Finding into death of Simon Mark Gray

Rule 60(1)

FORM 37

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court reference: 2648/08

Inquest into the Death of SIMON MARK GRAY

Delivered On: . Delivered At:

Hearing Dates:

Findings. of:

Appearances:

Place of death/

Suspected death:

SCAU

6 May 2010

Melbourne

9 April 2010

Coroner K.M.W. Parkinson

Mr P, Halley instructed by Ms K. Galanos of Holding Redlich Solicitors for Ms N. Gaitanis (Spouse)

4 Donald Street, Brunswick, Victoria 3056

Senior Constable K. Ramsey

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FORM 37 Rule 60(1)

) FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 2648/08

In the Coroners Court of Victoria at Melbourne

I, KIM PARKINSON, Coroner having investigated the death of: Details of deceased:

Surname: GRAY Firstname: SIMON MARK Address: 4 DONALD STREET, BRUNSWICK 3056

AND having held an inquest in relation to this death on 9 April 2010 at Melbourne ; find that the identity of the deceased was SIMON MARK GRAY and death occurred on 21st June, 2008

at 4 Donald Street, Brunswick, Victoria 3056

from la. COMBINED EFFECTS OF MULTIPLE DRUGS IN AN OBESE MALE WITH

FINDINGS SUGGESTIVE OF BRONCHOPNEUMONIA

In the following circumstances:

1. Mr Simon Mark Gray was 31 years of age, born 29 July 1976. He lived at 4 Donald Street, Brunswick with his wife, children and his mother. Mr Gray had been employed as a tow truck driver until 10 March 2006 when he suffered a significant injury during the course of his employment which resulted in him being incapacitated for work. He had: previously had an uninterrupted full time work history and had enjoyed working extensive houts and providing financially for his family. The evidence before me is that he took pride in his capacity to do. this and was proud of his ability to mcet his financial obligations.

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2. Injury to his spine was diagnosed as lumber disc prolapse and compression at L4, 85, S1 and S2. ‘After the injury, Mr Gray experienced significant pain for which he sought relief for the next 2 years. Surgery for his back injury was unsuccessful in relieving his pain, Mr Gray became increasingly anxious and depressed and more reliant upon medication for pain relief. He was attending his General Practitioner, Dr Zain Gorji and a number of other specialist practitioners for assistance with his pain management difficulties. He participated in rchabilitation programs and entered a pain management program for a short time. On occasions he expressed suicidal ideation and was admitted to psychiatric facilities for assistance.

3. His difficulties with pain, apparently compounded by his impatience to be well, caused him to be quite difficult to manage in a clinical sense. Mr Gray also apparently had difficulty in relating to and receiving assistance from some clinicians at various times.

4. Mr Gray had no history of depressive or any other mental illness, until his workplace injury. Nor did he have any prior history of substance abuse. It appears that he developed both a serious depressive illness and a significant reliance upon prescription medication after the injury

was sustained.

5, - On 6 June 2008, Mr Gray was admitted to the North Park Private Hospital psychiatric service by Dr Surya Tipirneni on the referral of Dr Gorji. His anxiety and depression had escalated and he was very distressed as a result of his inability to manage his pain. During the period of the admission he was treated by Dr Tipirneni. Mr Gray was a voluntary patient at North Park Hospital and therefore was not compelled to remain in the facility during his stay. During the course of his admission he did not actively participate in the various sessions available and was, in the latter stages of the admission, frequently absent during the day.

6. ‘The evidence is that he was anxious about erisuring that he had an adequate and continuing supply of pain relief medication. Dr Tipirneni described that Mr Gray’s personality type was such that it complicated his treatrnent for both pain management and substance reliance.

He noted that his reluctance to participate in counselling sessions whilst an inpatient did not assist his progress with the depressive illness. However his evidence was that in the absence of factors such as a significant pain and social dislocation as experienced by Mr Gray, his

personality type would be expected to function normally in the community,

7. Mr Gray was prescribed MS Contin 100mg bd, Efexor 375mg mane (increased al admission to 450mg mane), Seroquel 100mg nocte and 50mg prn, Diazepam 10mg tds and Xanax 10mg 1 bd. These medications had been prescribed by the GP and were reviewed and adjustment made by Dr Tipimeni during the course of his inpaticnt admission.

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8. I understood Dr Tipirneni’s evidence to be, that he was conscious of the dangers associated with the drugs, including depression of respiratory function and overdose, however having regard to his clinical status, pain management was necessary and in the absence of a pain management program, medication remained necessary. It was apparent that the depressive illness was intimately connected with the pain issue and social consequences and absent resolution of those issues the depressive illness would be unlikely to resolve.

9, Mr Gray was discharged from hospital with sufficient medication for one week, It is also apparent that during the course of his hospitalisation he had, whilst on day leave, attended his GP and obtained a prescription for that medication, which was dispensed.

10. Dr Tipirmeni accepted in his evidence that the multiple medications which Mr Gray was using and had become dependant upon were prescribed to him on account of:

(a) His unmanageable pain consequent upon his back injury; and

(b) His depressive illness sustained as a result of a number of factors including the unmanageable pain; his loss of participation in the community of work and his inability Lo provide in a manner he regarded as adequate for his spouse and

young family.

These matters wore heavily on Mr Gray.

11, We was discharged from the North Park hospital at 10.00am on 20 June 2008. He remained in severe pain. He had been recommended for referral to the pain management clinic at Royal Park however, as Dr Tipirneni explained in his evidence there was a lengthy waiting list, up to 12 months, to receive an assessment from that facility. In the meantime, Mr Gray was to continue with medication and do the best he could whilst awaiting treatment.

12, At approximately 11.30am Mr Gray and Ms Gaitanis arrived home from the hospital. Mx Gray complained of severe pain and indicated he was going to take some pain relief and lie down. Ms Gaitanis heard him taking his medication and had a discussion with him at approximately 4pm that day. When she called him for dinner he did not wake, He appeared to be in a deep sleep and she left him to sleep. At lam she noted that he was snoring. ‘The following morning, Mr Gray could not be roused. CPR was attempted by his mother, Mrs Gray, and by attending ambulance officers. Mr Gray was deceased.

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13: Police attended the scene. They identified numerous packets of prescription pain relief medication of varying prescribing and dispensing dates. A prescription dispensed for Oxycontin (morphine) dated 18 June 2008 was missing 16 tablets when located by policc. The prescribed dosage was 2. per day. It is apparent that Mr Gray was overmedicating and doing so T am satisfied in an attempt to relieve his pain. Police did not identify any suspicious circumstances connected with the death. , :

14. Dr Noel Woodford, Senior Forensic Pathologist with the Victorian Institute of Forensic Medicine, conducted an autopsy and reported that the cause of death was: 1(a) Combined effects of multiple drugs in an obese male with findings suggestive of bronchopneumonia. Dr Woodford’s evidence was that the identification of exact levels of certain drugs can be problematic in a post mortem context and that morphine is particularly so. However, his evidence was that the levels of diugs detected were consistent with therapeutic range and nol at excessive levels. He reported: Thus while the levels detected are consistent with therapeutic usage, the possibility that they have been contributory factors to the ultimate mechanism of death cannot be excluded, particularly since several of the drugs (including morphine, diazepam, alprazolam and ptopoxyphene) may combine to cause significant central nervous system (and respiratory centre)

depression.”

15, I am satisfied that this combisiation of medications in a person who had become significantly overweight, likely as a result of inactivity consequent upon injury, had the capacity to result in central nervous system and respiratory depression which may cause unconsciousness and death. The possibility of ante-mortem bronchopneumonia raises a further potential

compromise to his respiratory function.

16. There is no evidence before me to suggest that Mr Gray deliberately overdosed on this day. Whilst it appears that he took in excess of his prescribed dosage of pain relief, it is reasonable to conclude this was in response to his overwhelming pain and not in an attempt to take his own life. The evidence of the psychiatrist, Dr Tipirneni is that he was not suicidal or exhibiting suicidal ideation at the time of discharge. Whilst Mr Gray died less than 24 hours after discharge from the hospital, there is no evidence that would satisfy me that his discharge from hospital or its timing, caused or contributed to Mr Gray’s death.

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17. 1 find that Mr Simon Mark Gray died on 21 June 2008 of the combined effects of multiple drugs in an obese male with findings suggestive of bronchopncumonia, I find that his death was

accidental.

Signature:

Kim M.W. Parkinson Coroner Date: 6 May 2010

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