Coroner's Finding: VINER Robert John

ACT, 2003 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 19th day of June 2007, and the 2nd day of July 2007, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Robert John Viner.

The said Court finds that Robert John Viner aged 58 years, late of 82 Dunrobin Road, Warradale died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 30th day of July 2006 as a result of hypoxic encephalopathy secondary to cardiac arrest due to cardiomegaly. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Robert John Viner was 58 years of age as at the date of his death on 30 July 2006 at the Flinders Medical Centre. A post mortem examination was carried out by Dr Karen Heath who prepared a report which was admitted as Exhibit C3a in these proceedings. Dr Heath gave the cause of death as hypoxic encephalopathy secondary to cardiac arrest due to cardiomegaly, and I so find.

1.2. Mr Viner had suffered from a schizoaffective disorder for many years. An order for his detention pursuant to the Mental Health Act had been made on 28 July 2006.

While he was in the Flinders Medical Centre pursuant to that order of detention he suffered the cardiac arrest which ultimately resulted in his death. Accordingly, his cause of death arose while he was under detention and his was a death in custody within the meaning of the Coroners Act 2003. This Inquest was therefore required to be held by virtue of section 21(1)(a) of the Act.

1.3. Dr Annita Paull, Psychiatrist, made a statement which was admitted as Exhibit C8a in these proceedings. She was Mr Viner’s treating psychiatrist. She stated that Mr Viner had a long history dating back to at least 1982. She stated that schizoaffective disorder is a psychotic mental illness which has aspects of both schizophrenia and manic depressive illness combined. She stated that Mr Viner was medicated with both Lithium and Valproate and had intramuscular injections of Zuclopenthixol decanoate which were administered by his general practitioner Dr Farrent.

1.4. The investigating officer in this matter was Detective Brevet Sergeant Wendy McDonald. The investigation was extremely thorough and comprehensive. I commend Detective Brevet Sergeant McDonald and note that I have seen other investigations prepared by her which have been of a similar high standard. I express my appreciation.

1.5. According to the investigation summary prepared by Detective Brevet Sergeant McDonald, Mr Viner had been admitted to Glenside Campus during the following periods as a result of his illness: 25 October 1996 until 4 December 1996 5 February 1998 until 10 March 1998

1.6. According to the statement of Dr Paull1, she has known Mr Viner to have been detained on at least four occasions. She stated that on each of these occasions he had become aggressive, restless and verbally hostile towards members of the public or family members. She said that all of these events could be attributed to his mental illness.

1.7. In the days leading up to his death Mr Viner had been behaving erratically. On Sunday 23 July 2006 at about 3:00pm Mr Viner attended at the home of his niece Ms Suzanne Goh. This was unusual because Ms Goh would usually only see her uncle on birthdays and other family occasions. On a previous occasion when he had attended at her home unexpectedly he had been unwell because he had not been taking his medication. On this occasion, he wanted money for a drink and Ms Goh declined to give him money but instead invited him inside and gave him a drink and some food. He left without incident.

1 Exhibit C8a

1.8. On 27 July 2006 at about 8:00pm Mr Viner again attended at Ms Goh’s home. On this occasion there was a disturbance as a result of which Mr Viner smashed a glass in the kitchen sink and Ms Goh sought the assistance of relatives as well as contacting police. Mr Viner left before police arrived.

1.9. According to an affidavit of Jenny Sadler, Community Mental Health Nurse, Cleland Ward, Glenside Campus, which was admitted as Exhibit C10a in these proceedings, she was Mr Viner’s key worker. She stated that a key worker acts in a case management role for people who live in the community with a mental illness.

Mr Viner was one of twenty-five patients under her care. On Friday morning 28 July 2006 she was contacted by one of Mr Viner’s nieces who informed her of the events of the previous evening. Ms Sadler was making arrangements with Dr Paull to arrange for treatment for Mr Viner and was attempting to make contact with Mr Viner when she received a telephone call from Dr Farrent, Mr Viner’s general practitioner.

She was informed by Dr Farrent that Mr Viner had attended at Dr Farrent’s surgery, the Mawson Medical Centre at Hove. Mr Viner did not have an appointment and he had been verbally and physically intimidating towards Dr Farrent and staff at the clinic. Mr Viner had left the clinic by the time this call was made.

1.10. Ms Sadler asked Dr Farrent if he considered that Mr Viner was detainable under the Mental Health Act, and Dr Farrent stated that in his opinion Mr Viner was. Ms Sadler faxed Dr Farrent a Form 1 Detention Form and a Missing Persons Report for him to complete. Dr Farrent sent the completed forms by facsimile transmission to the South Australia Police. South Australia Police officers contacted Ms Sadler later in the day advising that they had received the paperwork and requesting her assistance in attending at Mr Viner’s house. This she did, but Mr Viner was not at home.

1.11. At about 3:30pm that day Amanda Deieso reported to police that she and her family had just left the children’s playground at Stanley Street, Glengowrie after they had been approached by a man apparently aged in his sixties who had been sitting in a Toyota Yaris motor vehicle. This man approached Ms Deieso’s children and caused her some concern as a result of which she made a report to police2. Upon attending at the park, police located Mr Viner sitting in his vehicle, the Toyota Yaris and listening to loud music. Constable Potter of Netley Patrols approached Mr Viner and spoke 2 Exhibit C17a

with him. Mr Viner was calm and cooperative but Constable Potter noted him to be somewhat vague. After making enquiries with police communications it was established that there was a current detention order for Mr Viner and so police informed him of this. He went with them cooperatively and they conveyed him to the Flinders Medical Centre. They arrived at the Flinders Medical Centre with Mr Viner at approximately 4:25pm and he was handed into the care of doctors in the emergency triage area at approximately 5:00pm.

1.12. Dr Kamran Kheirani is a psychiatric registrar at the Flinders Medical Centre. He saw Mr Viner in the Emergency Department at approximately 5:30pm that evening. He decided that Mr Viner required one-on-one nursing and two hourly observations. He was aware that a consultant psychiatrist would be reviewing Mr Viner after twentyfour hours. He was also aware that Olanzapine and Clonazepam had been prescribed and he concurred with that course of prescription3.

1.13. Dr Mark Fuidge is a career medical officer employed within the Emergency Department at Flinders Medical Centre. He made a statement which was admitted as Exhibit C12a in these proceedings. He said that Mr Viner was given 5mg of Olanzapine at 5:10pm. He explained that Olanzapine is used as a sedative or calming agent. He said that Mr Viner was given 1mg of Clonazepam at 7:50pm. He said that Clonazepam is used in conjunction with Olanzapine to have a calming sedative effect in severely agitated patients and that 1mg is considered a normal starting dose. He said that Mr Viner was given a second dose of Clonazepam at 12:58am, Saturday 30 July 2006.

1.14. Dr Mrudula Kanhere is an intensive care advanced training registrar at the Flinders Medical Centre. She was part of the emergency response team on the nightshift staring at 6:00pm on 28 July 2006 and finishing at 9:00am on 29 July 2006.

According to a statement made by her which was admitted as Exhibit C13a in these proceedings she received a page on her emergency pager at 5:25am on 29 July 2006.

She attended with the medical emergency team and saw a patient she subsequently identified as Mr Viner. When she arrived, she was informed by nursing staff that Mr Viner had been snoring throughout the night but had suddenly gone quiet and that the nurses had noticed gasping respiration. One of the nurses was performing 3 Exhibit C11a, statement of Dr Kheirani

cardiopulmonary resuscitation. Mr Viner was intubated and ventilated and had a return to spontaneous circulation at 5:34am. He received 1mg of adrenaline via intravenous injection on two occasions. His pupils were bilaterally sluggish in reaction to light.

1.15. Mr Viner was transferred to the Intensive Care Unit where he was cared for by Dr Evan Everest, critical care consultant at the Flinders Medical Centre. Dr Everest made a statement which was admitted as Exhibit C14a in these proceedings. He said that when he saw Mr Viner at approximately 12:20pm on 29 July 2006 he was on a ventilator and was sedated with Propofol. He had extensive extensor posturing to eye opening and minimal peripheral stimulus. That meant that he had suffered a severe hypoxic insult to his brain consistent with cardiac arrest. He was sedated further with a combination of Midazolam and Propofol with a view to further assessment in twenty-four hours. Dr Everest considered that Mr Viner’s prognosis was likely to be poor. His sedation was ceased at 7:00am on 30 July 2006 to enable Dr Everest to obtain an accurate impression of his neurological status. Dr Everest reassessed Mr Viner between 11:00am and midday on 30 July 2006. He was having frequent myoclonic jerks and there was no response to painful stimuli. Myoclonic jerks mean that there were very marked jerking movements of the limbs consistent with severe hypoxia and encephalopathy. Dr Everest met with Mr Viner’s sister and family members and told them that Mr Viner had severe hypoxic encephalopathy and there was almost no chance for him to return to the full function he had prior to admission to hospital. The family agreed that treatment should be withdrawn and that the endotracheal tube be removed that evening. According to Dr Everest, the decision to withdraw treatment was his with the agreement of the family. At around 6:00pm on 30 July 2006 the endotracheal tube was removed and Mr Viner pronounced deceased at 6:40pm that evening.

1.16. Detective Brevet Sergeant McDonald expresses the opinion in her investigating officer’s statement4 that Mr Viner’s treatment at the Flinders Medical Centre was appropriate and that there was no evidence to suggest or indicate that his death was in any way suspicious. I agree with that assessment.

4 Exhibit C23a

Key Words: Death in custody, Detention Order, Hypoxia.

In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 2nd day of July, 2007.

State Coroner Inquest Number 17/2007 (1120/06)