Finding into death of Magdalena Schauer

FORM 37 . Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 4443/07

Inquest into the Death of MAGDALENA SCHAUER

Delivered On: 22, March 2010

Delivered At: Melbourne

Hearing Dates: 13 January 2009 at Coronial Services Centre, Southbank and 22 March ‘2010 at the Coroners Court, 436 Lonsdale Street, Melbourne

Findings of: Deputy State Coroner Jain West

Place of death/Suspected death: Royal Melbourne Hospital, Grattan Street, Parkville VIC 3053

*SCAU: — Senior Constable, Kelly Ramsey

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 4443/07

In the Coroners Court of Victoria at Melbourne I, IAIN TRELOAR WEST, Deputy State Coroner

having investigated the death of: Details of deceased:

Surname: SCHAUER Firstname: MAGDALENA

AND having held an inquest in relation to this death on 13 J anuary 2009 and 22 March 2010 at Melbourne

find that the identity of the deceased was MAGDALENA SCHAUER

and death occurred on 3rd November, 2007

at Royal Melbourne Hospital

from

la, ACUTE BRAIN INJURY

lb, INTRACEREBRAL HAEMORRHAGE lc. SEPSIS

in the following circumstances:

1. Magdalena Schauer, aged 36 years, was ambulance transferred to the Emergency Department of the Royal Melbourne Hospital on the 26th October 2007, with a depressed conscious state after being found unconscious by her partner. Ambulance paramedics attended and gave her intramuscular antibiotics for presurned meningococcal sepsis, after observing a purpuric rash to her chest, abdomen and legs. Following hospital admission with a Glasgow Coma Score between 4 and 6, Ms Schauer was intubated and a subsequent CT scan of the brain revealed two intracranial haemorrhages. The initial diagnosis was of severe fulminant sepsis. Ms

Schauer was taken to theatre for evacuation of the cerebral hacmorrhages and. after which she was admitted to the Intensive Care Unit, with a very poor prognosis of neurological recovery.

Her antibiotics were changed when blood cultures isolated staphylococcus aureus and following consultation with family, palliative care was instituted. Ms Schauer subsequently died on the 3rd November, 2007.

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2. Investigations into the circumstances surrounding the death, revealed that Ms Schauer resided with her partner of 18 years, Mario Polistena, at community housing premises in Flemington. She had a past medical history that included intravenous heroin use, hepatitis C, depression and anxiety. Ms Shauer had been unwell for several days prior to the 26th October and on the 25th, had been assisted by Mr Polistena to take approximately 0.3 of a gram of heroin, This was a normal quantity for her, however, during the course of the day she decided to lie down and rest as she wasn’t feeling well. Mr Polistena subsequently observed her to be asleep

and snoring, shortly after she had requested and been given medication for a headache.

3. Mr Polistena spent the evening drinking wine and when he went to bed at approximately 2.00.am, he observed Ms Schauer to be sleeping, with nothing untoward about her appearance. When he woke the next morning, he observed white foam at her mouth and that her breathing was abnormal. Mr Polistena arranged for ambulance attendance which culminated in her hospital admission.

4. A consideration for the court is whether Ms Schauer was "a person held in care", at the time of her death, within the meaning of the Coroners Act 1985. She had previously been on parole, with the order having commenced 6n 31st May 2006, and expiring on the 21st January,

5. Community Correctional Services, however, were monitoring the outcome of further offences allegedly committed during the operational period of her parole and again after the expiry date of her order. Whilst these matters had not been finalized at the time.of her death, f am satisfied she was not “held in care" when she died.

5. I formally find that Magdalena Schauer died of natural causes.

Signature: ~ ‘ a () Iain West

Deputy State Coroner Date: 22nd March, 2010

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