Coroner's Finding: DUBBIOSO Roberto

CORONERS 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 7th day of December 2010 and the 23rd day of September 2011, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Roberto Dubbioso.

The said Court finds that Roberto Dubbioso aged 34 years, late of 47 Hilltop Avenue, Felixstow, South Australia died at the Glenside Campus of the Royal Adelaide Hospital, Fullarton Road, Fullarton, South Australia on the 7th day of March 2009 as a result of cardiomegaly with contributing aspiration. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Mr Roberto Dubbioso was 34 years of age at the time of his death on 7 March 2009 at the Glenside Campus of the Royal Adelaide Hospital. He was a detained patient under the Mental Health Act 1993 at the time of his death and, accordingly, his was a death in custody as defined by the Coroners Act 2003. This Inquest was held as required by section 21(1)(a) of that Act.

2. Background 2.1. Mr Dubbioso was born in Italy and came to Australia with his parents when he was 5 years old. He resided with his parents for his entire life, apart from periods of admission to hospital. He was first diagnosed with paranoid schizophrenia in 1996 at the age of 21. The diagnosis led to his first admission to Glenside Hospital. During the following years his mental and physical health deteriorated. He was known to have used marijuana and was a very heavy tobacco user. Over the next 10 years of

his life between the ages of approximately 21 and 31 years, he was managed in the community by his general practitioner and at home by his family. During this time his physical health declined and he was diagnosed with diabetes mellitus type 1 and insomnia with possible sleep apnoea. He gained a significant amount of weight and became morbidly obese.

2.2. During this time his parents were ageing and becoming increasingly unwell themselves. They were less and less able to cope with Mr Dubbioso and felt threatened and intimidated by him. He would display aggressive tendencies towards them and at one stage he physically assaulted them.

3. Circumstances leading to Mr Dubbioso’s death 3.1. On 3 March 2009 while at his parents’ home Mr Dubbioso became extremely violent and threatening towards them. The police were called to intervene. Mr Dubbioso made veiled threats to the police and the police formed the opinion that he was experiencing a psychotic episode. They detained him under section 23 of the Mental Health Act 1993 and he was conveyed to the Royal Adelaide Hospital. At the hospital he was examined and was found to be hearing voices and having grandiose delusions of getting God like powers. On 5 March 2009 his detention was reviewed and extended for a further 21 days. By this stage he had been transferred to the Glenside Campus of the Royal Adelaide Hospital.

3.2. The following day, 6 March 2009, Mr Dubbioso was observed to have been settling into the ward. However, at approximately 2300 hours Mr Dubbioso presented to the nurses station stating that he needed oxygen. His speech was slurred, he was sweating and his pulse was 140 beats per minute. He was given six litres of oxygen at this time via an oxygen tank and face mask. He sat in a chair in the foyer and fell asleep immediately. He continued to sleep in the chair and was observed by nursing staff to have regular sleep apnoea. The duty doctor was called to assess him at approximately 0100 hours. The duty doctor noted that Mr Dubbioso’s lungs were clear and air entry was noted on both sides. The doctor did not notice any obstructions in the mouth or throat and noted the pulse to be approximately 95 beats per minute. The doctor informed the nursing staff of his findings and was confident that Mr Dubbioso was being properly managed at that time. The doctor told the nursing staff to contact him if the patient deteriorated.

3.3. Mr Dubbioso moved to his bed at 0330 hours and was reported to have informed nursing staff that he was feeling better. He was noted to be audibly snoring when checked by nursing staff at 0440 hours. However, at 0530 hours he was found by nursing staff in a prone position and not breathing. Staff found that his peripheries were cold and he had no pulse. Resuscitative efforts were commenced immediately but without success. The duty doctor was called and assisted in the resuscitative effort.

4. Cause of death 4.1. A post-mortem examination was conducted by forensic pathologist, Dr Winskog. He found the cause of death to be cardiomegaly with contributing aspiration1, and I so find. Dr Winskog commented that cardiomegaly is known to be a predisposing factor to cardiac arrhythmia and sudden death. The episode of shortness of breath prior to Mr Dubbioso’s death was likely to have been caused by his chronic heart condition with impaired pumping capacity. Dr Winskog found food remnants in the airways and lungs and said that this suggested that aspiration could have contributed to the cause of death.

5. Recommendations 5.1. I have no recommendations to make in this matter.

1 Exhibit C2a

Key Words: Death in Custody; Psychiatric/Mental Illness In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 23rd day of September, 2011.

State Coroner Inquest Number 32/2010 (0412/2009)