Coroner's Finding: DUSZYNSKI Steve Stan Peter

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 3rd day of June and the 14th day of July 2020, by the Coroner’s Court of the said State, constituted of Elizabeth Ann Sheppard, Deputy State Coroner, into the death of Steve Stan Peter Duszynski.

The said Court finds that Steve Stan Peter Duszynski aged 66 years, late of 34 Iona Road, Aberfoyle Park, South Australia died at the FMC, Flinders Drive, Bedford Park, South Australia on the 27th day of June 2018 as a result of bronchopneumonia and influenza A complicating cardiac and renal failure associated with mesangiocapillary glomerulonephritis complicating non-Hodgkin's lymphoma. The said Court finds that the circumstances of his death were as follows:

1. Brief overview and reason for inquest 1.1. Steve Stan Peter Duszynski was born on 19 August 1951. He died in the Renal Unit of the Flinders Medical Centre (FMC) on 27 June 2018, aged 66 years.

1.2. Mr Duszynski had a complex medical history. In November 2016 he was treated for a Hepatitis C infection which cleared by May 2017. This condition appears to have played a possible role in his ultimate demise.

1.3. In the lead up to Mr Duszynski’s death, and while an inpatient at the FMC, he developed signs of delirium, agitation and paranoia to such an extent that he was placed on a Level 1 Inpatient Treatment Order (ITO) pursuant to section 21 of the Mental Health Act,

2009. In circumstances where Mr Duszynski’s death occurred during that period of detention, an inquest is mandatory pursuant to section 21(1)(a) of Coroners Act, 2003.

1.4. Mr Duszynski had been investigated by doctors at FMC during earlier presentations in April, May and early June 2018 to treat his decompensated heart failure, hypertension, renal impairment, fluid overload and a vasculitic skin rash.

1.5. He was urged to have a renal biopsy to help establish a diagnosis, however the procedure was delayed partly because Mr Duszynski refused to give his consent and did not wish to be treated by female medical practitioners. Ultimately the procedure was performed on 4 June 2018 by Dr Jeffrey Barbara and led to a diagnosis of cryoglobulinaemic vasculitis. This rare condition concerns an accumulation of abnormal proteins called ‘cryoglobulins’ in the blood which are generated by an ‘abnormal population of lymphocytes’. The cryoglobulins can be deposited in various blood vessels in the kidneys and elsewhere. It can also cause micro bleeding.1

1.6. At about the same time, a CT scan of the chest and abdomen revealed enlarged lymph nodes in the abdomen, or lymphadenopathy. It was considered that the lymph nodes were unable to be biopsied. The doctors therefore suspected that Mr Duszynski had a malignant lymphoma and needed referral to a haematologist. A bone marrow biopsy was considered necessary to establish the diagnosis.

1.7. When Dr Rachel Tan examined Mr Duszynski at a follow-up outpatient appointment on 12 June 2018 she noted that there were ‘reduced breath sounds bibasally consistent with pleural effusions’. Dr Tan also prescribed Endone for relief of Mr Duszynski’s lower leg pain, thought to be associated with fluid overload or his new diagnosis of vasculitis.2

1.8. After initially refusing to give his consent, a bone marrow biopsy was performed on 14 June 2018 which confirmed the suspicions of lymphoma.

1.9. During his final admission to FMC between 18 June 2018 and the day of death, Mr Duszynski was being managed by the renal unit to treat his fluid overload.

Intravenous frusemide was administered to deal with the oedema and intravenous methylprednisolone to manage the vasculitis. Approval was also given for the administration of rituximab.

1.10. From 22 June 2018, Mr Duszynski developed signs of delirium, agitation and paranoia which worsened to the point where the ITO was made at 2:50am on 27 June 2018.

1 Exhibit C8 2 Exhibit C13, Letter of Dr Rachel Tan dated 12 June 2018

Intramuscular olanzapine was administered to manage his aggression, however, by 5:50am he was found unresponsive. Attempts to resuscitate Mr Duszynski were unsuccessful.

2. Cause of death 2.1. A post mortem examination was conducted by Dr John Gilbert at 9:20am on 28 June

3. In Dr Gilbert’s opinion, the cause of death is summarised as follows: 'Bronchopneumonia and influenza A complicating cardiac and renal failure associated with mesangiocapillary glomerulonephritis complicating non-Hodgkins’ lymphoma.'

2.2. However, Dr Gilbert has helpfully elaborated in the body of his report as follows: 'Death appears likely to have ultimately resulted from respiratory failure contributed to (sic) pulmonary oedema, bronchopneumonia and influenza A and by compression of the lungs by large pleural effusions attributable to cardiac and renal failure.

Mesangiocapillary glomerulonephritis may be associated with non-Hodgkins’ lymphoma and the latter could possibly be a late complication of the deceased’s previously treated hepatitis C.' 3

2.3. I adopt the opinions expressed by Dr Gilbert as to the likely cause of death, and find Mr Duszynski’s cause of death to be bronchopneumonia and influenza A complicating cardiac and renal failure associated with mesangiocapillary glomerulonephritis complicating non-Hodgkin's lymphoma.

2.4. It is noted that the treating doctors at FMC do not appear to have recorded a finding of bronchopneumonia or influenza A as part of Mr Duszynski’s presentation. Yet Dr Gilbert has referred to it as the cause of death.

2.5. Lung specimens were forwarded to SA Pathology which reported the presence of staphylococcus, Influenza A and cytomegalovirus (CMV). Histological examination of the lungs revealed that they were oedematous and congested with patchy bronchopneumonia in some sections.

3. Background 3.1. Mr Duszynski was married to Wendy Duszynski for 40 years. They had two daughters, Corinna and Mae. At the time of his death Mr Duszynski was retired.

3 Exhibit C2a

3.2. Mr Duszynski used cannabis to ease chronic knee pain and assist his sleeping. He was a tobacco smoker in his youth, but had not smoked cigarettes for forty years4.

3.3. Mrs Duszynski noticed a gradual change in her husband’s personality from about December 2017 following his recovery from Hepatitis C.5 He became argumentative and abusive towards her and later towards others.

4. Hospitalisation 4.1. In April 2018 Mr Duszynski felt unwell and was troubled by a rash on the lower part of his body. After being admitted to FMC, he was diagnosed with hypertension and fluid overload and treated with medication.

4.2. Following discharge Mr Duszynski’s health declined. He experienced breathlessness, his rash was worse and he became uncharacteristically emotional.

4.3. On 23 May 2018 Mr Duszynski presented to the Emergency Department at the FMC but he refused admission.6

4.4. Mr Duszynski was treated in the FMC from 27 May to 5 June 2018 for decompensated heart failure due to fluid overload along with renal impairment, a vasculitic skin rash and abdominal lymphadenopathy. The diagnosis of vasculitis was confirmed by skin biopsy and renal biopsy.

4.5. On 14 June 2018 a bone marrow biopsy was performed to further clarify the diagnosis.

The biopsy results were consistent with lymphoproliferative disorder. Mr Duszynski had been reluctant to have the renal and bone marrow biopsies which caused some delay in his diagnosis. His wife and brother played a supportive role in having him agree to both tests. Renal physician Dr Caroline Milton considered it likely that the cryoglobulinaemic vasculitis was secondary to the lymphoproliferative disorder.7

4.6. The treating haematologist advised against chemotherapy in managing the lymphoma.

The plan was to treat the cryoglobulinaemic vasculitis with steroids and rituximab in consultation with the renal physicians. The latter drug (a monoclonal antibody) is administered by infusion and is used to treat auto-immune diseases.

4 Exhibit C1a, Affidavit of Wendy Duszynski dated 19 August 2018 5 Exhibit C7 6 Exhibit C7 7 Exhibit C7

5. Final hospital admission 5.1. Mr Duszynski returned to FMC on 18 June 2018 due to peripheral oedema despite taking Frusemide 40mg twice daily8. When Dr Milton saw him on 20 June 2018, Mr Duszynski was very unwell9. He was suffering from heart failure, severe oedema in his body tissues, scotal oedema, pleural effusions, renal failure and delirium.10

5.2. His fluid overload was treated with intravenous frusemide and fluid restriction. His vasculitis was treated with intravenous methylprednisolone until 25 June 2018 after which rituximab was administered.

5.3. From 22 June 2018 Mr Duszynski exhibited deteriorating behaviour with increasing delirium, agitation and paranoia. Medical staff were finding it more difficult to de-escalate Mr Duszynski’s behaviour. He expressed paranoid thoughts about female nurses and Asian nurses who were caring for him and accused doctors of lying to him.

5.4. The doctors considered that the reason for the decline in his mental health might be related to his cryoglobulinaemic vasculitis which had the potential for neurological or cerebral involvement, or central nervous system vasculitis.11 It was also recognised that prednisolone may have been making his delirium worse. I understand that Mr Duszynski was sometimes very abusive towards his wife during this time. It would have been distressing to members of Mr Duszynski’s family, and to Mrs Duszynski in particular, to witness his uncharacteristically aggressive behaviour.

5.5. An MRI of the brain was contemplated, but would have required administering potentially risky sedation in the absence of his co-operation. There were contingency plans for future management in the event that Mr Duszynski might require ventilation if he deteriorated further. Consideration was also given to Mr Duszynski having dialysis to remove fluid, but that may have required him to be in intensive care due to his delirium.

5.6. On 25 June 2018, Mr Duszynski told Dr Caroline Milton that he wished to have another opinion about his treatment from a male doctor. After discussing the situation with Mr Duszynski and his wife, the medical team reviewed his medications and 8 Exhibit C6, Affidavit of Dr Natalie Pink 9 Exhibit C7, Affidavit of Dr Caroline Milton 10 Exhibit C7 11 Exhibits C6 and C7

commenced rituximab on 26 June 2018. The optimum therapy of rituximab and prednisolone was prescribed to target his cryoglobulinaemic vasculitis.12

6. Circumstances of death 6.1. In the early hours of 26 June 2018 Mr Duszynski complained of shortness of breath and chest tightness. Troponin levels and ECG tended to rule out an acute cardiac event.

Examination by doctors confirmed the continued presence of fluid overload with pleural effusions, however, his oxygen saturations were stable.13 He was given additional intravenous frusemide. After a period of improvement he complained of more shortness of breath at 1pm. Mr Duszynski’s breathing was becoming more laboured and his sputum was frothy and blood stained. He improved after passing significant amounts of urine and the crepitations in his lungs had improved. By 6pm, he had walked to the toilet unaided and his oxygen saturation levels became stable on two litres of oxygen via a nasal catheter.

6.2. Mr Duszynski became disruptive in the ward and was moved to a single bed bay near the nurses' station by about 9pm. He was restless thereafter, taking off his oxygen mask and refusing his medication.14 There is a gap in his observation chart until 11:45pm where it is simply noted ‘refused’, which I take to mean that Mr Duszynski was uncooperative.15

6.3. Registered Nurse David Rennie spoke to Mr Duszynski at about 2:45am on 27 June 2018 after he was seen to walk out of his room. RN Rennie tried to guide him back to his room, but Mr Duszynski became aggressive towards the nurse and protested that he wanted to see the doctor or to go home.16

6.4. Shortly after this incident, a code black was called due to his ongoing aggressive behaviour in which he was physically combative towards staff. Mr Duszynski was placed on a Level 1 Inpatient Treatment Order by Dr Natalie Pink.17 This decision was made in consultation with Drs Long, Coupland and Marx.18 12 Exhibits C7 and C8 13 Exhibit C7, paragraphs 24 to 28 14 Exhibit C5 15 Exhibit C14 16 Exhibit C5 17 Exhibit C12, MD1, Inpatient Treatment Order Level 1 Form 18 Exhibit C6, paragraph 14

6.5. There is no criticism of the decision to place Mr Duszynski under an ITO in the circumstances. I find that is was carefully thought through and was justified.

Psychiatric registrar Dr Long prescribed 5mg of olanzapine as a form of ‘chemical restraint’, bearing in mind the likelihood that Mr Duszynski’s behaviour resulted from vasculitis of the brain.19 After Mr Duszynski refused an oral dose of olanzapine an intramuscular dose was administered, which I note was in line with an established delirium management plan.20

6.6. For the following two hours after 3am, RN Rennie conducted visual observations every thirty minutes and four-hourly observations in line with the ITO care protocol. During this time, Mr Duszynski complained of abdominal pain. He was given Endone and diazepam at 3am, but it did not appear to settle him.21

6.7. At 4am his respiratory rate and oxygen saturations were recorded at about 95% on two litres of oxygen.22 No further observations are recorded in the observation chart. At 4:30am Mr Duszynski had gone to the toilet by himself, but was uncooperative with staff.23

6.8. A lengthy entry by RN Rennie, purportedly made at 5:20am, suggests that Mr Duszynski’s behaviour was very challenging for a period of about two and half hours. Mr Duszynski was said to be very restless and demanding and was regularly removing his nasal oxygen cannula which was delivering between two and three litres.

6.9. By 5:20am Enrolled Nurse Reid observed Mr Duszynski lying on his back in his room.

In her affidavit prepared for this inquest, EN Reid stated that ‘he didn’t look distressed at all and was breathing normally without any obvious discomfort’.24 The medical notes entry describes the observation at this time as ‘breathing and sleeping’. It is difficult to be confident from EN Reid’s affidavit that at 5:20am Mr Duszynski was accurately observed to be ‘breathing normally’.

6.10. In hindsight, given the combination of medications administered to Mr Duszynski which had the potential to depress respiration, it might have been prudent to pay 19 Exhibit C6 20 Exhibits C4 and C7 21 Exhibits C4 and C5 22 Exhibit C14 23 Exhibit C5 24 Exhibit C5

particular attention to the manner of his breathing, level of consciousness and oxygen saturations.

6.11. At 5:50am on 27 June 2018, Mr Duszynski was found unresponsive. Resuscitation was attempted after a code blue was called, but those attempts proved unsuccessful.25.

Life was certified extinct at 6:35am on 27 June 2018.

6.12. I note in Dr Gilbert’s report that a peripheral specimen of Mr Duszynski’s blood was preserved and tested to determine whether toxic levels of drugs were present at the time of death. In the circumstances in which a dose of Endone and olanzapine was given before the code blue was called, I am satisfied that both drugs were detected at nontoxic levels together with non-toxic levels of morphine, codeine, diazepam, nordiazepam as well as 11-nor9-carboxy-delta 9-THC (cannabis). There is no suggestion in Dr Gilbert’s report that the medications contributed to Mr Duszynski’s respiratory failure, however Dr Gilbert later suggested that, in combination, they may have aggravated his failing respiratory function. I accept Dr Gilbert’s opinion in that regard.26

6.13. As far as the role played by bronchopneumonia is concerned in the lead up to Mr Duszynski’s death, I note that he was administered a broad spectrum antibiotic27, although I am unable to find a note explaining why he was prescribed this medication on 26 June 2018.28 The medical notes record that a sample of sputum was sent for testing before his death, although I assume that the results may not have been available prior to Mr Duszynski’s demise.29 According to Dr Gilbert’s report, a specimen of blood at death showed the presence of Trimethoprim, which is another antibiotic.

6.14. In a follow-up email to counsel assisting dated 29 May 2020, Dr Gilbert expressed the view that bronchopneumonia would have been easily overlooked because it was not severe. If Mr Duszynski was otherwise well and had reported the typical symptoms of fever and muscle aches, it would have been easier to identify. I note that the observation chart at all relevant times recorded normal temperature readings.

6.15. Dr Gilbert also made an additional suggestion that hypoxia may have contributed to Mr Duszynski’s delirium. Whilst the recorded oxygen saturation levels did not appear 25 Exhibit C4, paragraph 9 26 Exhibits C2a, C3a and C15 27 Bactrim 28 Exhibits C7 and C14 29 Exhibit C14

to concern the treating doctors, I accept Dr Gilbert’s opinion that hypoxia may have contributed to Mr Duszynski’s delirium.30

7. Coronial investigation 7.1. Due to Mr Duszynski’s death being deemed a death in custody, a police investigation was conducted. Nothing of concern was noted.

7.2. Mrs Duszynski indicated that she would have liked to have been warned by the medical practitioners that Mr Duszynski’s blood vessel issues could change his behaviour. She found his behavioural changes very dramatic and upsetting. I note that she found her husband’s behaviour so distressing that she was unable to visit him in the last few days before his death.

7.3. I find that Dr Milton did explain to Mrs Duszynski that the prednisolone would increase her husband’s paranoia and aggression.31 I make no criticism of the medical practitioners for not giving additional warnings in the circumstances.

7.4. Dr Jeffrey Barbara commented that the outlook for patients with cryoglobulinaemia is improved with early diagnosis. In the present case it is unfortunate that there was some delay caused by Mr Duszynski’s reluctance to be hospitalised and to submit to diagnostic testing. His behaviour, no doubt occurring as part of his complex medical conditions, would have posed significant challenges to hospital staff. I am satisfied that the medical practitioners concerned in Mr Duszynski’s care provided timely and appropriate medical management.

7.5. I make no recommendations.

Key Words: Death in Custody; Natural Causes; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed her hand and Seal the 14th day of July, 2020.

Deputy State Coroner Inquest Number 58/2020 (1162/2018) 30 Exhibits C14 and C15 31 Exhibit C1a