Deceased
John William Chardon
Demographics
73y, male
Coroner
Ryan
Date of death
2020-10-21
Finding date
2022-11-15
Cause of death
Coronary atherosclerosis with hypertension, diabetes mellitus, emphysema and peripheral vascular disease
AI-generated summary
John William Chardon, a 73-year-old prisoner, died from coronary atherosclerosis with severe calcified atheroma causing >70% stenosis of coronary arteries. He presented with dizziness on 21 October 2020, which initially resolved with normal vital signs and normal gait. He returned minutes later with recurrent dizziness, vomited, complained of chest pain, then rapidly became unresponsive. CPR was commenced promptly and continued for over 45 minutes until paramedics declared him deceased. The coroner found the medical response appropriate and timely. The rapid deterioration could not have been anticipated given initial presentation. No clinical errors or omissions were identified; healthcare provided met community standards.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of John William Chardon TITLE OF COURT: Coroners Court
JURISDICTION: BRISBANE FILE NO(s): 2020/4512 DELIVERED ON: 15 November 2022 DELIVERED AT: Brisbane HEARING DATE(s): 15 November 2022 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, death in custody, natural causes.
REPRESENTATION: Counsel Assisting: Mr Alex Vanenn Queensland Corrective Services: Ms Vanessa Price
Contents
Introduction
The investigation
The investigation into Mr Chardon’s death was led by Plain Clothes Senior Constable James Anderson of the Corrective Services Investigation Unit (CSIU).
Following the death, the location was secured. Queensland Corrective Services (QCS) staff maintained the status of the locked room in the prison’s medical centre with a guard posted and a log book record maintained.
Police from CSIU were notified by the acting General Manager of the prison. At 8:09pm PCSC Anderson, Detective Sergeant Greg Bishop and a Scenes of Crime Officer attended the prison where they were briefed by the Acting General Manager before being escorted to the medical centre. They were joined by other officers, including an officer from the Homicide Squad. Other prisoners from Mr Chardon’s unit were interviewed.
A direction for a targeted coronial investigation was issued. This included seeking medical records, interviewing the next of kin about any concerns and obtaining statements from relevant medical staff, custodial correctional officers and fellow prisoners. A comprehensive Coronial Report was prepared and provided to the Coroners Court in April 2021.1
PCSC Anderson formed the view that there were no suspicious circumstances surrounding Mr Chardon’s passing, and he was provided with appropriate care and treatment while incarcerated.
Dr Ian Home from the Clinical Forensic Medicine Unit (CFMU) also examined Mr Chardon’s medical records and reported on them for the Coroners Court.
The inquest
At the time of his death, Mr Chardon was a prisoner in custody under the Corrective Services Act 2006. As Mr Chardon’s death was a ‘death in custody’ an inquest was required by the Coroners Act 2003.
The inquest was held at Brisbane on 15 November 2022. All statements, records of interview, medical records, photographs and materials gathered during the investigation were admitted into evidence. No witnesses were called to give oral evidence.
The issues considered in the inquest were the findings required by s45(2) of the Coroners Act 2003. I am satisfied that all the material necessary to make the requisite findings was placed before me at the inquest.
1 Ex A11 Findings of the inquest into the death of John William Chardon Page 1
The evidence Identity
Mr Chardon’s identity was confirmed by fingerprint identification carried out by the Queensland Police Service.2 Personal History
Mr Chardon was born in Brisbane on 19 July 1947. He had two daughters from his first marriage, which ended in divorce.
Mr Chardon worked as a mechanic before starting a small business producing, selling and distributing Inox lubricants for automotive and other purposes. The business grew and was operated by Mr Chardon, trading as Candan Industries Pty Ltd. He accumulated significant personal wealth.
Mr Chardon met Novy Mansur in 2000 and they married in 2001. Together they had two children, and separated in 2012.
At the time of his death, Mr Chardon was imprisoned at the Wolston Correctional Centre serving a 15-year sentence. He had been found guilty of the manslaughter of his wife, Novy Chardon, and was sentenced in the Supreme Court of Queensland on 11 September 2019. He had been charged with the offence of murder in June 2016, when he was already in custody serving a term of imprisonment for sexual offences against children. That sentence was imposed in the District Court at Southport on 15 August 2014. Mr Chardon was not eligible for parole until 10 September 2031.
Mr Chardon was categorised as a ‘protection prisoner’ and was accommodated in ‘residential accommodation’.3 Circumstances of Death ‘Code Blue’
At 5:16pm on 21 October 2020, Cluster 1 Officers called a ‘Code Blue Cluster 1’ outside R3A4 where Mr Chardon was seated on a wooden bench.
Typically when a ‘Code Blue’ is called, the Team Leader will respond, with an emergency trolley containing all necessary equipment including equipment to monitor blood pressure. However, on 21 October 2020 when the Code Blue was called in relation to Mr Chardon, another Code Blue was in progress and Team Leader and Acting Clinical Nurse Glen Gudenswager (CN Gudenswager) was attending the other Code Blue.5 2 Ex A4 3 Correctional Centres – Offender Profile – Offender ID: E40262.
4 See QCS Medical Log book – log of events and movements page 2 of 3.
5 Ex B24 at paragraph 16.
Findings of the inquest into the death of John William Chardon Page 2
First response by RN
Registered Nurse Ginu Varghese (RN Varghese) was escorted to respond to the Code Blue.
RN Varghese had a medical equipment bag provided to her by RN Owen Strong (RN Strong). RN Varghese was not familiar with the equipment contained within the medical bag6 as it belonged to RN Strong.
RN Varghese observed Mr Chardon seated on the bench and described him as ‘alert as he sat on the bench talking to another prisoner’.7 Mr Chardon was ‘oriented to time, place and person and had no complaints of pain or any other discomfort apart from dizziness’.8
Mr Chardon said he had felt dizzy while walking to the phone and had to hold a post to stop himself falling. He was assisted by another prisoner to sit on the bench.9
RN Varghese recalled Mr Chardon denied experiencing headaches or changes in vision. When asked if he had a cardiac history, Mr Chardon replied: ‘no there is nothing wrong with my heart’.10 Mr Chardon’s pulse was 94 beats per minute (‘bpm’), his oxygen level was 96%, and temperature was 36.6 degrees Celsius.
Blood pressure (BP) could not be checked as RN Varghese did not have a BP machine.11
RN Varghese waited approximately five minutes for CN Gudenswager to arrive and was unaware that they were attending to another Code Blue.12
RN Varghese decided that Mr Chardon should be taken to the medical centre to have his blood pressure taken. Mr Chardon was escorted in a wheelchair by a QCS Officer. RN Varghese described Mr Chardon as ‘talkative’ and calm. He stated repeatedly that he was ‘feeling better’.13
Mr Chardon was placed in Consultation Room Two at the medical centre.14 RN Varghese reported Mr Chardon’s blood pressure as 101/71 mmHg and a pulse of 78 bpm. Mr Chardon denied chest pain, his pulse and breathing were regular, there was no shortness of breath, and he no longer complained of dizziness.15
RN Varghese instructed Mr Chardon to stand from the wheelchair, slowly, and take a few steps. RN Varghese observed Mr Chardon walk to the opposite door and back to the wheelchair, displaying a normal gait. Mr Chardon said he felt ‘fine’ and was happy to return to his unit.16 6 Ex B24 at paragraph 10.
7 Ex B24 at paragraph 11.
8 Ex B24 at paragraph 13.
9 Ex B24 at paragraph 12.
10 Ex B24 at paragraph 14.
11 Ex B24 at paragraph 15.
12 Ex B24 at paragraph 16.
13 Ex B24 at paragraph 17 & 18.
14 Ex B24 at paragraph 19.
15 Ex B24 at paragraph 19.
16 Ex B24 at paragraph 19.
Findings of the inquest into the death of John William Chardon Page 3
RN Varghese discussed Mr Chardon’s presentation with CN Gudenswager. She reported that Mr Chardon had suffered a dizzy spell, but had not had a fall and his vital signs were normal. CN Gudenswager replied that Mr Chardon could return to his unit.17
RN Varghese instructed Mr Chardon to drink plenty of water, rest, and inform nursing staff of further concerns. RN Varghese said Mr Chardon would be reviewed by nursing staff tomorrow during the morning pill round. Mr Chardon returned on foot to his unit, with a QCS officer.18
A few minutes later, Mr Chardon returned to the medical centre, escorted by a QCS Officer. Nurse Varghese observed Mr Chardon was seated in a wheelchair.
He reported that he had felt dizzy again and asked to return to the medical centre.19
Mr Chardon asked to go to the toilet. He walked unaided20 and returned to sit in the wheelchair, before vomiting.21 Mr Chardon asked to lay down and moved himself from the wheelchair to the bed. After laying down Mr Chardon complained of centralised chest pain.22
RN Varghese left consultation room two to find an ECG machine, but it was being used for another patient. RN Varghese called for RN Holly Robbins (RN Robbins) for assistance. Upon returning to the consultation room, Mr Chardon was unresponsive to verbal cues, breathing and making gurgling sounds that RN Varghese described as ‘attempts to cough’.23
RN Varghese called to CN Gudenswager24 for assistance. He instructed that Mr Chardon be placed in a recovery position. This was done by RN Robbins and RN Varghese who subsequently called to RN Strong for assistance. Mr Chardon remained unresponsive during this time.25
As Mr Chardon remained unresponsive, RN Strong lifted Mr Chardon’s legs up onto the bed.26 RN Strong checked for a radial pulse for fifteen seconds. RN Strong noted Mr Chardon’s pulse to be very weak and observed very laboured breathing. RN Strong could not locate a carotid pulse.27
RN Strong28, RN Varghese and RN Robbins rolled Mr Chardon onto his back.29 RN Varghese briefly left the room to get the emergency bag.30 RN Strong could not locate Mr Chardon’s radial pulse. RN Strong observed Mr Chardon give two laboured irregular deep breaths, before Mr Chardon stopped breathing.31 17 Ex B24 at paragraph 20.
18 Ex B24 at paragraph 21 & 22.
19 Ex B24 at paragraph 23 & 24.
20 Ex B24 at paragraph 25.
21 Ex B24 at paragraph 26.
22 Ex B24 at paragraph 27.
23 Ex B24 at paragraph 28.
24 Ex B24 at paragraph 30.
25 Ex B24 at paragraph 30.
26 Ex B23 at paragraph 10.
27 Ex B23 at paragraph 10 & 11.
28 Ex B23 at paragraph 11.
29 Ex B24 at paragraph 31.
30 Ex B24 at paragraph 31.
31 Ex B23 at paragraph 12.
Findings of the inquest into the death of John William Chardon Page 4
CPR commenced
RN Strong commenced CPR on Mr Chardon by straddling his chest. Due to Mr Chardon’s large build, RN Strong deemed this the best way to access the chest cavity for CPR.32
RN Strong performed two cycles of thirty compressions, pausing between each cycle for RN Varghese to check Mr Chardon’s pulse.33
CN Gudenswager arrived and applied a resuscitation bag, valve and mask to Mr Chardon’s mouth while RN Strong continued compressions.34
RN Robbins took over airway management and counting compressions. RN Strong continued to provide CPR – thirty compressions to two breaths for another two cycles.35 Defibrillator attached
CN Gudenswager took over compressions while RN Strong connected the defibrillator (LifePac 1000). RN Strong placed the pads onto Mr Chardon.36
QCS Officers arrived as the defibrillator was connected and were asked to take over compressions, which they did.37
At 5:58pm RN Strong turned on the defibrillator. The defibrillator performed an analysis, and a shock was advised at 5:59pm. The charge was completed at 5:59pm and the first shock was delivered at 5:59pm. The defibrillator advised CPR to commence and a QCS Officer re-commenced compressions under nursing supervision.38
RN Strong prepared a cannular to administer medication. RN Varghese left the room and called 000, requesting a Category 1 Ambulance.39 Upon return to the room, RN Varghese drew up the adrenaline however it was not administered as an IV site could not be accessed.40
At 6:03pm the QAS attended including an Advanced Care Paramedic. QCS Officers assisted in providing compressions, but resuscitation efforts were unsuccessful. Mr Chardon was declared deceased at 6:40pm.
32 Ex B23 at paragraph 13.
33 Ex B23 at paragraph 14.
34 Ex B23 at paragraph 15.
35 Ex B23 at paragraph 16.
36 Ex B23 at paragraph 17.
37 Ex B23 at paragraph 18.
38 Defibrillator records. Ex B23 at paragraph 19 & 20.
39 Ex B24 at paragraph 33.
40 Ex B24 at paragraph 34.
Findings of the inquest into the death of John William Chardon Page 5
Autopsy results
On 23 October 2020, Dr Christopher Day (Forensic Pathologist) conducted an autopsy consisting of an external and internal examination of the body.41
A whole-body CT scan showed cerebral atrophy (brain shrinkage, often seen with age), spinal degeneration, rib fractures (attributed to resuscitation efforts) and generalised calcification of the coronary arteries and great vessels (major arteries and veins of the body).
External examination was relatively unremarkable with minor oedema (swelling due to fluid retention) of the lower limbs and a number of bruises.
Internal examination revealed fractures of the sternum (breastbone) and anterior (front) ribs due to chest compressions. Emphysematous changes (destruction of the air sacs of the lungs) and discolouration of the lungs were evident, consistent with chronic smoking.
The heart was enlarged with mild calcification of valves and moderate to severe calcified atheroma (build-up of fatty material and calcium in the walls of arteries known as plaque) of the coronary arteries resulting in greater than 70 percent stenosis (narrowing) in two vessels. A possible thrombus (blood clot) was observed within the left circumflex artery.
Atheroma was also observed to the carotid (neck) arteries and aorta (the largest artery in the body that distributes blood from the heart).
Histology (microscopic examination) confirmed the presence of mild scarring of the heart muscle along with significant calcified atherosclerosis (hardening of the arteries due to atheroma) of the coronary arteries with severe disease to the left circumflex artery with evidence of recent intra-plaque haemorrhage (bleeding due to ‘rupture’ of an established atheromatous lesion).
Toxicology identified the anti-arrhythmic drug amiodarone at a level consistent with therapeutic use.
The cause of death was listed as coronary atherosclerosis with other significant conditions including Hypertension, diabetes mellitus, emphysema and peripheral vascular disease.
Dr Day considered that the degree of heart disease identified was sufficient to have caused sudden death at any time. There were no defensive marks, trauma or injuries that would indicate a violent or unnatural cause of death.
41 Ex A9 Findings of the inquest into the death of John William Chardon Page 6
Review of Health Care
Dr Thomas O’Gorman, Clinical Director, Prison Health Services, reviewed the three volumes of Mr Chardon’s prison medical records over the period 2014 to 2020.42 Dr O’Gorman had not had any direct contact with Mr Chardon.
Dr O’Gorman noted that, upon entry to custody in 2014, Mr Chardon was a 67year-old man with a number of co-morbidities including but not limited to bronchitis secondary to smoking history (40 pack years), gout, type 2 diabetes mellitus and peripheral vascular disease.43
While under the care of Prison Health Services Mr Chardon was diagnosed, treated and underwent surgery for prostate cancer, bowel obstruction, and abdominal hernias. Mr Chardon received weekly and sometimes daily nursing reviews received in relation to recording his observations or wound care management, secondary to poor circulation from peripheral vascular disease.44
Dr O’Gorman considered that because of his comorbidities and age, Mr Chardon was at higher risk of an acute adverse health event. On the day of his death, he presented as feeling dizzy, initially without pain or other red flag symptoms. Dr O’Gorman said that perhaps owing to treatment with his antihypertensive medication, Mr Chardon had previously been recorded as presenting with dizziness on other occasions in the past, all of which went on to spontaneously resolve. Mr Chardon's quick deterioration on the evening of his death could not have been anticipated by the nursing team who responded quickly in attempts to resuscitate him when he complained of chest pain and became unconscious.
Appropriate attempts were made to resuscitate Mr Chardon for well over fortyfive minutes before his life was eventually pronounced extinct by paramedic staff from the Queensland Ambulance Service.
Dr O’Gorman considered that having had the opportunity to peruse the last six years of Mr Chardon's medical files, Mr Chardon received a high standard of care from Prison Health Services staff whilst an inpatient at Brisbane, and later Wolston Correctional Centres.45
A report from CFMU was also requested to address whether the medical treatment provided to Mr Chardon on 21 October 2020 was appropriate. A report was provided by Dr Ian Home, Senior Forensic Physician on 4 April 2022.
Dr Home noted that Mr Chardon had a past medical history including obesity, hypertension, peripheral vascular disease (narrowing of the blood vessels outside of the heart and brain) with lower limb venous ulcers (impaired healing of skin wounds due to inadequate circulation), bronchitis (inflammation of the airways) from smoking, type II diabetes, chronic kidney disease and gout.
42 Ex B21.
43 The equivalent of 1 pack daily for 40 years 44 Nursing staff at the prison confirmed Mr Chardon was well known to them from medication rounds and regular reviews.
45 Following Mr Chardon’s death, the Office of the Health Ombudsman reported that a complaint had been made about the health care provided to him. That complaint was not resolved at the time of his death. A fellow prisoner also alleged that Mr Chardon had instructed his lawyers to complain about the standard of care he received.
Findings of the inquest into the death of John William Chardon Page 7
Dr Home noted Mr Chardon experienced atrial flutter (upper chambers of the heartbeat too quickly) following surgery and had undergone a small bowel resection, abdominal hernia repair and prostate cancer treatment. During his incarceration, Mr Chardon was reviewed regularly by prison health staff as well as outpatient appointments with cardiology, vascular and urology.
On 29 January 2020, Mr Chardon reported an irregular heartbeat and chest pains. He was assessed at the Princess Alexandra Hospital and returned with advice to cease his regular amiodarone (a medication used to treat and prevent arrhythmias or abnormal heart rhythms) that had been prescribed following the atrial flutter. He subsequently requested to stop his blood pressure medication as well. His lipids were checked in March 2020.
On 10 July 2020, Mr Chardon reported chest pains that he felt were muscular in nature. He was assessed by nursing staff with routine observations and an electrocardiogram (trace of the electrical activity of the heart) appearing unremarkable. Despite a recommendation for further review, Mr Chardon declined.
Mr Chardon was prescribed the anti-hypertensive perindopril on 14 October 2020 due to persistently mild to moderately elevated blood pressure.
Dr Home noted that Mr Chardon was overweight, had known hypertension, peripheral vascular disease and diabetes and had been a long-term smoker.
These factors, combined with his age, placed him at risk for coronary artery disease.
While there was an episode of chest pain in July 2020, Mr Chardon declined further review and there were no subsequent reports until the day of his death.
Dr Home saw no reason to be critical of the care provided on the day of Mr Chardon's death. There were no other symptoms during the initial episode of dizziness that appeared to resolve spontaneously. In that case, it would have been reasonable to assume the effects of recently commenced anti-hypertensive medication combined with possible reduced oral fluid intake as the cause of hypotension. His subsequent collapse was fairly swift and was identified and managed appropriately.
Dr Home said that while the QAS identified a double dose of 2mg was inadvertently administered during the fourth round of adrenaline administration, this had no impact on the final result as Mr Chardon had not responded to resuscitation efforts up until that point and there were no obvious sequelae identified as a result of the excess adrenaline.
Dr Home also noted amiodarone was detected on toxicology but was not a prescribed medication, having been ceased in January 2020. Although not mentioned in the QAS electronic ambulance report form, the most likely explanation for its presence is that amiodarone was administered as part of the treatment protocol during the cardiac arrest.
Findings of the inquest into the death of John William Chardon Page 8
Conclusions
After considering the material gathered in the coronial investigation, I am satisfied that Mr Chardon died from natural causes. I find that none of the inmates, correctional or health care staff at Wolston Correctional Centre caused or contributed to his death. There were no suspicious circumstances.
It is an accepted principle that the health care provided to prisoners should not be of a lesser standard than that provided to other members of the community.
The evidence tendered at the inquest established the adequacy of the health care provided to Mr Chardon when measured against this benchmark.
Although he was largely symptom free in the months preceding his death, he was at increased risk for coronary artery disease. He died following a sudden cardiac arrest at the prison.
Place of death – Wolston Correctional Centre, Grindle Road Wacol, Queensland Date of death– 21 October 2020 Cause of death – Coronary atherosclerosis. Other significant conditions included hypertension, diabetes mellitus, emphysema and, peripheral vascular disease.
Terry Ryan State Coroner
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