Coroner's Finding: Revell, Dianne Judith

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of Dianne Judith Revell Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Dianne Judith Revell (Ms Revell); b) Ms Revell died in the circumstances set out below; c) Ms Revell’s cause of death was decompensated liver failure; and d) Ms Revell died on 13 August 2022 at Hobart, Tasmania.

Introduction In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Ms Revell’s death which includes the following:  Police Report of Death for the Coroner;  Affidavits establishing identity and life extinct;  Report of the forensic pathologist Dr Andrew Reid;  Affidavit of Jessica Quaggin, the daughter of Ms Revell;  Ms Revell’s medical records obtained from the Tasmanian Health Service (THS);  Death report to coroner from THS; and  Ms Revell’s medical records obtained from her general practitioner.

Background Ms Revell was born on 2 October 1956. At the date of her death she was 65 years of age.

She had 3 adult children namely Jessica Quaggin, Dylan Lawler and Hannah Lawler. She had been divorced from her former husband Phil Lawler for around about 20 years and she was retired. Ms Revell had been married to Mr Lawler for about 20 years and had, during her working life, worked as a book keeper.

Dylan Lawler had lived with his mother and was her carer. He helped her with her everyday chores for a number of years. Ms Revell’s other children assisted. Ms Quaggin says that as far back as she can remember, her mother had been quite a heavy drinker and her diet was not particularly good and that she did not eat enough food. The medical records confirm Ms Revell was quite a frail person and she reported daily alcohol use for 20 years following her divorce. In addition Ms Revell had severe osteoporosis and about 6 months prior to her death she had suffered from a TIA.1 Ms Quaggin says Ms Revell’s doctors told her that if she did not make any lifestyle changes then her health would deteriorate very quickly. In addition she says her mother was secretive about her health which she believes was her way of attempting to protect her children.

Health Ms Revell attended the Kingborough Medical Centre for her health care. The records of that general practice were obtained and they cover the period from 9 October 2013 until 1 July

2022. Ms Revell saw a number of general practitioners at that practice but she predominantly saw Dr Mark McKay. The records reveal difficulties with alcohol abuse and a diagnosis of cirrhosis of the liver in 2013. In addition Ms Revell suffered from anxiety, gallstones, chronic obstructive pulmonary disease (COPD), a pancreatic enzyme deficiency, pancreatitis, osteoporosis and hepatitis C. She also suffered a hip fracture in 2001 and underwent a colonic polypectomy in 2016. In addition she suffered from glaucoma which was first diagnosed in 2015. She was prescribed medication and she had received 4 COVID19 vaccine shots on 27 May and 11 August 2021; and 20 January and 17 May 2022.

The records of the THS reveal Ms Revell had 8 admissions to the Royal Hobart Hospital (RHH) for treatment. She underwent liver biopsies in May and June 2012, July 2012 and September 2015. In May 2017 she underwent a gastroscopy. This procedure was required because she had returned a positive result on the national bowel cancer screening test. In April 2020 Ms Revell was admitted for surgery because she had suffered a neck of humerus fracture secondary to a fall due to alcohol intoxication on 9 April 2020. Between 9 and 13 June 2020 Ms Revell was admitted to the RHH for an open reduction and internal fixation of her left shoulder. Then finally she was admitted to that same hospital on 4 August 2022, the details of which are set out below.

Ms Revell also attended a number of outpatient clinics at the RHH. From 2006 until about 2009 she was treated for rheumatoid arthritis and then from 2012 onwards she was treated at the gastroenterology clinic. In relation to her diagnosis of cirrhosis this was said to be 1 A transient ischemic attack (TIA) is a temporary period of symptoms similar to those of a stroke. A TIA usually lasts only a few minutes and it does not cause any permanent brain damage.

brought upon by alcoholism and hepatitis C. The hepatitis C was well treated. The Child Pugh score2 with respect to her cirrhosis condition was initially said to be class A. However by the time of her death it was a class C condition.

Circumstances leading to Ms Revell’s death On 4 August 2022 Ms Revell was admitted to the Royal Hobart Hospital via an ambulance after having an unwitnessed fall while intoxicated. This fall led to a fracture of her olecranon3 and a deep laceration down to the bone. She underwent surgery to repair the fracture and wound. That procedure went well however it was noted by the attending medical staff Ms Revell was very slow to wake from the anaesthetic. It was thought her history of liver cirrhosis and hepatitis C resulted in her liver being unable to process the anaesthetic in a normal manner.

The records show that post operatively Ms Revell was alert but she could be confused at times. On other occasions she was incoherent. By 8 August 2022 a CT scan detected a small bowel obstruction. On 9 August 2020 there was post-operative swelling, Ms Revell was suffering from mild pressure injuries and irritation after the insertion of an indwelling urinary catheter. There were also crackles detected on her chest. Given her general condition and significant comorbidities she was not a surgical candidate for general surgery with respect to the bowel obstruction and it was thought that should she deteriorate then she was likely to require palliation. On 11 August 2020 medical staff advised Ms Revell that her prognosis was very poor because of the bowel obstruction, her poor nutritional status, her failing liver function and osteoporosis. It was at that time she agreed to her daughters being contacted and to being transferred to the Whittle ward. On the morning of 12 August 2022 medical staff noted a dramatic deterioration in her condition overnight. Her death was imminent.

Later that day Ms Revell was in and out of consciousness. She passed away in the early hours of 13 August 2022.

Investigation Dr Reid, an experienced forensic pathologist, conducted an autopsy on 15 August 2022. He noted Ms Revell’s death was reportable because it was caused by a combination of complications arising from hepatic alcohol toxicity and viral hepatitis to which an accidental fall and injury contributed. In his view Ms Revell died as a result of decompensated liver 2 This is a system for assessing the prognosis – including the required strength of treatment and necessity of a liver transplant – for people with chronic liver disease primarily cirrhosis of the liver. A class A score means a person has good hepatic function whereas a class C score means a person has advanced hepatic dysfunction.

3 The olecranon is the part of the ulna that cups the lower end of the humerus, creating a hinge for elbow movement.

failure on a background of Child Pugh class C hepatic cirrhosis of the liver, alcohol toxicity and a hepatitis C infection. He noted Ms Revell suffered an open olecranon fracture which was sustained in a fall while she was intoxicated and that she also suffered from osteoporosis and chronic obstructive pulmonary disease. I accept Dr Reid’s opinion.

Comments and Recommendations Ms Quaggin says the following in her affidavit: “ The only concern I have is that she went in with a broken arm for 6 days and it wasn’t until the morning of the 6th or 7th day that I was alerted to mum’s liver problems and then that afternoon that she was being transferred to palliative care due to them. I do not know if they were unaware, she had liver issues the whole time or if they did not inform us until that last day.” As set out above the medical records disclose Ms Revell had received treatment at the RHH for her liver condition from about 2012. In addition it was not until 11 August 2022 she consented to details of her condition being provided to family members.

The circumstances of Ms Revell’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 the family and loved ones of Ms Revell.

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

Robert Webster Coroner