Coroner's Finding: MAZMANIDIS Kiriakos Jack

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 16th day of March and the 30th day of June 2021, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Kiriakos Jack Mazmanidis.

The said Court finds that Kiriakos Jack Mazmanidis aged 83 years, late of 43 Golding Street, Beverley, South Australia died at the Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, South Australia on the 28th day of July 2019 as a result of respiratory failure due to chronic obstructive lung disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Kiriakos Jack Mazmanidis was born on 29 October 1935 and died at the Queen Elizabeth Hospital on 28 July 2019 at the age of 83 years.

1.2. A pathology report by Dr Iain McIntyre1 from Forensic Science South Australia provides the cause of death as respiratory failure due to chronic obstructive lung disease, and I so find.

2. Reason for Inquest 2.1. Mr Mazmanidis was subject to a Level 2 Inpatient Treatment Order (ITO) at the time of his death and, at the time the inquest was heard, the death of Mr Mazmanidis was defined as a death in custody and this was a mandatory inquest.2 1 Exhibit C1a 2 From 7 June 2021, as a death from natural causes, it is no longer a mandatory inquest following the amendment of section 21 of the Coroners Act 2003.

2.2. A Level 1 ITO was authorised at 7pm on 20 July 2019 by Dr Andrew Peel at The Queen Elizabeth Hospital. The Level 1 ITO was confirmed by psychiatrist Dr Elizabeth Markwick on 22 July 2019.

2.3. On 25 July 2019, Dr Elizabeth Markwick confirmed a Level 2 ITO at 1:56 pm.

Dr Markwick noted a history of delirium due to an upper respiratory tract infection, improving but ongoing confusion, hallucinations, paranoia and pulling out his IV line.

The ITO was due to expire on 5 September 2019.

3. Background 3.1. Mr Mazmanidis’ background has been obtained from the police investigation report and from his daughter, Sofia Andreucci.3

3.2. Mr Mazmanidis was born in South Australia. He and his wife Paraskevi Koula Mazmanidis had three children, Sofia, Helen and Georgie. The family resided at Beverley for over 50 years. The couple maintained a happy relationship and the family remained close.

3.3. Ms Andreucci states the family were not aware of their father having any mental or psychological illnesses. He had been diagnosed with the thickening of one of his lungs which she believed to be attributed to pneumonia. He was due to be treated for this every six months, however began to refuse biopsies out of fear.

3.4. Although he was refusing treatment, the family had no concerns with his health.

Ms Andreucci states the family were of the view all was well following her father’s check-up in January 2019.

3.5. In April 2019, the family noticed Mr Mazmanidis becoming more fearful, confused and scared. He was also displaying signs of hallucinations, saying things to the effect that ‘he was a prisoner and that he wanted to protect their family’.

3.6. Ms Andreucci states when her father was admitted to The Queen Elizabeth Hospital on 20 July 2019, his mental state quickly deteriorated. He became increasingly confused and began to think that he was at war and needed to protect everyone. She notes that he kept saying ‘they’re going to kill you, like they’re killing me’.

3 Exhibit C2a

3.7. Medical staff informed the family that he was suffering from delirium and that it would fluctuate. However, the family were not under the impression that he would pass away.

3.8. About two days prior to his passing on 26 July 2019, the family were informed a chest X-ray of the lungs revealed possible exposure to asbestos. The family were given the option to either permanently intubate or remove the oxygen and let him pass away naturally.

3.9. His family made the difficult decision to cease life support on 26 July 2019.

Ms Andreucci states her father had moments of lucidity and did not appear aggressive or delusional before he slipped away.

4. Medical history 4.1. Dr Luigi Pisaniello was Mr Mazmanidis’ general practitioner.4 The doctor first had contact with Mr Mazmanidis in 2005 and remained his general practitioner until he passed away. Dr Pisaniello lists a history of medical conditions which included hypertension, spinal canal stenosis and type 2 diabetes.

4.2. In 2010 Mr Mazmanidis was diagnosed with chronic kidney disease (stage 1), pneumonia and depression. On this occasion, the doctor noted signs of delusion.

4.3. In 2015, he was again diagnosed with pneumonia and pleurisy. He showed signs of delusion and contracted influenza A.

4.4. On 3 July 2018, a CT of his chest showed ongoing collapse of the left lower lobe, associated pleural thickening and small pleural effusion. He was required to attend the Queen Elizabeth Hospital but failed to attend his appointment on 12 July 2018.

4.5. On 16 August 2018, Mr Mazmanidis attended the Queen Elizabeth Hospital respiratory clinic. His results were unremarkable and conservative management was preferred and a scan was arranged in six months.

4.6. The general practitioner considered the possible diagnosis of mesothelioma, however Mr Mazmanidis refused to have this further investigated due to the pain of a biopsy.

Dr Pisaniello states without a diagnosis recovery was much more difficult. A care plan for management of chronic disease was implemented in 2018. The doctor states 4 Exhibit C5

Mr Mazmanidis was attending the Queen Elizabeth Hospital regularly for plural plaque, plural effusion and pneumonia.

4.7. On 4 April 2019, he presented at the clinic with pneumonia and pleural effusion.

Mr Mazmanidis had been disorientated for two days.

4.8. On 3 June 2019, the general practitioner had received a discharge summary from the Queen Elizabeth Hospital due to respiratory failure, delirium and lower respiratory tract infection.

4.9. Dr Pisaniello believed Mr Mazmanidis prognosis was poor, especially due to the nondiagnosis of the suspected plural plaque in his left lung, which was not tested at his request.

5. Mr Mazmanidis’ hospital admission 5.1. On 20 July 2019, Mr Mazmanidis was brought to The Queen Elizabeth Hospital Emergency Department with worsening confusion and possible pneumosepsis and type 2 respiratory failure.

5.2. Mr Mazmanidis was examined by Dr Andrew Peel.5 Dr Peel noted Mr Mazmanidis was very aggressive towards staff and paranoid that people were attempting to kill him.

5.3. Dr Peel diagnosed type 2 respiratory failure and a BiPAP (Bilevel Positive Airway Pressure) device was applied to prevent CO narcosis. Mr Mazmanidis was significantly agitated and removed the BiPAP; his oxygen saturation fell below 80%.

It was apparent to Dr Peel that an ITO was required.

5.4. On 20 July 2019 at 7pm, Dr Peel imposed a Level 1 ITO which was subsequently confirmed by consultant psychiatrist Dr Markwick on 22 July 2019.

5.5. Dr Peel assessed the most pertinent issue was the worsening hypoxia and type 2 respiratory failure which was likely the cause of his delirium. As such the management focused on treating reversible causes of the hypoxia, including a lower respiratory tract infection.

5 Exhibit C4

5.6. Mr Mazmanidis’ agitation required management with haloperidol and olanzapine.

With the assistance of ICU it was decided low flow oxygen therapy would be sufficient.

5.7. Dr Peel states not all reversible causes of confusion could be excluded at the time of his assessment due to the agitation. However significant hypoxia was deemed the most likely cause. Mr Mazmanidis was provided oxygen therapy, IV antibiotics and was admitted for ongoing monitoring.

5.8. Dr Peel believes that if Mr Mazmanidis had not passed away, he would continue to have multiple and frequent presentations of cognitive decline, delirium and gradual deterioration.

5.9. Dr Nguyen was an intensive care registrar in the ICU at the Queen Elizabeth Hospital and took part in the ward rounds with ICU consultants.6 Dr Nguyen saw Mr Mazmanidis on 24, 25 and 27 July 2019. Dr Nguyen’s role was to take notes and order medication under auspice of the senior doctors.

5.10. Dr Nguyen states Mr Mazmanidis was transferred to the ICU on 21 July 2019 following a medical emergency call for oxygen saturation. On 25 July 2019, he was discharged from the ICU and moved back to the ward, however this was short lived and he was returned to ICU on 26 July 2019 due to decreased consciousness levels secondary to hypercarbia.

5.11. Mr Mazmanidis was not responding to treatment with non-invasive ventilation. The medical consensus of ICU consultant Dr John Moran and the home team respiratory team was that in view of his advanced airway disease and failure to respond to treatment, the goal of his care should be keeping him comfortable. The family were consulted and consented to the course of action.

5.12. Dr Nguyen states Mr Mazmanidis’ health continued to decline until he passed away on 28 July 2019. Dr Nguyen declared life extinct on 28 July 2019 at 2:45am.

6 Exhibit C3

6. Coronial investigation 6.1. Due to the imposition of a Level 2 ITO a police investigation was undertaken.

Probationary Constable Prior provided a statement setting out her observations.7

6.2. Brevet Sergeant Megan Hintz from the Western District Criminal Investigation Branch provided a final report to the Court.8 Brevet Sergeant Hintz concluded that the care and treatment provided at the Queen Elizabeth Hospital was appropriate and that the ITO was valid and appropriate. I agree with that assessment and I so find.

7. Recommendations 7.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Natural Causes; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 30th day of June, 2021.

State Coroner Inquest Number 88/2020 (1531/2019) 7 Exhibit C6 8 Exhibit C7