Coroner's Finding: Combes, Margot Janeece

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Margot Janeece Combes Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Margot Janeece Combes; b) Mrs Combes died in the circumstances described below as a result of a fall at her workplace; c) The cause of death was pulmonary thromboembolus; and d) Mrs Combes died on 23 September 2017 at Lenah Valley, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mrs Combes’ death. The evidence comprises the police report of death; an opinion of the forensic pathologist who conducted the autopsy; police and witness affidavits; medical records and reports; an opinion of the coronial medical consultant; and forensic evidence.

Margot Janeece Combes was born in Hobart on 1 September 1970 and was aged 47 years at her death. She had been married to her husband, Leigh Alan Combes, for 27 years. The couple did not have any children. At the time of her death, Mrs Combes worked as a nurse for Southern Cross Care (Tas) Inc. at Sandown Village residential aged care facility in Sandy Bay.

Mrs Combes suffered hypertension, for which she was medicated, and was morbidly obese.

At 9.50am on Friday 15 September 2017, Mrs Combes was walking back to her car in the staff car park of the aged care facility. She was running late for a 9.30am meeting and was going to her car to retrieve her phone. In the process, she suffered a fall in the car park near the passenger side of her car and landed at least partly in some pine bark. Immediately after her fall, a fellow worker, Ms Margaret Lesser, found her in a hunched over position brushing pine bark from her dress. Mrs Combes was conscious and told Ms Lesser that she had tripped rushing to her car to get her phone for the meeting. Although Mrs Combes initially stood up, she was clearly in pain and was assisted inside in a wheelchair.

Mrs Combes attended Calvary Hospital for treatment the same day and underwent x-rays. She was assessed as suffering a left medial malleolar (ankle) fracture. The consultant orthopaedic

surgeon was contacted and recommended immobilisation with a back slab (temporary cast) for one week. Following that period, the plan was for further radiology and, if the fracture position remained satisfactory, a complete below knee plaster cast was to be applied. During her week with the temporary cast, Mrs Combes was able to walk but required crutches.

On Friday 22 September 2017, Mrs Combes attended the North Hobart Medical Centre and had the temporary cast removed and a permanent one fitted by a plaster technician. She then returned home. Once home, she had dinner then sat on the couch watching television, where she fell asleep and commenced snoring.

Mr Combes left the room for a short time and upon his return he noted that Mrs Combes’ snoring had changed to a gurgling sound. She was conscious at this time, but speaking in a slurred manner. She asked him to help her to use the bathroom, but she was unable to get up and subsequently fell to the floor. She declined an ambulance. She continued to appear very unwell and so Mr Combes called for an ambulance which attended a short time later.

On arrival, ambulance paramedics found Mrs Combes hypoxic and in cardiac arrest with Mr Combes performing CPR. The paramedics continued to work on Mrs Combes but were unable to resuscitate her and determined that she was, unfortunately, deceased.

Upon subsequent autopsy, Dr Donald Ritchey, forensic pathologist, concluded that Mrs Combes died as a result of a pulmonary thromboembolus. I accept his opinion as to cause of death. Dr Ritchey reported that pulmonary thromboemboli begin as blood clots usually in the deep veins of the legs. When they break free they travel through the venous vascular system and the right side of the heart to become impacted in the pulmonary artery. The sudden blockage of this main artery causes enormous stress on the right side of the heart and subsequent death by cardiac arrhythmia. Dr Ritchey stated that immobilisation of the leg and obesity greatly increase the risk of development of deep vein thrombus (DVT) and pulmonary embolus (PE). I am satisfied that Mrs Combes’ immobilisation and obesity were causative factors in the development of the PE.

One issue considered in this investigation is whether Mrs Combes should have been prescribed anti-coagulation medication during her cast immobilisation period when she may have been a person at risk of suffering from DVT or PE as a result of the medical requirement for her immobilisation below the knee. Dr Anthony Bell, coronial medical consultant, provided a report in which he stated that the medical care provided to Mrs Combes was of a good standard. He noted that there is continuing debate in the literature regarding the benefit of anticoagulation in the case of below-knee injury requiring immobilisation. He reported that studies have consistently demonstrated that patients at high risk are likely to benefit from

pharmacologic prophylaxis. In this case the fact that Mrs Combes was morbidly obese placed her into a higher risk category.

In the circumstances, I make no adverse comment concerning the decision not to prescribe anticoagulant medication to Mrs Combes. This decision was no doubt carefully considered. I also cannot find that, had she been so prescribed, she would not have suffered the PE.

Unfortunately Mrs Combes suffered an accidental fall, required immobilisation by a cast and developed a well-recognised complication of that immobilisation despite good medical management.

Comments and Recommendations I repeat the comments made in other recent coronial findings that treating doctors should apply an individualised approach to the question of risk of DVT and PE in each case where below-knee injury requires immobilisation.

I extend my appreciation to investigating officer Constable Candice Barron for her investigation and report.

The circumstances of Mrs Margot Combes’ death are not such as to require me to make any recommendations pursuant to Section 28 of the Coroners Act 1995.

I note that Mrs Combes died as a result of the consequences of an injury occurring at her workplace. As such, her death would ordinarily be the subject of a public inquest pursuant to section 24 of the Coroners Act 1995. However, I have received a representation from the senior next of kin under section 26A(2) of the Act that he does not seek that an inquest takes place. Further, I am satisfied under section 26A(3) of the Act that it is not contrary to the public interest not to hold an inquest. In particular, there are no issues arising in the investigation regarding Mrs Combes’ workplace or employment that require comment or recommendations. I therefore decided not to hold a public inquest.

I convey my sincere condolences to the family and loved ones of Mrs Combes.

Dated: 3 January 2020 at Hobart Coroners Court in the State of Tasmania.

Olivia McTaggart Coroner