Coroner's Finding: Steshic, John Norman

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Rod Chandler, Coroner, having investigated the death of John Norman Steshic Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is John Norman Steshic; b) Mr Steshic was born in Hobart on 8 March 1957 and was aged 60 years; c) Mr Steshic died at the Royal Hobart Hospital (RHH) in Hobart on 30 November 2017; and d) The cause of Mr Steshic’s death was ischaemic heart disease due to severe single vessel atherosclerosis.

Background Mr Steshic resided at Warrane with his long-term partner Ms Rosemary Barry. He was self-employed in a gardening business known as Goodies Garden Care. He employed Mr Jamie Harwood on a casual basis.

Mr Steshic’s general medical practitioner was Dr Edward Foley of the Lauderdale Doctors Surgery. His medical history included hepatitis C viral infection with cirrhosis and a gastric ulcer treated with a proton pump inhibitor. A biopsy on 4 October 2017 showed nonspecific chronic gastritis. An electrocardiogram on the same date was normal. On 20 October 2017 Mr Steshic had a right rotator cuff repair. He had a repeat gastroscopy on 10 November 2017 which showed a near-healed ulcer surrounded by normal appearing mucosa.

The records show that Mr Steshic last consulted Dr Foley on 30 October 2017. The reason recorded for the attendance was ‘nausea’. The records also state ‘ongoing recurrent reflux-type CP (chest pain) relieved sitting forward and eating…no blood in stool, no dark stools…..sore L) shoulder as using L) arm more.’ Dr Foley’s earlier records do not suggest a history of chest pain or coronary heart disease.

Circumstances Surrounding the Death Just after 1.00pm on 30 November 2017, Mr Steshic was driving his Holden utility on Acton Road at Acton Park when it veered to the left and then travelled off the bitumen surface, onto the verge and through a fence, coming to rest against several trees.

Mr Harwood was travelling as a front seat passenger in the Holden. He reports that following the crash Mr Steshic was slumped forward in his seat and was unresponsive.

He dialled 000 and an ambulance attended. Mr Steshic was pulseless when the paramedics arrived. Spontaneous circulation was recovered with intravenous adrenaline fluid and bilateral needle decompressions of the chest. Mr Steshic was then conveyed to the RHH. Radiology showed a molar tooth in the left main bronchus, diffuse bilateral consolidation and a possible right-sided pneumothorax. There was significant hypoxia. Mr Steshic was actively treated in the Emergency Department but the situation was considered futile. He was declared deceased at 4.22pm.

Post-Mortem Examination This was carried out by State Forensic Pathologist, Dr Christopher Lawrence. His report includes these statements: ‘Autopsy reveals severe ischaemic heart disease which is the underlying cause of death. It is likely that the heart attack caused the subsequent motor vehicle collision. There is also some damage to the right lower lung which has been caused by one of the large bore cannulas inserted in the chest wall and some damage to the left lung caused by the thoracotomy.

‘He also has a tooth which has become lodged in his left main bronchus. I cannot tell with certainty when this has occurred but the tooth has probably been dislodged during the initial minor collision and has then been inhaled. This has blocked the air supply to the left lung and made resuscitation difficult.

‘He also has emphysema which is why [the] large bore cannula has probably caused the damage in the first place. He also has quite significant cirrhosis which has caused an enlarged spleen.’ In Dr Lawrence’s opinion the cause of death was ischaemic heart disease due to severe single vessel atherosclerosis. I accept this opinion.

Investigation and Findings The circumstances surrounding Mr Steshic’s crash have been comprehensively investigated by Tasmania Police. It leads me to be satisfied that:  In the morning of 30 November Mr Steshic had been working on jobs at New Town and Warrane. Mr Harwood was working with him. He reports; ‘John seemed really worn out. He had no energy and wasn’t himself.’  En route to Acton, Mr Steshic pulled over to the side of the road because he was not feeling well. They waited for about 15 minutes before Mr Steshic drove on.

 The crash was low impact with minimal damage to Mr Steshic’s vehicle.

 No other vehicle was involved in the crash.

 The crash was not attributable to a mechanical failure.

 At the crash scene there was not any evidence of steering input or braking. All the evidence indicates that Mr Steshic was driving in a state of disassociation.

The evidence enables me to find that the crash came about because Mr Steshic suffered a heart attack which rendered him incapable of controlling his utility and led to it leaving the roadway and coming to rest among adjoining trees.

Mr Steshic’s death also gave rise to several medical issues requiring investigation, namely, the treatment provided by Ambulance Tasmania and by the RHH. The other issue is whether it should reasonably have been recognised by Dr Foley, prior to the crash, that Mr Steshic suffered from a heart condition. This aspect of the investigation has included consideration of Mr Steshic’s records at the Lauderdale Doctors Surgery and the RHH along with the provision of a report by Dr A J Bell as medical adviser to the coroner. Upon the first two issues Dr Bell advises me that:  In the circumstances confronting them it was reasonable for the paramedics to suspect a tension pneumothorax and to treat it by inserting a needle into the pleural cavity. The subsequent lung damage and pneumothorax was a complication of this necessary procedure.

 The treatment provided at the RHH was appropriate and properly carried out.

I accept Dr Bell’s opinion upon these matters.

I turn now to the evidence touching upon Mr Steshic’s pre-crash cardiac condition.

In her affidavit, Ms Barry reports that two to three weeks after Mr Steshic’s right shoulder operation he began to complain of chest pain and of pain down his left arm.

She says; ‘John went to see Dr Foley about the chest pains and pain down his left arm because they weren’t going away.’ Clearly this led to the consultation on 30 October and I have set out earlier in these findings the notes made by Dr Foley concerning that visit. It is apparent that Ms Barry did not attend this consultation because she says; ‘John came home and told me Dr Foley told him that the pains were a side effect of giving up the alcohol and cigarettes.’ This is not consistent with Dr Foley’s own notes where he indicates that he attributed Mr Steshic’s chest pain to his pre-existing gastric condition and his left upper limb pain (described as affecting the shoulder as distinct from the arm) to the increased use of that limb as a response to the recent surgery on his right rotator cuff.

Dr Bell has opined that the explanations for chest pain range from life-threatening conditions to those that are relatively benign. The most common causes are musculoskeletal and gastrointestinal conditions. However, he says that proton pump inhibitors are ordinarily a most effective means of managing gastrointestinal pain and contraindicate a conclusion that Mr Steshic’s chest pain was attributable to his gastric ulcer rather than an alternative cause. These opinions, which I accept, lead me to state that with the benefit of hindsight it would have been prudent for Dr Foley to have further investigated Mr Steshic’s complaints of pain. It is not of course possible for me to predict the outcome of those investigations and whether they would have enabled the diagnosis of Mr Steshic’s underlying heart condition and its successful treatment.

Comments and Recommendations The circumstances of Mr Steshic’s death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to Mr Steshic’s family and loved ones.

Dated: 18 day of March 2019 at Hobart in the State of Tasmania.

Rod Chandler Coroner