Coroner's Finding: CUCUK Radomir

CORONERS ACT, 1975 AS AMENDED SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 3rd and 13th days of February 2004, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Radomir Cucuk.

I, the said Coroner, find that, Radomir Cucuk aged 38 years, late of Glenside Hospital, 226 Fullarton Road, Eastwood, South Australia died at the Royal Adelaide Hospital, South Australia on the 7th day of January 2004 as a result of multi organ failure secondary to intestinal ischaemia.

1. Reason for Inquest 1.1. On 6 June 2003 Mr Cucuk was a detained patient at the Glenside Campus of the Royal Adelaide Hospital (RAH). The Guardianship Board of South Australia had made an order pursuant to Section 13(1) of the Mental Health Act 1993 detaining him until 11 June 2003.

1.2. Accordingly, on 7 January 2003 Mr Cucuk was ‘detained in custody pursuant to an Act or law of the State’ within the meaning of Section 12(1)(da) of the Coroners Act 1975, and an Inquest into his death was therefore mandatory by virtue of Section 14(1a) of the said Act.

2. Introduction 2.1. Radomir Cucuk was born on 8 October 1964. He was 38 years old at the date of his death. He had been a detained patient at the Glenside Campus of the RAH since 14 October 2002.

2.2. On the morning of 6 January 2003, Mr Cucuk complained of abdominal pains. He was examined and then transferred to the RAH Emergency Department, arriving at 5:33pm.

2.3. At about 9:40pm Mr Cucuk suffered a cardiac arrest. He was resuscitated, and then underwent an emergency laparotomy. It was noted that his entire colon was grossly distended and had a poor blood supply. A total colectomy and ileostomy were performed.

2.4. Mr Cucuk died at about 3:45am on 7 January 2003 in the Intensive Care Unit of the RAH.

3. Cause of death 3.1. A post-mortem examination of the body of the deceased was performed by Professor R W Byard at the Forensic Science Centre at about 10:30am on 7 January 2003.

Professor Byard diagnosed the cause of death as ‘multi organ failure secondary to intestinal ischemia’. He commented: 'Death was due to multi organ failure from ischaemic necrosis of the intestine. This had resulted from toxic megacolon related to profound constipation. This is a recognised entity in individuals with psychiatric disorders, particularly in schizophrenia, and may require surgical reduction of the colon. Clinical assessment of this case was complicated by an unclear history and although cardiac arrest occurred, clinical examination and radiological studies had not indicated any perforation. It is likely that septicaemia had occurred due to bowel ischaemia before perforation had occurred. Given the extent of the intestinal necrosis, a fatal outcome would not be unexpected. No other underlying organic diseases were present which could have caused or contributed to death. There was no evidence of significant trauma.' (Exhibit C3a, pp1-2)

3.2. I accept Professor Byard’s diagnosis and find the cause of Mr Cucuk’s death was as he described.

4. Background 4.1. Mr Cucuk’s first psychiatric admission was in 1981 at the age of 16 years. He was admitted for a drug-induced psychosis related to glue sniffing.

4.2. Mr Cucuk had a total of 13 admissions to South Australian psychiatric hospitals, some of which were for quite extended periods. Indeed, the investigating police officer, Detective Senior Constable H P Hill, commented in his report that: 'Between the ages of 17 and 38 years, Cucuk spent most of his time in institutional environments at Northfield Security Hospital, Yatala Labour Prison, Hillcrest and Glenside Hospitals.

According to his medical records, Cucuk also had admissions in Queensland and the Northern Territory. During this period, Cucuk committed numerous criminal offences, such as assaults, offensive language, a building break, property damage and theft.' (Exhibit C11a, p4)

5. Circumstances leading to final admission 5.1. At about 11:45pm on 13 October 2002, Mr Cucuk was found by police overturning rubbish bins in the middle of Magill Road at Kensington Park. He was detained pursuant to Section 23 of the Mental Health Act 1993.

5.2. Mr Cucuk was conveyed to the RAH, where he was examined by Dr K Lee and detained for three days pursuant to Section 12(1) of the Mental Health Act 1993. He was transferred to the Glenside Campus.

5.3. On 15 October 2002 Mr Cucuk was examined by Dr P D Norrie, a Psychiatrist. Dr Norrie confirmed Dr Lee’s detention order pursuant to Section 12(4) of the Mental Health Act 1993.

5.4. On 17 October 2002 Mr Cucuk was examined by Dr B K Sha, who detained him for a further period of 21 days pursuant to Section 12(5) of the Mental Health Act 1993.

5.5. On 6 and 7 November 2002, Drs Asokan and Allison made orders for further detention for 21 days pursuant to Section 12(6) of the Mental Health Act 1993.

5.6. The final order for detention lapsed at midnight on 28 November 2002. At 9:45am on 29 November 2002 Dr R Kurlinkus examined Mr Cucuk and made a further order pursuant to Section 12(1) of the Mental Health Act 1993. This was confirmed by Dr Allison pursuant to Section 12(4) at 9:50am that day. The order was extended for a further 21 days pursuant to Section 12(5) of the Mental Health Act 1993 by Dr Allison on 2 December 2002.

5.7. On 11 December 2002 the Guardianship Board of South Australia made an order for ‘Continuing Detention and Treatment’ for a period up to and including 11 June 2003.

This order was made pursuant to Section 13(1) of the Mental Health Act 1993.

5.8. Psychiatrist Dr Richard Allison described Mr Cucuk’s background as follows: 'A person can only be detained if it’s in the interests of their health and safety or the safety of others. And in Mr Cucuk’s case he had ended up in a homeless shelter, prior to admission and exhibiting violent behaviour and being evicted from where he was staying so he would have not even be able to stay at the homeless shelter. So he was not able to care for himself. He was too unwell to see to his needs and there would have ultimately been concern for the safety of others. Obviously I didn’t see him at that time but the admission notes say that he was picked up by police for damaging private property on the street, breaking windows, overturning bins and very uncooperative, suspicious, and acting on the basis of these psychotic symptoms, so he was out of control. I mentioned that I’d treated him on a previous occasion and he’d been particularly violent prior to that admission and assaulted members of the public as well as doing damage to property.

That previous violent behaviour and many other examples would have been taken into account in the assessment of the risk of violence.' (Exhibit C5a, p5)

5.9. Dr Allison said that Mr Cucuk responded to treatment during his final admission, particularly while he was on Clozapine therapy.

6. Circumstances leading to admission to Royal Adelaide Hospital 6.1. Mr John Needs, a Social Worker employed at Glenside Hospital, spoke to Mr Cucuk during the morning of 6 June 2003. he said: 'Roy (Radomir) seemed as normal as I’ve seen him any time on the ward. His mental attitude was fairly bright although confused. As far as he physically goes, he did complain to me that he had pain in his stomach but he said that wasn’t anything unusual for him, that he quite often got that sort of pain. I did know that and after the interview I took him across to the nurses’ station and told one of the nurses could they please look at Roy because he’s complaining that he has stomach pain.' (Exhibit C6a, p2) Mr Needs said that there had been a ‘bug’ going around Glenside Hospital at the time.

6.2. Enrolled Nurse Elizabeth Rowe saw Mr Cucuk at about 12 noon. She took the usual observations which were relatively normal, although his temperature was slightly elevated at 37.8ºC (normal is 36.5ºC). Having regard to Mr Cucuk’s complaints of severe pain, EN Rowe reported the matter to the Registered Nurse on duty, who called

the duty doctor, Dr Weihong Liu. Dr Liu examined Mr Cucuk soon afterwards. Dr Liu noted that he was not in severe distress, his vital signs were normal, and his abdomen was soft on palpatation (although Mr Cucuk was grossly overweight).

6.3. Dr Liu decided to see Mr Cucuk again later in the afternoon. When he returned to Mr Cucuk’s room at about 4:10pm he was asleep. He examined him again, and decided to send him to the Royal Adelaide Hospital to be reviewed by a surgeon (Exhibit C8a, p3). This was arranged.

6.4. Dr Jatinder Rai saw Mr Cucuk at the Royal Adelaide Hospital Emegency Department at about 6:00pm on 6 January 2003. He had arrived at 5:33pm. Dr Rai noted his complaints of abdominal pain, he had vomited twice, and had used his bowels recently.

6.5. Dr Rai examined Mr Cucuk rectally and noted hard faeces. The stomach was distended and tense, and Mr Cucuk was tender all over. His bowel sounds were present, although quiet. His other vital signs were relatively normal (although the pulse rate was elevated at 88 beats per minute).

6.6. Dr Rai arranged for x-rays which showed a distended colon, so he arranged for a surgical review. Dr Rai finished the examination at about 6:30pm (Exhibit C91, p4).

6.7. At about 9:40pm, while Mr Cucuk was awaiting surgical review, he suffered a cardiorespiratory arrest. Emergency measures were taken in the Emergency Department, and he was successfully resuscitated. It was decided that he required emergency surgery, so he was taken to the operating theatre where Mr Julian Hayes performed a laparotomy. Mr Hayes was the Colorectal Fellow at the Royal Adelaide Hospital at the time. Dr Hayes said: 'At laparotomy he had a grossly distended colon with a poor blood supply. There was no obvious perforation or split in the colon, and no peritoneal soiling. The rectosigmoid colon was loaded with faeces but there was no obstructing lesion palpable.

The surgical diagnosis I made was of an ischemic colon with impending stercoral perforation (because of gross faecal loading). This was associated with severe hypotension. A total colectomy and end ileostomy was performed.

I last saw the patient when the operation was completed at 0115hrs on 7 January 2003.

My opinion is that the patient is likely to have suffered from gross faecal loading of his colon for a number of days.

This seems to me to be an extreme case. I have not previously treated a patient who was so unwell as a result of this condition.' (Exhibit C10a)

6.8. Unfortunately, Mr Cucuk’s condition continued to deteriorate until he died at 3:45am.

Death was certified by Dr Kean Woon Chong at that time (Exhibit C2a, p1).

7. Issues arising at Inquest 7.1. Medical treatment provided There is no doubt that constipation is a well-known side effect of psychotropic medication in general, and of Clozapine in particular. Dr Allison said: 'The anti-cholinergic side effects are well known to all trained staff and patients are asked to say if they have any problems with their bowels. It is a routine part of nursing practice to ask about people’s ablutions and self-cares. Furthermore, Mr CUCUK who had many, many visits to hospital and many doses of laxative would had been very familiar with the nursing respond to any problems with constipation. Although it’s not noted on his recent admission I think that other volumes of notes will show that he had been given laxatives at times when he has been constipated and that he had no problem in coming to staff when he was constipated. He has been given treatment for constipation on many occasions.' (Exhibit C5a, p6)

7.2. In addition to the Clozapine, Mr Cucuk was also being treated with Oxybutamin for urinary incontinence which was causing him distress. This medication also causes constipation (Exhibit C5a, p8).

7.3. The evidence here suggests that both the doctors and nursing staff were aware that constipation was a known side effect of these medications, and that they needed to be alert to that. EN Rowe, for example, said: 'Well certainly in these wards, where patients that are probably much older and they’re kept in constant nursing in care. In the more open wards the patients are fairly well independent and we do rely on them to approach us and say there’s some constipation.

Obviously if they’re complaining of stomach ache or they’re very bloated or something and the nurse notices that, they might ask them how long since their bowels have been opened. But as a more independent patient we wouldn’t keep like a bowel chart or anything everyday or anything like that.' (Exhibit C7a, p4) See also the evidence of Dr Lui at Exhibit C8a, p5-6.

7.4. The consensus of opinion is that Mr Cucuk suffered a particularly acute form of constipation, which progressed remarkably quickly to the point where he suffered a cardio-respiratory arrest. (See the comments of Professor Byard at Exhibit C3a, p1-2, Dr Lui at Exhibit C8a, p7 and Mr Hayes at Exhibit C10a, p2).

7.5. Mr Cucuk was transferred to the Royal Adelaide Hospital as soon as a problem was detected, and treated there until his cardio-respiratory arrest when appropriate emergency measures were taken. In those circumstances, I see no grounds for criticism of the medical treatment given to Mr Cucuk.

8. Recommendations 8.1. There are no recommendations pursuant to section 25(2) of the Coroners Act, 1975.

Key Words: Death in Custody; Hospital Treatment; Bowel obstruction; Psychiatric/Mental Illness In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 13th day of February, 2004.

Coroner Inquest Number 2/2004 (0055/2003)