Coroner's Finding: Zarrella, Dominic

ACORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign King at Adelaide in the State of South Australia, on the 14th day of May and the 13th day of September 2024, by the Coroners Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Dominic Zarrella.

The said Court finds that Dominic Zarrella aged 88 years, late of 8 Blanche Street, Paradise, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 16th day of June 2022 as a result of aspiration pneumonia complicating vascular dementia and metastatic prostate cancer. The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Mr Dominic Zarrella was born on 27 June 1933 and died on 16 June 2022 at the age of 88 years.

1.2. A pathology review undertaken by Dr Erin O’Connor of Forensic Science South Australia, and discussed with senior forensic pathologist Professor Roger Byard, gave a suggested cause of death as ‘aspiration pneumonia complicating vascular dementia and metastatic prostate cancer’,1 which I find to have been the cause of death.

2. Reason for Inquest 2.1. Mr Zarrella was under an inpatient treatment order pursuant to the Mental Health Act 2009 at the time his cause of death (aspiration pneumonia) may have arisen. This is therefore a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

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3. Background 3.1. Mr Zarrella was born in 1933 in L'Aquila, Italy and was named at birth Dominic Congressi.

3.2. Mr Zarrella arrived and settled in Australia in 1952 at the age of 19 years. When he was 22 years old he married Janice Hebbard.

3.3. They had a number of children together, including Mr Robert Congressi.2 There were three children of the marriage before Robert was born, however they all passed away at a young age. After Robert was born, Mr Zarrella and his wife Janice adopted another son and daughter.

3.4. Mr Zarrella and his wife eventually separated, and as Janice retained the surname, Mr Zarrella changed his name by deed poll to Renzi.

3.5. In approximately1984 when he married his second wife, Matilda Zarrella, he took on her surname and became Dominic Zarrella.

3.6. Mr Zarrella retired when he was about 65 years old. Prior to retirement he owned several restaurants and cafes, but was forced into retirement due to his poor eyesight and resulting loss of independence.

3.7. Mr Zarrella and his wife Matilda lived together until her passing in May 2019.

3.8. Matilda was taken to the Royal Adelaide Hospital (RAH) ill and she passed away in hospital. That caused significant distress to Mr Zarrella who subsequently became very worried about attending hospitals, particularly the RAH.

4. Mr Zarrella’s medical history 4.1. In the years preceding his death, Mr Zarrella had an extensive and well-documented history of metastatic prostate cancer, chronic kidney disease with hypertension and type 2 diabetes and was under the treatment of a number of RAH specialists including an oncologist, a urologist and a renal physician.

4.2. In a report written by oncologist Dr Tan on 10 May 2022, he noted Mr Zarrella had metastatic prostate cancer with extensive bone metastases. At that time though, the 2 Exhibit C1

main concern was dysphagia and the pain associated with toileting, in addition to existing comorbidities.

4.3. He had significant degenerative joint and bone pain and was known to have had paranoid delusions in the past. He was considered likely to be suffering from vascular dementia.

4.4. Mr Zarrella’s son Robert cared for his father who continued to reside alone.

4.5. In March 2022, when Mr Robert Congressi reported there had been a significant deterioration in Mr Zarrella’s physical and mental health, Mr Zarrella was placed under the care of the Eastern Older Persons Mental Health Service (EOPMHS) and the Central Adelaide Palliative Care Service (CAPCS).

5. Circumstances leading to Mr Zarrella’s death 5.1. On 29 May 2022 Mr Zarrella reportedly had a fall at home. He was located by his son, but refused ambulance assistance.

5.2. On 1 June 2022 Mr Zarrella was admitted to the RAH under a Level 1 Inpatient Treatment Order (ITO) initiated by a doctor from the EOPMHS.

5.3. The EOPMHS doctor had reviewed Mr Zarrella following a request by CAPCS who had reported concerns due to refusal of food, fluids, medication and care services.

5.4. Dr Jeffrey Faunt,3 who was involved in the care of Mr Zarrella for the duration of his stay at the RAH, stated that on his admission to hospital Mr Zarrella had various blood tests, a chest x-ray and a CT scan of his head.

5.5. Results of the blood tests showed he had chronic kidney disease, mild anaemia and evidence of mild elevation in his inflammatory markers. The chest x-ray showed a left lower lung collapse, fluid on the right lung and a number of hyper-dense lesions in his vertebrae and ribs, suggesting cancer had spread to his bones.

5.6. According to Dr Faunt, Mr Zarrella’s stay at the RAH was complicated due to his multiple medical conditions.

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5.7. He was treated for paranoia and was reviewed by a psychiatrist who recommended medications to help settle his symptoms.

5.8. It was suspected that Mr Zarrella had either an infection or cancer, or both, in his lungs.

5.9. Mr Zarrella became dehydrated due to a lack of food and fluid intake. He was given fluids intravenously, but became overloaded by the fluid as a result of his kidney disease.

He became short of breath and was treated with diuretics and oxygen.

5.10. On 5 June 2022 there was a medical note querying whether Mr Zarrella may have had a fall while trying to get out of bed, but no specific information is recorded about any such incident being witnessed.

5.11. On 7 June 2022 Mr Zarrella was placed on a Level 2 ITO by Dr Chesterman due to his confusion, minimal eating, occasionally refusing medications, incontinence and requirements for a high level of assistance for activities of daily living.

5.12. On 10 June 2022 Dr Chesterman reviewed Mr Zarrella and noted he presented as settled and not acutely depressed or psychotic. Mr Zarrella was unable to recall Dr Chesterman’s previous assessments but was feeling comfortable and safe.

5.13. Mr Zarrella’s son agreed that his presentation had improved compared to his admission on 1 June 2022 and Mr Zarrella was said to have fed himself breakfast that morning.

5.14. At 2:50pm that same day, the Level 2 ITO was revoked by Dr Chesterman. In the days that followed, Mr Zarrella's physical condition continued to deteriorate, and he transitioned to end of life care.

5.15. On 12 June 2022 Mr Zarrella became quite drowsy and was seen by the Medical Emergency Response Team who repeated blood tests, a chest x-ray and a scan of the head.

5.16. The second scan of the head showed a small subdural haematoma with a thickness of 7 millimetres. The neurosurgical team conducted an assessment but did not believe surgical intervention was warranted. Mr Zarrella’s conscious state improved without intervention.

5.17. I note there was a normal CT of the head on admission, despite reports of a fall prior to admission. I also observe that in the context of scant and unclear information about a

potential fall in hospital, this finding is concerning. However, I also note that Mr Zarrella’s conscious state improved with no intervention and this subdural haematoma was not determined through pathology review to be a contributor to the cause of Mr Zarrella’s death.

5.18. On 13 June 2022 Mr Zarrella developed a fever and oxygen requirement and a chest x-ray showed mild progression of the pleural effusion and new infective infiltrates. He was treated with intravenous antibiotics to cover for aspiration, however he continued to deteriorate with low oxygen levels and a wet cough with ‘gurgly’ respirations.

5.19. He was transitioned to end of life care.

5.20. On Thursday 16 June 2022, during a routine 30-minute check, Mr Zarrella was unresponsive to being roused and was subsequently found to have no pulse. Mr Zarrella was pronounced life extinct at 8:45pm, 15 days after his admission to hospital.

6. Conclusion and recommendation 6.1. I find that there were no suspicions circumstances surrounding Mr Zarrella’s death and that the standard of care afforded to Mr Zarrella was appropriate.

6.2. I note the concerns expressed by Mr Zarrella’s son, Robert Congressi, about his father’s experience in the RAH and acknowledge the distress he suffered. I extend my condolences to Mr Congressi and all of Mr Zarrella’s family.

6.3. I make no recommendations.

Key Words: Death in Custody; Natural Causes; Inpatient Treatment Order;Mental Health In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 13th day of September, 2024.

State Coroner Inquest Number 29/2024 (1435/2022)