafa Alaoui-Hichami: Mr John Fisicaro John Fisicaro and Company

Findings: Basilio Alesandro Petsas died on 26 December 2016 at St Vincent’s Hospital, Darlinghurst, New South Wales.

The manner and cause of his death are unascertained.

Table of Contents Inquest into the death of Basilio Petsas

Background Basilio Petsas died on the morning of 26 December 2016 at St Vincent’s Hospital, Darlinghurst. At the time of his death he was 54 years old.

Mr Petsas was born in Argentina, the son of Maria Petsas and Athanasios Petsas.

He arrived in Australia, with his family, at the age of eight.

On leaving school he completed a certificate of technical production and stage management at NIDA and worked in stage productions for organisations such as Opera Australia and the Western Australian Symphony Orchestra. He stopped work in October 2009 as a result of health problems and moved from Perth, where he had been living, to Sydney.

Mr Petsas had a close relationship with his mother who died on 26 November 2016, only weeks before her son. She was, at the time of her death, married to El Mostafa Alaoui Hichami. Mr Petsas’s father had died in 1998.

At the time of his death Mr Petsas lived at 134 Dowling Street, Woolloomooloo, with his friend, Scott Moon, who was also his carer.

Functions of the Coroner Section 81 of the Coroners Act 2009 sets out the principal functions of a Coroner conducting an inquest. Those are to record the identity of the person who has died, the date and place of his death and the manner and cause of that death.

Findings as to identity, date and place of death Basilio Alesandro Petsas died on 26 December 2016 at St Vincent’s Hospital, Darlinghurst, New South Wales.

The focus of coronial proceedings and this inquest has been the manner and cause of Mr Petsas’s death.

Medical history Mr Petsas had a very significant history of illness and had been a regular user of intravenous drugs, including methylamphetamine. He was diagnosed with HIV (human immunodeficiency virus) in 1997 and hepatitis C in 2007 and, in 2010, was diagnosed with cirrhosis of the liver, thought to be as a result of the hepatitis C. His medical history included a diagnosis of syphilis and recurrent urinary tract infections.

He suffered from a degenerative joint disease of the spine.

Inquest into the death of Basilio Petsas

On his admission to St Vincent’s Hospital in December 2016 it was noted that, as of September 2015, Mr Petsas was taking a range of retroviral and other medications.

Those were noted as valacyclovir, ritonavir, darunavir, emtricitabine, bactrim and (a short course of) ciproflaxin to treat a urinary tract infection. Hospital staff were, in December 2016, unable to confirm whether that was a current list of medications then being taken by Mr Petsas.

He was noted, throughout his medical records, including on the medical records from St Vincent’s Hospital, to have an allergy to penicillin.

Admission to hospital On the evening of 22 December Mr Petsas watched movies with Mr Moon until about midnight. Each of them then went to bed. On 23 December Mr Moon woke briefly at about 2 or 3am and had a short conversation with Mr Petsas. Mr Petsas was drinking a glass of watered down wine at the time and appeared to Mr Moon to be in good spirits.

Later in the morning of that day, Mr Moon found Mr Petsas on the toilet, complaining of stomach pains, diarrhoea, vomiting and shortness of breath. He was having difficulty speaking.

Mr Moon called an ambulance. That call was received at 10:55am. Ambulance officers attended and observed that Mr Petsas was alert, oriented, but in severe respiratory distress. He gave them a history of diarrhoea and vomiting overnight, with the sudden onset of abdominal pain and shortness of breath. He was febrile.

Ambulance officers treated him in accordance with the sepsis protocol with IV fluids and high flow oxygen therapy and transported him rapidly to St Vincent’s Hospital.

On admission to hospital he was noted to be hypotensive, pale, diaphoretic, cyanotic, tachipnoeic, tachycardic and febrile. He was treated for possible sepsis and was administered vasopressin (to support his blood pressure) and antimicrobials.

Deterioration and death On admission to the hospital Mr Petsas was initially conscious but his respiratory distress became so great that he was intubated and ventilated.

Despite significant investigation, to which I will return, and aggressive medical support and treatment, Mr Petsas’s condition continued to deteriorate. He developed coagulopathy, disseminated intravascular coagulation, acute kidney injury (with Inquest into the death of Basilio Petsas

anuria), and liver dysfunction. He was pronounced dead at 6am on 26 December 2016.

Cause of Mr Petsas’s illness Investigations in hospital Mr Petsas underwent CT scanning of his chest, abdomen, pelvis, chest x-ray and abdominal and renal ultrasound. He had cultures of his blood, urine and faeces and viral swabs taken. Acidosis was demonstrated on cultures taken.

Dr Jeffrey Masters, infectious diseases registrar and one of Mr Petsas’s treating doctors, noted that he was ‘empirically treated’ with antibiotics, antifungals and antivirals. 1 The antibiotic treatment included antibiotics which would cover Bordetella infection. A viral swab had become positive with Bordetella pertussis but his treating doctors thought it to be a false positive.

The CT scan of the chest and abdomen showed ‘cirrhosis, splenomegaly and portal hypertension with small volume ascites, cholelithiasis, collapse/consolidation of the bilateral lung lobes, and severe L4/L5 disc disease’.2 Dr Rebecca Irvine, forensic pathologist, who conducted a post-mortem investigation, noted that: Negative microbiology investigations included: trichomonas and Neisseria gonorrhoea via gram stain (penile swab): MRSA (methicillin resistant Staphylococcus aureus and VRE (Vancomycin resistant Enterococcus (rectal/nasal swabs); Legionella and pneumococcal antigens (urine); urine chemistry and microscopy, and faecal microscopy and DNA evaluation for enteric bacterial pathogens, protozoa and viruses. Blood cultures (dated 23 December 2016 at 11:52am and 3:52pm, possibly following initial administration of antimicrobials) were without growth.

An upper respiratory tract infection was initially investigated as the source of the sepsis. An intra-abdominal source was then sought. Dr Masters reported that, despite all investigation and treatment, ‘the cause of Mr Petsas’s illness was not known’ to his treating physicians.

1 Dr Rebecca Irvine, forensic pathologist, noted that those agents may have interfered with the forensic recovery of organisms on laboratory investigation.

2 Post-mortem report of Dr Irvine.

Inquest into the death of Basilio Petsas

Investigation by forensic pathologist Following Mr Petsas’s death, the possibility of an autopsy being undertaken by the hospital was canvassed. There was, however, some confusion caused, inter alia, by the identification and availability of a next of kin and initial advice received as to whether the matter should be reported.

The matter was ultimately reported to the coroner on 12 January 2017. A postmortem investigation was undertaken by Dr Irvine on 17 January 2017.

Dr Irvine thought it unlikely that a primary site of infection would be identified on post-mortem examination in an individual in whom this could not be discerned following three days of potential diagnosis in an Intensive Care Unit setting.

In any event, as a result of the delay, her investigation was severely constrained: Given a post-mortem interval of 21 days (at the time of post-mortem external examination) and the other factors that would tend to accelerate post-mortem deterioration (sepsis, obesity, freezing), full post-mortem examination at this point would be all but futile.

The extended delay also meant that, at the time of forensic investigation, no useful post-mortem samples could be obtained and no antemortem specimens were available to the forensic pathologist for analysis, inter alia, for drug toxicity. In accordance with, what would appear to be, the routine practice of hospitals, the specimens, obtained when Mr Petsas was in the hospital, were discarded after seven days post-mortem.

Illicit drug use in the hours before admission to hospital Mr Petsas had a history of addiction to crystal methylamphetamine and, in the months preceding his admission to hospital, had pleaded guilty to a charge involving its possession. Mr Moon told the hospital social worker that Mr Petsas had been addicted to ‘crystal meth’ for over five years. He told police that there were drug paraphernalia, including resealable plastic bags, syringes, spoons and a cannabis pipe, scattered around the house they shared.

Mr Moon told the social worker, on 23 December 2016, that Mr Petsas had been abstaining but, that, since his mother’s death, his resolve had ‘weakened until he relapsed last night’.

Inquest into the death of Basilio Petsas

On the morning of 23 December 2016, Mr Petsas said, either directly or impliedly, on a number of occasions that he had used ‘ice’ in the hours or day leading up to his admission to hospital. Although he was having difficulty speaking, Mr Petsas said to Mr Moon words to the effect ‘I just wanted to take the edge off. I think I made a mistake. I’m sorry.’ He told ambulance officers, when they arrived, that he had had ‘ice’ the previous night. Hospital notes reveal that he gave a history of ‘IV ice used 2 hours ago’.

A urine ‘dipstick’ drug screen, conducted at the hospital, did not reveal the presence of amphetamine. Dr Irvine noted that that screening did not exclude the presence of ‘other classes’ of drug.

The statements made by Mr Petsas, in the context of his history of addiction make it very likely that Mr Petsas, on the night of 22 December 2016 or in the early hours of 23 December 2016 took a substance intravenously that he believed to be methylamphetamine.

I find that, on the balance of probabilities, in the hours or days leading up to his death, Mr Petsas injected himself with a substance he believed to be methylamphetamine. On the available evidence, it is not possible to determine whether that fact played any role in his death.

Dr Irvine’s report notes that, she could not determine the cause of Mr Petsas’s death and could not address ‘objectively’ any possible role of drug toxicity in his death.

Mr Moon’s assertion of involvement of a third party More than a week after Mr Petsas’s death, in conversation with the hospital staff, Mr Moon speculated that someone may have gained access to the premises and administered a drug to Mr Petsas. The motive, he speculated, may have been financial gain. That speculation is at odds with the version of events that Mr Moon gave to the hospital social worker on 23 December 2016 and, otherwise, has no merit. The evidence establishes that there was no indication of any forced entry to the premises and Mr Petsas had very little money.

Manner of death Mr Petsas was a man who suffered from a range of serious medical conditions and whose immune system was compromised. There is a significant possibility that Mr Petsas died of natural causes. I cannot, however, on the evidence before me, discount a role played by the intravenous use of an illicit drug in his death. For those reasons I cannot determine the manner of his death.

Inquest into the death of Basilio Petsas

Findings Basilio Alesandro Petsas died on 26 December 2016 at St Vincent’s Hospital, Darlinghurst, New South Wales.

The manner and cause of his death are unascertained.

I close this inquest.

Magistrate P Russell Deputy State Coroner Glebe Date: 16 October 2018 Inquest into the death of Basilio Petsas