Finding into death of Hannah Paige Pain Fowler

Rule 60(1)

FORM 37

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court reference: 2054/08

Inquest into the Death of HANNAH PAIGE PAIN FOWLER

Delivered On:

Delivered At:

Hearing Dates:

Findings of:

Representation:

Place of death:

18th May, 2011

Coroners Court of Victoria Level 11, 222 Exhibition Street, Melbourne 3000

15th, 16th November, 2010 at County Court, Melbourne

HEATHER SPOONER Mr J.R. Champion appeared on behalf of Gary Fowler

Royal Children’s Hospital 50 Flemington Road, Parkville 3052

Police Coronial Support

Unit (PCSU):

Sergeant Tracey Weir

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FORM 37 Rule 601)

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

Court reference: 2054/08 In the Coroners Court of Victoria at Melbourne I, HEATHER SPOONER, Coroner having investigated the death of: Details of deceased:

Surname: FOWLER

Firstname: HANNAH

Address: 21 Chardonnay Drive, Skye 3977 AND having held an inquest in relation to this death on 15th and 16th November, 2010 at County Court, Melbourne

find that the identity of the deceased was HANNAH PAIGE PAIN FOWLER and death occurred on 15th May, 2008

at Royal Children’s Hospital, 50 Flemington Road, Parkville 3052

from

la. SEPSIS

1b, ACUTE PERITONITIS

1c, PERFORATED GANGRENOUS ACUTE APPENDICITIS

in the following circumstances:

Brief Background

1. Hannah was aged just 11 when she died. She lived at 21 Chardonnay Drive Skye with her father Gary Fowler, her half sister Samantha, Gary’s partner Sheonagh Donaldson and her two children (Megan and Thomas) plus a boarder, Christopher Hemer. Mr Fowler and Ms Donaldson and their respective children had commenced living together about cleven months prior to Hannah’s death.

2. Pursuant to a Family Court agreement between Hannah’s mother, Julie Pain and Mr Fowler, Ms Pain apparently had contact with Hannah every second weekend, during school holidays and by telephone every Wednesday. Hannah was a Year 6 student at Rowellyn Park Primary School, Carrum Downs. She was apparently in good health and well nourished prior to her demise.

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Chronology of Circumstances Leading up to Death

On Friday 9 May Ms Pain collected her daughter for an access visit over the Mothers Day weekend. She appeared well. Hannah shopped, ate dinner and watched movies.

On Saturday 10 May they went out shopping together and visited friends before returning home. That afternoon Hannah played on the computer and had a quiet early night, Although Hannah ate normally Ms Pain noticed she seemed a little more tired than usual,

On Sunday 11 May (Mothers Day) Hannah made her mother breakfast in bed. They went to a local nursery where they met up with Hannah’s grandmother, Mrs Anne Mooney. Later that day they had dinner to celebrate Mothers Day at the home of Mr & Mrs Mooney. Hannah enjoyed a swim in their pool before eating her dinner. Although Hannah made no mention to her mother, she did complain to her grandmother of pain in the lower part of her stomach.

Mrs Mooney thought Hannah may have wanted to talk about the commencement of period pain which she had discussed with her granddaughter sometime prior, As Hannah left she told her grandmother that she would call her on Tuesday. Ms Pain returned Hannah to her home at about 8pm that night. She seemed happy. Hannah had a second meal that evening at her home and afterwards she told Ms Donaldson that she had a pain in her stomach.

On Monday 12 May Hannah went to school. That night she ate less than usual and during the night she suffered two episodes of vomiting. It was assumed that Hannah had contracted gastroenteritis that the boarder, Mr Hemer, suffered the week before.

On Tuesday 13 May Hannah stayed home from school, That night she only wanted chips for dinner, She complained to her father of pain down her gro. She was given panadol and a heat pack. That evening she vomited again. Her father and Ms Donaldson assumed she must have eaten a caramel slice.

On Wednesday 14 May Hannah stayed home from school again. Hannah complained of pain to the top of her stomach but was not vomiting. She only wanted toast for dinner.

On Thursday 15 May Hannah again stayed home from school. She complained of pain to her stomach. Later that morning Ms Donaldson was concerned about what Hannah described as vomit in the bucket in her bedroom and indicated she would ask her father to take her to a doctor. Hannah asked if she could shower and whilst she was in the bathroom Ms Donaldson heard a loud thump. She found Hannah moaning on the floor. Ms Donaldson called Mr Fowler and left a message for him to come home and assist. After he arrived emergency services were notified and attended. Paramedics tried to resuscitate Hannah at her home and arranged a helicopter transfer to the Royal Childrens Hospital. Despite intensive medical efforts and a brief return of output Hannah could not be revived and she passed away at 2.24 pm that afternoon.

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Issue at Inquest

3, The Inquest focussed on the apparent failure to obtain medical assistance for Hannah during the course of her brief illness leading up to her death.

Evidence at inquest

4, Dr Woodford Senior Forensic Pathologist VIFM told the Inquest that the sepsis causing Hannah's death could have developed over a matter of hours. It was the end result of a complex series of events following on from the appendix being obstructed by natural causes, becoming inflamed, necrotic, gangrenous and rupturing into the abdominal cavity. He indicated that a grumbling appendix (with pain coming and going) could occur over a number of days however once the appendix ruptured, acute peritonitis and sepsis could occur over a period of hours. He emphasised that the presentation could be incredibly variable with possibly vague, non-specific or minimal symptoms at the outset. He stated that fever (ranging from minor to significant) was a usual associated sign or symptom of appendicitis. Abdominal pain was also a typical symptom.

Loss of appetite, vomiting, groin pain and diarrhoea were all possible symptoms. Dr Woodford told the inquest that the diagnosis of appendicitis could be difficult. By contrast the diagnosis of gastroenteritis may not be associated with abdominal pain but some of the symptoms might be similar to appendicitis, Dr Woodford was unable to comment on whether a child with pain should expect to be taken to a doctor. At p.26 of the Transcript he stated, "...pain is a subjective thing, I don’t know how severe the pain was, whether it came and went over those three days, whether it was constant, unremitting, increasingly severe.... but to a lay observer if the person appeared sweaty, unwell, off colour, grey, those would be more worrying signs."

5. Ms Pain told the Inquest that she dropped Hannah home on Sunday as she always did. Over the weekend she had a normal appetite and her health was good, Hannah had not complained of being ill, Ms Pain had Hannah on her Medicare card but she had no reason to take her to a doctor. Ms Pain had not rung her daughter on Wednesday evening as planned because it got too late and she had planned to ring Thursday evening instead. According to Ms Pain she was unaware that her daughter was ill or away from school until it was too late.

6. Mrs Mooney gave evidence consistent with her daughter regarding their activities on Mothers Day. She told the inquest that Hannah had a hot shower after swimming in her pool and it was then that she complained of pain and pointed to the bottom of her stomach. Hannah got dressed and did not mention it again. Mrs Mooney told the inquest that she had recently spoken to Hannah about starting periods. Mrs Mooney thought Hannah may have wanted to talk about periods again because she had indicated to Hannah during their prior conversation that she may have some pain associated with her period. Later Hannah had seemed fine, helping out with laying the table for dinner and enjoying a pasta meal together. As she left with Ms Pain, Hannah had said that she would phone her grandmother on Tuesday evening but unfortunately the call never came.

7. On Thursday Mrs Mooney was called to Hannah’s home and both Mr Fowler and Ms Donaldson were saying how sorry they were and they should have taken Hannah to the doctor.

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Mrs Mooney told the inquest that Ms Donaldson had indicated she left Hannah with Mr Hemer that morning and when she returned and saw Hannah stumbling to the shower she had thought it was because Hannah had been in bed so long.

8. Mr Mooney told the Inquest that whilst Mr Fowler may have tried to be a good father and was obviously loved by Hannah, the degree of his discipline and instances of bullying caused he and his wite some difficulty, He confirmed that Hannah had seemed well prior to Ms Pain returning her to Mr Fowler on Sunday evening. When he arrived at the scene the following Thursday the final outcome was still unknown and he offered some comfort to Mr Fowler.

However when Mr Fowler told him that he should have taken Hannah to the doctor and was trying to toughen her up, Mr Mooney walked away.

9, Ms Donaldson told the inquest that she was not at home when Hannah had been returned on Sunday night. When she heard of the stomach pain she mentioned it to Mr Fowler who was already aware of it. Ms Donaldson thought it may be due to indigestion from cating two dinners or from possibly hitting her stomach whilst swimming in the pool.

10, On Monday morning Hannah had eaten her breakfast and walked off to school without complaint. That evening Hannah did not eat all her dinner and at about 9,30 she told Mrs Donaldson that she had vomited. It was then that she presumed Hannah was suffering from Mr Hemer’s gastroenteritis. An hour later Hannah vomited for a second time. Ms Donaldson had run out of bed linen from the earlier vomit and gave Hannah a sleeping bag and bucket should she be sick again,

11. On Tuesday morning there was nothing in the bucket but as Hannah had been sick Ms Donaldson kept her home from school. Samantha apparently stayed home to care for her whilst Mr Fowler and Ms Donaldson went to work, When Ms Donaldson returned home Hannah was in bed watching TV and told her that she still had a pain in her stomach, She only wanted hot chips for dinner,

12. That evening Ms Donaldson heard Hannah complain to Mr Fowler of a pain running down her groin and right leg. Later Hannah emerged from her bedroom and vomited again, When questioned about her vomit Hannah apparently said she hadn’t eaten anything but the colour of the vomit led Ms Donaldson and Mr Fowler to believe she must have consumed a caramel slice.

13. On Wednesday Hannah was kept home again with Samantha to look after her. She still had what Ms Donaldson described as a niggling pain in her belly and Hannah had called it a sore pain. Ms Donaldson would have sent her to school had she not vomited the night before. That afternoon Hannah continued to complain that her stomach still hurt indicating the top of her stomach. Ms Donaldson assumed it was due to Hannah being hungry. She went to the shop and bought her a fresh bottle of water. Hannah only wanted toast for dinner but could get up and go to the toilet and fill her water bottle.

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14, On Thursday morning Ms Donaldson asked Hannah how she was feeling as she had apparently asked her daughter Megan if she should get up to go to school. Hannah was worried about missing her T-Ball practice but Ms Donaldson thought she should have one more day at home while Hannah complained that she still had a bit of a pain in her tummy.

15, Ms Donaldson had an appointment at 9.30am in Cranbourne and although Mr Hemer thought he did not get home until 11am she maintained he was there when she left. When she returned she checked on Hannah. The contents of Hannah’s bucket and her concern about possible dehydration led to a decision that she would tell Mr Fowler when he rang as usual around midday that she should see a doctor.

16. Ms Donaldson told the inquest she suggested to Hannah that they could just jump in the car and go to the doctor but Hannah wanted to have a shower, Ms Donaldson stated that Hannah had walked normally to the shower without difficulty and denied telling Mrs Mooney that Hannah had been wobbly . She was at her computer for five minutes when she heard a thump in the bathroom. Ms Donaldson described the difficulty opening the door and she thought that Hannah might have slipped or collapsed.

17. Hannah was moaning, speaking quickly, mumbling her words and trying to get up. Ms Donaldson saw brown liquid coming from her mouth. Although in retrospect Ms Donaldson realised she should have been very concerned she had never experienced anything like it. She rang Mr Fowler and left a message which she claimed he immediately responded to. Ms Donaldson estimated it to be no more than five minutes from the time Hannah collapsed until Mr Fowler came home. She had no explanation for not phoning triple 0 and acknowledged making a mistake in not accepting Mr Hemer’s suggestion to do so. She apologised for that lapse.

Just prior to Mr Fowler’s arrival, Hannah stopped responding,

18. Although Ms Donaldson knew nothing about appendicitis she had dismissed an earlier query (probably on Tuesday) about it from Mr Fowler based on the position of the pain.

19. Ms Donaldson told the inquest she thought Hannah had just been suffering gastroenteritis - a ‘48 hour thing and she would be fine.’ Mr Hemer had recently had it and her own children had suffered from it in the past.

20. Ms Donaldson was not shy about going to a doctor and there was a bulk billing clinic nearby.

She had never known Hannah to vomit prior to this incident and when shown a photo of the contents of the bucket taken by the investigator on Thursday, Ms Donaldson did not recall seeing it all.

21. Mr Hemer told the inquest that he had been living with Mr Fowler and his family for about six months prior to this incident. He went to the doctor on either 7 or 8 May after a day or two of illness with vomiting. He was diagnosed with gastroenteritis which he suffered for about four or five days altogether. He was prescribed Stemetil to stop the vomiting.

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22, On Tuesday he was aware that Hannah was ill and found her sleepy when he popped into her room to check.

23. On Wednesday when he went to her room she was asleep. He had not considered whether she had been infected following his gastroenteritis.

24, On Thursday he believed he had gone to work as usual but when pressed could not recall if he may have taken the day off to look after Hannah. He saw Hannah ask Ms Donaldson if she could shower. Hannah was not staggering but did have her hand over her stomach. Later Mr Hemer responded to Ms Donaldson’s call for assistance after Hannah fell. Mr Hemer said he ‘freaked out’ and ‘froze’ when queried about not immediately calling an ambulance. He had however suggested it to Ms Donaldson. Mr Hemer told the inquest that Hannah was not unlike most kids in that she occasionally pretended to be sick. Otherwise he felt she appeared to be a very happy and healthy girl.

25, Counsel for Mr Fowler sought and was granted a certificate of indemnity for Mr Fowler to give evidence pursuant to s.57 Coroners act 2008.

26. Mx Fowler told the Inquest that on Monday 12 May he had started a new job as a process worker just five minutes from home. He expressed some concerns about Hannah’s behaviour and described her as a ‘lazy girl’ who needed to be pushed. According to Mr Fowler she was overweight and he monitored her intake with small meals. He also thought Hannah was vague and insufficiently focussed. Mr Fowler had taken her to Monash Medical Centre a few years prior for an assessment but was told that it was too early to diagnose any form of schizophrenia.

He told the inquest that on too many occasions Hannah tried to have a day off school but he did not disagree with the school records relating to Hannah’s absences.

27, Mr Fowler maintained that in the days prior to her death Hannah did not display signs of serious/excruciating pain stating ‘Hannah has cried wolf too many times with me’. She had apparently declined his offer to take her to a doctor when she complained of pain. He thought it was gastroenteritis. Mr Fowler maintained that Hannah was returned home Sunday evening by Mrs Mooney, Although Hannah seemed fine Sunday he had agreed that the pain in her stomach would be monitored. Mr Fowler also stated that Hannah had ‘appeared to feel sorry for herself/quiet’.

28, On Monday evening he assumed Hannah was suffering Mr Hemer’s gastroenteritis when she declined her dinner and had diarrhoea. Mr Fowler had obtained some water for Hannah and thought that she was spitting into the bucket to make it look like she had vomited. He gave her a panadol and hot water bottle when she complained of pain in her inner thigh. He agreed that he had not mentioned two additional episodes of vomiting on Monday night in his statement.

29. On Tuesday evening both he and Ms Donaldson thought that the further episode of vomiting

was due to Hannah eating a caramel slice because he had checked the fridge and found one missing. He disputed telling the police that Hannah had suffered a fever but on Tuesday evening

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he did think Hannah had a bit of a temperature because she was clammy and sweaty which he put down to her being wrapped up in her doona.

30, On Wednesday and Thursday Mr Fowler considered sending Hannah back to school as she had appeared to be her normal self, even improving.

31, On Thursday when he received a call from Ms Donaldson at work he had chosen not to answer it as he was close to a lunch break. When he did ring her back he immediately left his workplace and went home. Upon his arrival he saw Hannah on the floor and assumed straight away that it was serious and got onto tripic 0.

32. In his statement Mr Fowler referred to a conversation with Mr Mooney where he acknowledged saying ‘if only I’d got off my backside and known how serious it was I would have taken her to the doctor. No-one knew how serious it was though’. He also told the Inquest that he agreed with Mr Mooney’s assertion that he also stated he was trying ‘to toughen her up.’

33. Despite his earlier evidence he denied thinking that Hannah had been pretending to be sick but he never thought that it was serious, He had raised with Ms Donaldson the possibility of Hannah having appendicitis however he really had no idea and did not appreciate the potential seriousness of the disease, He just put it down to gastro for which he himself had previously sought medical help.

34, Mr Fowler felt that Hannah would have been too embarrassed to talk about the possibility of period pains with him and he could not recall if she had ever vomited in the past. It was some time since he had last taken her to a doctor.

Post Mortem Examination

35. Dr Woodford performed an autopsy and formulated the cause of death. In his report he made the following Comments:

"The cause of death in this 11 year old female is natural disease and related to the presence of significant peritoneal pathology, There was evidence of perforated acute gangrenous appendicitis with rupture into the peritoneal cavity and the development of acute peritonitis, This has resulted in sepsis and a significant degree of dehydration with renal functional impairment, The appendicitis appears to have been caused by impaction of a faecolith within the neck of the appendix.

The deceased appeared to be a normally developed and well nourished prepubescent Jemale and, within the limits of examination, there was no contributory natural disease

identified.

There was no cardiac pacemaker present in the body."

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Findings

I find that Hannah suffered stomach pain, diarrhoea, vomiting, loss of appetite, symptoms of an elevated temperature and general malaise in the days leading up to her death.

I find that whilst Mr Fowler and Ms Donaldson may have initially thought Hannah was suffering gastroenteritis they also considered the possibility of appendicitis, They had sought medical assistance for gastroenteritis in the past for themselves (Mr Fowler for himself and Ms Donaldson for her children) and it could have been easily obtained for Hannah, Although Mr Fowler told the Inquest that Hannah had declined his offer to take her to a doctor on Tuesday that decision should never have been left with an eleven year old child.

I find that where there were any discrepancies in the witnesses statements and evidence, it was Mr Fowler and Ms Donaldson who were mistaken.

I find that both Ms Donaldson and Mr Fowler sought to doubt and minimise Hamnah’s symptoms and subsequent medical decline.

T find the cvidence of Dr Woodford about the course of Hannah’s illness leading to her death was clear.

I find that had Hannah received the medical attention she so urgently required, she may have survived the appendicitis or peritonitis and made a full recovery.

I find Mr Fowler’s utterances that he should have taken Hannah to the doctor and that he was trying to toughen her up were very telling against him and revealed either a callous disregard or tough love gone terribly wrong,

I find the failure to obtain prompt medical attention for a sick, young, vulnerable child with persisting symptoms has led to her ultimate needless death.

COMMENTS: Pursuant to s.69(2) Coroners Act 2008 I direct the principal registrar notify the Director of Public Prosecutions pursuant to s 49 (1) of the Act,

Signature:

Heather Spooner Coroner

Date: 18th May, 2011

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