Coroner's Finding: Sheedy, Barbara

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Duncan Fairley, Coroner, having investigated the death of Barbara Sheedy Find that: a) The identity of the deceased is Barbara Sheedy; b) Mrs Sheedy died in the circumstances set out below; c) Mrs Sheedy died as a result of a large acute subdural haemorrhage leading to uncal herniation subsequent to an accidental fall; d) Mrs Sheedy died on 25 April 2016 at the Launceston General Hospital; e) Mrs Sheedy was born in Launceston on 24 November 1938 and was aged 77 years; and f) Mrs Sheedy was married and was retired at the date of her death.

Background: Barbara Sheedy was born in Launceston, Tasmania on 24 November 1938. She married Alan Noel Sheedy and there were 4 children to the union - Keryn, Glenn, Darren and Mandy.

Mrs Sheedy’s life was dedicated to raising her children and was otherwise occupied with the care of the family home.

Mrs Sheedy smoked cigarettes for the majority of her life. A review of the available medical records indicates that, as at the date of her death, Mrs Sheedy was suffering from chronic obstruction pulmonary disease in addition to kidney disease. She also required surgery to replace her right hip and left knee in 2014 and 2015 respectively.

By early 2016 Mrs Sheedy required assistance with daily care tasks. Mrs Sheedy’s granddaughter, Jessica Marston, provided regular gratuitous care. During March 2016 Ms Marston accompanied her grandmother to an appointment with Dr Paul Kerkenezov

(General Practitioner) who confirmed that Mrs Sheedy was struggling to breathe and that, as a result, her mobility was significantly restricted.

Circumstances Surrounding the Death: Mrs Sheedy attended upon Dr Kerkenezov on Monday 18 April 2016 at which time the General Practitioner ordered a chest x-ray and a bank of pathology tests. The following day Mrs Sheedy returned to Dr Kerkenezov who, after reviewing the blood test and radiological investigation results, caused her to be admitted to the Launceston General Hospital. The General Practitioner’s progress notes indicate that the admission was required due to “overall weakness, general disabled state and for further care and assessment”. When admitted Mrs Sheedy was provided with a wheeled walker for mobility assistance.

On Sunday 24 April 2016 Mrs Sheedy remained situated in a room at the Launceston General Hospital Department of Emergency Medicine. At approximately 3.30pm nursing staff heard Mrs Sheedy call out from her room. She was located half-sitting, half-kneeling on the floor next to her walker. Mrs Sheedy explained that she had been moving towards the bathroom when the walker slipped out from under her. She assured staff that she did not hit her head and complained only of right sided elbow, hip, chest and rib discomfort. Mrs Sheedy was examined, however, no sign of a head injury was detected. A Glasgow Coma Scale assessment did not reveal any decline in cognitive function. Mrs Sheedy was observed to mobilize normally for the remainder of the afternoon and early evening.

At approximately 7.00pm Mrs Sheedy complained of breathing difficulties and a severe headache. She was examined and it was considered that the symptoms related to her preexisting conditions. At 9.45pm a Resident Medical Officer reviewed Mrs Sheedy and noted that her breathing was shallow and fast and that she was still complaining of a frontal headache. Temazepam and a long-acting opioid were prescribed.

Mrs Sheedy was reviewed once more at 1.00am on 25 April 2016 and found to have rapid atrial defibrillation. The Medical Registrar considered Mrs Sheedy’s symptoms were related to the application of a nicotine patch and an exacerbation of her pulmonary disease. She was administered IV digoxin to slow her heart rate and the nicotine patch was removed. At 4.25am Mrs Sheedy was found to be unresponsive and staff observed that her right pupil was dilated. An urgent CT scan was performed.

The CT scan revealed a large right sided subdural haemorrhage with midline shift. The shift was assessed as exerting pressure on the brain stem. At 7.40am the General Medical Consultant concluded that the fall which Mrs Sheedy had suffered the previous day was the likely cause of the subdural haemorrhage, notwithstanding the lack of any obvious signs of head trauma. Mrs Sheedy’s husband and family were advised by medical staff that the brain injury suffered was non-survivable. She was provided with comfort care thereafter. Mrs Sheedy was declared deceased at 8.40pm on 25 April 2016.

Dr Rosanne Devadas (Pathologist) conducted a post-mortem investigation into the cause of death on 29 April 2016. She found that Mrs Sheedy had suffered a large acute subdural haemorrhage leading to uncal herniation, associated with a mechanical fall. I accept Dr Devadas’ opinion and am satisfied that Mrs Sheedy died in the circumstances set out in this finding.

Comments and Recommendations: In the circumstances there is no need for me to make any further comment or recommendations.

In concluding, I convey my sincere condolences to the family of Mrs Sheedy.

Dated: 19th April 2017 at Launceston Coroners Court in the State of Tasmania.

Duncan Fairley Coroner