Coroner's Finding: KL

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased, family, friends, and others by direction of the Coroner pursuant to s57(1)(c) of the Coroners Act 1995) I, Robert Webster, Coroner, having investigated the death of KL Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is KL; b) KL died in the circumstances set out below; c) KL’s cause of death was global hypoxic brain injury; and d) KL died on 29 April 2019 at Hobart, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into KL’s death. That evidence includes:  The Police Report of Death for the Coroner;  Affidavits establishing identity and life extinct;  Affidavit of Dr Donald Ritchey Forensic Pathologist;  Forensic Science Service Tasmania (FSST) – toxicological and analytical report;  Ambulance Tasmania (AT) electronic patient care report;  Royal Hobart Hospital (RHH) - death report to coroner;  Affidavit of Mrs T;  Affidavit of Mr T;  Affidavit of Constable Jonathan Walter;  Affidavit of Senior Constable Melanie Redburn;  Medical records obtained from KL’s general practitioner; and  Medical records of KL obtained from the RHH.

Background KL was born in Hobart, Tasmania in November 1987. At the date of his death he was single and living with his parents. He had not married and did not have any children. He was educated in Tasmania and after leaving school he was employed as an administration assistant. He was an avid cricketer.

KL’s Health KL was diagnosed with epilepsy when he was about 15 years of age. From this point on he was on and off prescribed medication to treat this condition. At times he was reported to have episodic seizures when he did not take his medication or when he was sleep deprived.

KL had previously been treated for a fractured right mandible in 2015, a fractured right metatarsus in 2016, onychogryphosis in 2016 and some wisdom tooth pain in 2018. He also suffered a left orbital blowout fracture which required surgery in 2012 and which occurred when he was playing cricket.

At the time of his death he was known to smoke, was reported by his mother to have an undiagnosed sleep apnoea and he was obese.

The general practitioner’s records cover the period of 17 years from 2002. The first recorded prescription of medication to treat epilepsy was in 2004. These records confirm KL experienced seizures after not taking his medication regularly and/or after nights where he has gone out and not had enough sleep. KL’s last attendance on his general practitioner occurred on 25 March 2019 where he reported a seizure that morning and that he may have been having a few seizures over the last couple of nights. It was noted sleep deprivation and missed medication usually caused the seizures. The entry in the records says KL was due to see the neurologist Dr Jones in the middle of that year. He was prescribed his anti-epileptic medication and a referral for some pathology testing was provided.

The RHH records reveal KL was admitted for treatment on a number of occasions after suffering seizures. This occurred once in 2008, 2013 and 2018. There were 2 admissions in 2015 although the second one was for a fractured mandible which occurred as a result of a seizure. KL was admitted to the RHH on 4 occasions in 2016 for treatment with respect to his suffering of seizures. In addition there were a number of attendances at the emergency department over the years for treatment of this condition which did not result in an admission to hospital. KL was also seen regularly in the epilepsy clinic by the neurologist at that hospital, Dr Jones. It is clear Dr Jones reviewed KL every year from 2009 and sometimes on a couple of occasions each year. His last review of KL occurred in July 2018. Dr Jones noted, at that time, much improved compliance

on the part of KL in taking his medication. It appears a dosette box was being used to ensure a more regular pattern of medication administration.

The Circumstances Leading to KL’s Death On 26 April 2019 at approximately 07:45 hours KL rose from bed as he was due to go to work.

Mr T left home for work and shortly afterwards, at about 08:00 hours, Mrs T heard a loud noise coming from the toilet which she says sounded like her son falling over. This was followed by noises of him hitting the wall. She knew, given his history, KL was having a seizure and she immediately went to the door and called out to him. The door was locked and as she was trying to open it she called an ambulance. She got the door open and saw KL lying on his back with his head twisted against the wall. His face was blue. She tried to pull his arm to move him but she could not. She witnessed the arrival of personnel from AT and their treatment of her son until they took him to hospital.

Mr and Mrs T say that from about 08:30 hours onwards on 29 April 2019 they were at the intensive care unit (ICU) at the RHH. They were advised about the results of testing which had been conducted on KL. They were told he did not have any brain activity and by that they understood he had passed away. Subsequently they discussed organ donation with representatives from Donate Life.

Investigation AT’s report discloses the emergency services call from KL was received at 08:02 hours, the ambulance was dispatched at 08:05 hours and it arrived at KL’s home 8 minutes later. Two ambulances with 5 paramedics attended. KL was treated for a very lengthy period of time, given the seriousness of his condition, before he was taken to hospital. His Glasgow coma score is not recorded above 3 at any stage. Notes recorded in this report indicate Mrs T advised ambulance personnel that her son “had a late night last night and often has seizures after long nights”.

On 30 April 2019 at approximately 19:30 hours police were advised KL had been declared brain dead at the ICU of the RHH. On arrival an ICU doctor explained to police KL had been brought to hospital by paramedics after a seizure with prolonged asphyxia. Brain death had been declared at 12:30 PM on 29 April 2019 and KL was being maintained by life support for the purpose of organ donation. Police observed KL and confirmed his identity. No obvious signs of trauma were found. They then met and spoke to KL’s parents.

Dr Ritchey conducted a post-mortem on 2 May 2019. He calculated KL had a body mass index of 39 kg/m2. The organs which were donated were identified by Dr Ritchey. Samples were taken for histological and toxicological examination. As a result of conducting his post mortem and after considering the results of histology and toxicology Dr Ritchey says the cause of death was global hypoxic brain injury1. This occurred because of positional asphyxia2 following an epileptic seizure. Dr Ritchey goes on to say significant contributing factors were idiopathic epilepsy and morbid obesity. I accept Dr Ritchey’s opinion.

The report from FSST indicates no alcohol or illicit drugs were detected. There were 4 drugs detected which the report indicates were administered during treatment provided by AT and the RHH. Two antiepileptic medications were detected as was a non-steroidal anti-inflammatory drug.

Comments and Recommendations I am satisfied KL’s very unfortunate death was caused by global hypoxic brain injury as a result of positional asphyxia following an epileptic seizure. I am also satisfied, as a result of my examination of all the medical records, the treatment which KL received from both his general practitioner and the RHH over many years was appropriate and of a good standard.

The circumstances of KL’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 extend my appreciation to investigating officer Constable Jonathan Walter for his investigation and report.

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

Dated: 11 November 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner 1 There was widespread necrosis of the brain consistent with this diagnosis. In addition there was marked bruising of the anterior and right sides of the tongue which is consistent with peri-mortem tongue biting sustained in a seizure.

2 Positional asphyxia is a form of asphyxia which occurs when someone's position prevents the person from breathing adequately.