Inquest into the death of Pamuk RONA

CORONERS COURT NEW SOUTH WALES Inquest: Inquest into the death of Pamuk Rona Hearing dates: 14 April 2021 Date of findings: 16 April 2021 Place of findings: NSW State Coroner’s Court, Lidcombe Findings of: Magistrate C Forbes, Deputy State Coroner Catchwords: CORONIAL LAW-cause and manner of death-unexpected death of involuntary patient in a mental health facility-undetermined cause of death File number: 2018/00243361 Representation: Sgt S Kelly, Advocate Assisting Findings: I find that Pamuk Rona died on 7 August 2018 at Blacktown Hospital, NSW. The cause of her death was unascertained natural causes and the manner of her death was natural causes

IN THE NSW STATE CORONER’S COURT LIDCOMBE SECTION 81 CORONERS ACT 2009 REASONS FOR DECISION Introduction

1. This is an inquest into the death of Ms Pamuk Rona who died while she was a patient in Bungarabee House. Bungarabee House is the psychiatric unit at Blacktown Hospital. She initially presented to the Emergency Department at Blacktown Hospital on 6 August 2018 by ambulance where she was reviewed and then transferred as an involuntary patient to Bungarabee House. The following afternoon, on 7 August 2018 she was found unresponsive in her bed.

2. In NSW, coroners have special jurisdiction to investigate the deaths of patients of a psychiatric hospital. All such deaths must be reported to a coroner.

3. Mentally ill patients are by definition vulnerable and in need of protection. Coronial investigations of the death of such patients are one way that our society seeks to ensure that hospitals remain accountable and the patients are properly cared for.

4. The role of a Coroner as set out in s.81 of the Coroner’s Act 2009 (“the Act”) is to make findings as to:

(a) the identity of the deceased;

(b) the date and place of the person’s death;

(c) the physical or medical cause of death; and

(d) the manner of death, in other words, the circumstances surrounding the death.

5. The issues in this case as to identity, date, place and manner are uncontroversial. The principal issue in this case is the cause of Ms Rona’s death and whether anything could have been done to prevent her death.

Pamuk Rona

6. Ms Rona was 53 years old at the time of her death. She was born in Turkey. She married Mr Nadi RONA in 1999 before moving to Australia in 2002 to reside at Blacktown. In 2003 they had a son, Stephen.

7. Some years prior to her death Ms Rona began to experience bouts of depression and first came under the attention of mental health authorities in 2006 when she was diagnosed with major depression.

8. She had previous admissions to Bungarribee House in 2016, 2017 the most recent being from 15 November 2017-15 January 2018.

9. Leading up to her admission on 6 August 2018 she had been unresponsive with her family and refusing to eat or drink. The medical notes included references to Ms Rona walking down the street aimlessly, pacing back and forth at home and turning the vacuum cleaner on and off when someone was vacuuming. Despite usually being talkative, Ms Rona had been quiet and stopped eating and taking her medications and was spending a lot of time in bed.

10. About 12 pm on the 6th August 2018 Ms Rona was noticed by family walking on the road near her address. Her family managed to get her inside and NSW Ambulance was contacted and she was taken to the Emergency Department at Blacktown Hospital.

According to paramedics, Ms Rona was found lying down on the floor in her home with rigid limbs.

11. After undergoing routine physical examination, Ms Rona was reviewed by the Emergency Department Staff Registrar and then medically cleared by the Emergency Department Specialist.

12. Ms Rona was then also reviewed by the Psychiatric Registrar and she remained mute during the interview with her eyes closed. Her history was provided by family and in consultation with the consultant psychiatrist the clinical impression at the time was that Ms Rona was experiencing a relapse of a major depressive disorder with catatonic features.

13. At 8:51 pm Ms Rona was transferred to the mental health unit as an involuntary patient under the Mental Health Act (2007) for observations with the following medications: Lorazepam1 0.5mg , Effexor2 150mg and Olanzapine3

14. Ms Rona refused taking any medications and remained non communicative with staff upon her transfer to Bungarabee House. At about 10:45 am the next morning she was assessed by the Consultant Psychiatrist who described her as not engaging and showing limited responsiveness. Around this time a decision was made that she required closer management and support in a medical psychiatry unit in a general hospital setting. Plans were made for her to be transferred to Westmead Hospital.

15. At approximately 1.15pm that day Ms Rona was noted as continuing to refuse food and was not responding to staff or allowing physiological observations. At about 1.50pm she was observed to be resting in bed and she refused a prescribed dose of lorazepam.

16. Shortly afterwards, at about 2pm ,Ms Rona was found unresponsive and CPR was commenced. The Hospital’s Medical Emergency Team arrived and continued advanced 1 Is a benzodiazepine indicated for anxiety, short term treatment of insomnia associated with anxiety.

2 Venlafaxine is used to treat depression 3 Is an antipsychotic drug

life support for almost one hour before declaring Ms Rona deceased.

Post Mortem report

17. On 10th August 2018 a post mortem examination was conducted by Dr Van Vuuren (Forensic Pathologist) who was unable to determine the cause of her death. She noted that there were no suspicious injuries and based on her examination, both with the naked eye and microscopically, and on evaluation of the neuropathology, biochemistry and toxicology results, the cause of death in her opinion was undetermined.

Medical Assessments on 6 and 7 August 2018

18. Dr Behzad Vasfi, Visiting Medical Officer, at the Emergency Department at Blacktown Hospital on the 6th August 2018 assessed Ms Rona and noted her vital signs were within the normal range with a respiratory rate of 16, oxygen saturation of 98%, heart rate of 118bpm, systolic blood pressure of 150mmHG, temperature of 36.5C and a blood glucose level of 6.3mmol/L.

19. On physical examination, he noted Ms Rona’s airway to be patent with no evidence of obstruction. Her lungs were clear with good air entry and her oxygen saturation was normal. Blood tests were undertaken and the results were unremarkable. In his opinion, there was nothing in the blood results that explained her presentation from a physiological perspective. An ECG was also performed which did not raise any concerns at the time.

20. Dr Thomas Luong, Consultant Psychiatrist, who had previously consulted Ms Rona in early 2018 and was the on call psychiatrist on the 6th August 2018 gave evidence of her medication.

21. Dr Luong recalled that he saw Ms Rona on the 13th July 2018 when she attended his practice with a support worker from Disability Interaction Services. During this consultation he decided to increase her Effexor medication (antidepressant) from 75mg to

150mg and to continue Seroquel 100mg nocte (anti-psychotic). Dr Luong stated that Ms Rona had indicated at the time that she had diminished energy which he had attributed to her medication having previously being reduced. According to him she had previously had a positive response when she was on the antidepressant Effexor.

22. He was next consulted on the 6th August 2018 when he was contacted by the psychiatric registrar about Ms Rona’s presentation at the Emergency Department. He stated that he was advised that Ms Rona had stopped taking her usual anti-depressant and antipsychotic medication for about a week and she was displaying catatonic like features.

23. Dr Bikas Shrestha, Psychiatric Registrar, examined Ms Rona on the night she was brought to Blacktown Hospital by Ambulance. He had difficulty completing an assessment with her as she remained completely mute, even though a Turkish interpreter was available on the phone. He said her eyes remained closed. He did obtain a history from Ms Rona’s mother in law over the phone and after discussions with the on call Consultant, Dr Thomas Luong, his clinical impression at the time was Ms Rona was experiencing a major depressive disorder with possibly melancholic features and possible catatonia.

24. At Bungarabee House she was assessed by psychiatric Registrar, Dr Khan and Consultant Psychiatrist, Dr Sloss who described her as not engaging and showing limited responsiveness. Her presentation was described as consistent with a diagnosis of likely catatonia. He also said Ms Rona was showing physical resistance to the Doctors performing a physical examination of her.4 Independent Opinion on cause of death:

25. An independent opinion was a sought from Dr Christopher Ryan 5 who is a Clinical Associate Professor at the University of Sydney and a Consultation – Liaison Psychiatrist at Westmead Hospital. Dr Ryan was provided with all the information in relation to Ms Rona’s care and treatment and past medical history.

4 Exhibit 1 Tab 6 para 16-17 5 Exhibit 1 Tab 10

26. It was his opinion Ms Rona was exhibiting symptoms of catatonia. This is a rare syndrome characterized by, and defined by, a series of behavioral abnormalities, many of which were exhibited by Ms Rona. He said a diagnosis can be made when a patient has three or more of twelve known symptoms. In Ms Rona’s case, she had at least five of the criteria, being: a. Stupor, b. Mutism c. Negativism (as manifest by her resistance to attempts to open her eyes) d. Posturing (eg during Dr Mahmoud’s examination he noted that she held her arms ‘flexed’ and ‘stiff’ and her legs, ankles and toes partially flexed).

e. Stereotypy (eg reports that Ms Rona had been turning the vacuum clear on and off and [w]alking down the street aimlessly.

27. It was also his opinion that persons suffering from this condition in the vast majority of cases have another underlying illness. In Ms Rona’s case, this underlying diagnosis was major depression and he believed that the diagnosis of ‘Major Depressive Disorder’ proffered by Dr Shrestha on 6th August 2018 was appropriate.

28. He noted that Ms Rona was moved to the inpatient psychiatry ward at around 20:35hrs on 6 August 2018. Observations conducted at 21:00 revealed a respiratory rate of 18 breaths per minute and at 2027hrs her blood pressure was in the normal range and she was afebrile.

29. On the 7th August 2018 she was reviewed by Dr Gordon Sloss, psychiatrist, with a psychiatry registrar, Dr Khan in the mid-morning. Dr Sloss noted, Ms Rona was lying in bed and not responding to questions or simple commands. She was still resisting opening her eyelids and would make some spontaneous movements of her head if her shoulders were rubbed. At that time, Dr Sloss said Ms Rona’s mental state was little changed and she had not had food or fluid since admission. On the basis of her poor oral intake, he determined that Ms Rona should be transferred to the medical psychiatry ward in Westmead as soon as possible and liaised with the ward director – Dr Frances Wilson who agreed to the

transfer.

30. In Dr Ryan’s opinion it was appropriate in all the circumstances to admit Ms Rona involuntarily to the psychiatric unit as she was not in a position to consent and he satisfied the criteria as a mentally ill person under the Act. He also believed it was appropriate to admit her to the psychiatric unit (rather than a medical ward) as it would have been felt at the time, with good reason that her primary problem was psychiatric and there was no reason to believe she could not be safely managed in that environment despite her poor food and fluid intake. He also stated, “when patients who are resisting oral intake are admitted to a psychiatry ward it is very often, but not always, the case that staff can persuade the patient to the starting food and fluid” He further stated, “In my opinion, the psychiatric care and treatment afforded to Ms Rona at Blacktown Hospital was appropriate in the circumstances. Specially: her psychiatric assessment was reasonable and appropriate, meeting a standard set out in peer reviewed literature, the diagnoses she was assigned were reasonable and consistent with recognized diagnostic systems; and the management plan formulated and actioned for Ms Rona was appropriate and consistent with common practice and treatment guidelines. I was unable to identify any missed opportunities in relation to Ms Rona’s management at Blacktown Hospital”.

31. In relation to her cause of death he stated, “I am unable to offer an opinion as to the cause of Ms Rona’s death. Though catatonia has been associated with sudden death on occasion, I could not find a case in the literature that seemed relevant to Ms Rona. More broadly, it is worth noting that sudden unexplained death has been reported in a small percentage of patients admitted to psychiatric units”.

32. In Dr Ryan’s opinion, it was appropriate for medical staff to believe Ms Rona could be safely looked after in Bungarabee House. Although she was not eating or drinking fluids, he said people can go days, weeks or even months without eating or drinking very much.

He said the Doctors conducted tests in the emergency department that showed Ms Rona was not medically unwell. At the time, the biggest concern was probably Ms Rona had become mentally unwell again. He said medical staff had every reason to believe she could be looked after safely in Bungarabee House and this would be the best place to treat her mental illness.

33. Dr Ryan indicated he does not know why Ms Rona died. However, he did not believe her death was due to her not eating or drinking or through any neglect in her care and treatment.

Conclusion

34. Ms Rona’s death was sudden and unexplained and after careful review of all the evidence including the medical records, the Forensic Pathologist’s report and Dr Ryan’s independent opinion I have been unable to determine what caused Ms Rona’s death. I am satisfied that Ms Rona’s death was not due to any suspicious circumstances and that the medical care and treatment she received was appropriate in all the circumstances. Dr Ryan gave evidence that sometimes deaths occur where the cause is not able to be determined.

35. For the purposes of s.81 Coroner’s Act 2009 I am satisfied that Ms Rona’s death was due to undetermined natural causes.

36. Since Ms Rona’s death the Western Sydney Local Health District (LHD) has provided the following information in relation to relevant changes that have occurred: “The LHD has conducted a review into the community mental health model of care, including staffing levels and case load sizes, taking into account acuity and clinical demand. This review (“WSLHD Mental Health Service Adult Community Mental Health Services: Snapshot And Opportunities For Investment Into

The Future” dated October 2018) was presented to the Executive Director of Mental Health for consideration.

The LHD has developed and disseminated business rules to utilise the Consumer Wellness plan for relapse prevention planning with consumers and family members. Further work is being done in this area.

In August 2020, the LHD’s Mental Health Service submitted a ‘Formulary Application’ to the District Drug Committee, seeking to add parenteral (intramuscular/ intravenous) Lorazepam as a first line treatment for catatonia in mental health. The Committee suggested some amendments and the application was endorsed in September 2020 during the LHD Drug Committee Meeting.

Lorazepam injection is currently available and in use, particularly in Bungarribee House. Prior to September 2020, intramuscular Lorazepam was available through the special access scheme.

The LHD has developed a formal presentation to communicate lessons learned with an emphasis on the importance of escalating concerns with nursing observations and providing directives on the clinical management of catatonic symptoms in mental health inpatient units (including pharmacological treatment and the use of input / output charting). This presentation has been delivered to relevant stakeholders by a psychiatry consultant, including a presentation on 16 June 2020 at Blacktown Hospital Ground Rounds, a ‘Lesson Learned’ presentation at Cumberland Hospital Grand Rounds in 2019, and a presentation to the Mental Health Service Clinical Council in July 2019.”6

37. I commend the changes and do not propose to make any recommendations.

38. Those who suffer psychiatric illness often die prematurely. Their deaths, especially those who are involuntary patients, are of special concern for coroners. I hope that Ms Rona’s family will find reassurance in the fact that their concerns in relation to her death have been listened to and addressed. I also hope that they will accept my sincere and respectful condolences on the loss of who, despite her illness, was much loved.

Findings: s 81 Coroners Act 2009 I find that Pamuk Rona died on 7 August 2018 at Blacktown Hospital, NSW. The cause of her death was unascertained natural causes and the manner of her death was natural causes 6 Information provided to Coroner’s Court by letter dated 14 April 2021

Magistrate C Forbes Deputy State Coroner 16 April 2021