Finding into death of Glenn Raymond Johns

Rule 60(1)

FORM 37

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court reference: 2085/08

Inquest into the Death of GLENN RAYMOND JOHNS

Delivered On: Delivered At: Hearing Dates:

Findings of:

Representation:

Place of death:

5 March 2010

Melbourne

5 March 2010

AUDREY JAMIESON, Coroner

L/S/C Greigory McFarlane, SCAU, Assisting the Coroner

Box Hill Hospital, Nelson Road, Box Hill

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008

Court reference: 2085/08 In the Coroners Court of Victoria at Melbourne, I, AUDREY JAMIESON, Coroner having investigated the death of: Details of deceased:

Surname: JOHNS

First name: GLENN RAYMOND

Address: 29 Berry Street, Box Hill North, 3129

| AND having held an inquest in relation to this death on 5 March 2010 at Melbourne

find that the identity of the deceased was GLENN RAYMOND JOHNS and death occurred on 17 May 2008

at Box Hill Hospital, Nelson Road, Box Hill

from:

la. ASPIRATION PNEUMONITIS IN A SETTING OF LENNOX-GASTAUT

SYNDROME

in the following circumstances:

1. Mr GLENN RAYMOND JOHNS was born on 24 February 1967. He was 41 years old at the time of his death, He resided at a Department of Human Services supported accomodation facility in Berry Street, Box Hill.

2. Mr Johns had a medical history which included intellectual disablity, duodenal ulcers, numerous bouts of aspiration pneumonia consequent of severe gastro-oesphageal reflux, a PEG!

tube inserted in 2002 and Lennox-Gastaut syndrome2. His disabilities were such that he was unable to walk or stand and he was fully bed bound. Mr Johns was non-verbal and entirely dependant on his carers.

IPEG = percutaneous endoscopic gastrostomy

2 Lennox-Gastaut syndrome is a form of epilepsy characterised by childhood onset of frequent seizures and developmental delay.

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3. On 5 May 2008, Mr Johns was admitted to Box Hill Hospital with vomiting after a PEG feed.

The provisional diagnosis was aspiration pneumonia. This was his 64th admission for this condition. He was treated with intravenous antibiotics, steroids, oxygen and chest physiotherapy.

PEG feeds were stopped.

4, On 7 May 2008, Mr Johns’ PEG feeds were recommenced at a lowered rate and delivered while he remained in an upright position.

5. On 8 May 2008, PEG feeding was recommenced but discontinued after 90 minutes due to the onset of coughing. A gastroscopy was scheduled for the following day to check the position of the PEG and consider replacing it with a PES? feeding tube. The PEG was manually repositioned and PEG feeding recommenced. At 10,00pm, Mr Johns redeveloped signs of aspiration pneumonia requiring treatment with suction and bronchodilators. Antibiotics continued.

6. On 9 May 2008, Mr Johns was not well enough to undergo the scheduled gastroscopy. He remained ‘nil by PEG tube’. ‘A Not for Resuscitation’ order was put in place following consultation with his family. Intravenous fluids and medications continued.

7, On 10 May 2008, Mr Johns had an episode of haematemesis and melena which was treated with fluids.

8. On 13 May 2008, following some improvement in his condition, Mr Johns proceeded to gastroscopy where a BARD jejunal feeding tube was inserted via the PEG. On the following day, its position was confirmed and feeding commenced.

9. In the following days Mr Johns’ condition again deteriorated. On 17 May 2008, there was a rapid deterioration which was unresponsive to numerous treatment modalities. A decision was made to palliate him. Mr Johns died at 1.40pm. His family were present at the time of his death.

10. Mr Johns’ death was reportable* because immediately before his death, he was a person held in care as it is defined in section 3 Coroners Act 1985.

11, Dr Mathew Lynch, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an external examination and reviewed a post mortem CT scan. Dr Lynch reported that his findings were consistent with the recorded circumstances of Mr Johns’ death. Dr Lynch attributed the cause of death to aspiration pneumonia in the setting of Lennox-Gastaut Syndrome.

SPEJ = percutaneous endoscopic jejunostomy = feeding tube passed into the top part of the small bowel (jejunum) just below the stomach.

4 “reportable death” means a death -

(a) where the body is in Victoria; or

(b) that occurred in Victoria; or

{c) the cause of which occurred in Victoria; or

(d) of a person who ordinarily resided in Victoria at the time of death - being a death -

(e) that appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from accident or injury; or...

(i) of a person who immediately before death was a person held in care; or...

"person held in care" means-

12, The Clinical Liasion Service (CLS)® was requested to review the management of Mr Johns immediately before and during his last admission to Box Hill Hospital including the management of the PEG tube and timing of the insertion of the PEJ tube. Statements were obtained from the Director of Clinical Goverance, Box Hill Hospital, Dr Patricia Molloy, Mr Johns’ general medical practitioner, Dr T. R. Vanderzeil, Mr Marco Balestra, carer, and Associate Professor Christopher Gilfillan, Director of Endocrinology, Eastern Health. CLS did not identify any issues of concern with Mr John’s clinical management.

COMMENTS:

Pursuant to section 67(3) of the Coroners Act 2008, J make the following comments connected with the death:

1. I am satsified that there is no relationship between Mr Johns death and the fact that immediately before his death he was a person held in care.

2. Lam satisfied that the medical mangement of Mr Johns at Box Hill Hospital was reasonable and appropriate in the circumstances, He had complex medical issues and co-morbities rendering his management extremely challenging for his health care providers.

Finding:

I accept and adopt the medical cause of death identified by Dr Lynch and find that GLENN RAYMOND JOHNS died from aspiration pneumonitis in a setting of Lennox-Gastaut syndrome.

Signature:

AUDR CORONER 5th March, 2010

Distribution of Findings

• Mr Raymond Johns

~ Director of Medical Services, Box Hill Hospital

• Department of Human Services, Disability Services Division

6The role of the CLS is to assist the Coroner’s investigation into the nature and extent of deaths which occurred during the provision of healthcare, and identify potential system factors in healthcare related deaths, CLS personnel comprise of practising Physicians and Clinical Research Nurses who draw on their medical, nursing and research experiences, skills and knowledge to independantly evaluate clinical evidence for the investigation of reportable healthcare deaths and to assist in identifying remediable factors that may assist in prevention and risk management in health services settings.

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