Finding into death of Alan Bishop

FORM 38 Rule 60(2)

FINDING INTO DEATH WITHOUT INQUEST

Section 67 of the Coroners Act 2008 Court reference: 4253/08 In the Coroners Court of Victoria at Melbourne I, PARESA ANTONIADIS SPANOS, Coroner, having investigated the death of:

Details of deceased: Surname: BISHOP Firstname: ALAN Address: 305/188 Canterbury Road, Canterbury, Victoria 3126

without holding an inquest:

find that the identity of the deceased was ALAN ERNEST BISHOP born on the ist July 1942,

and that death occurred on or about 21st September, 2008 at 188 Canterbury Road, Canterbury, Victoria 3126 from: l(a) INJURIES SUSTAINED IN FALL FROM HEIGHT

Pursuant to Section 67(2) of the Coroners Act 2008, an inquest into the death was not held and the deceased was not immediately before the person died, a person placed in custody or care; but there is a public interest to be served in making findings regarding the following circumstances:

1. Mr Bishop was a 66 year old man who resided at the above address with his partner of 32 years, Ms Faye Spinks. Mr Bishop had a past medical history which included Parkinson’s disease first diagnosed in 1994 and non-Hodgkin’s lymphoma in 2001. In the last six years before his death, the last two in particular, the symptoms of Parkinson’s disease were particularly debilitating for him. According to Ms Spinks, he never complained or spoke to anyone about it.

2. Mr Bishop was first seen in the Movement Disorder Clinic (the Clinic) at the Austin Hospital in 1998, but remained under the regular care of a private neurologist until 2006 when he commenced attending the Clinic for regular review, under the care of Mr Andrew Hughes, Neurology Consultant. According to Mr Hughes, by mid 2008, Mr Bishop was having a lot of difficulty with fluctuating motor functions. At times he could move fteely without major disability and at other times, usually associated with his anti-Parkinsonian medications wearing

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off, he had a lot of trouble with gait initiation, with frequent gait freezing. A number of medications were trialled with little improvement.

3. After discussions between Mr Bishop and Mr Hughes of the risks and benefits of a new treatment modality, a duodenal infusion of levodopa and carbidopa or "Duodopa",! Mr Bishop elected to go ahead with the treatment. A percutaneous endoscopic jejunostomy (PEJ) tube was inserted on 19 August 2008 which allowed infusion of a gel preparation directly into the duodenum to improve absorption and consistency of motor response to the drug.

4, Initially, Mr Bishop’s motor function appeared to respond well to the treatment, although he was experiencing some sedation. At a review in the Clinic on 10 September 2008, Mr Bishop said he had continued to experience daytime sleepiness but his motor response was very good.

According to Ms Spinks, the new treatment enabled Mr Bishop to walk without a frame, in a distorted way, so long as he wore the belt/cassette through which the Duodopa was administered.

Once he took the belt off he could not walk.

5. Ms Spinks last saw Mr Bishop alive at about 8.00pm on Saturday 20 September 2008 when she went to bed and left him watching the football on television. The following morning, when Ms Spinks realised Ms Bishop was not in the apartment, she started looking for him.

Seeing his walking frame at the foot of the bed and his medication belt on the floor, she thought he could not have gone far. Ms Spinks noticed that the sliding door from the lounge to the balcony was closed but not locked as it usually was. She went out and looked over the balcony and saw Mr Bishop lying on the ground floor below. Mr Bishop was deceased and had bled from a head injury.

6. Police attended at about 11.30am and commenced their investigation of Mr Bishop’s death. They identified "disrupted dust" on the balcony railing of apartment 305 immediately above the place where Mr Bishop lay. They found no suicide note, and no signs of disturbance within the apartment or anything else to suggest that any other person was involved in Mr Bishop’s death. Ms Spinks advised that without his walking frame and medication belt on, Mr Bishop would have to have crawled to reach the balcony railing.

7. An autopsy was performed by Senior Forensic Pathologist Dr Matthew Lynch from the Victorian Institute of Forensic Medicine (VIFM) who identified multiple bruises, abrasions and lacerations to the head with compound fracturing of the skull and parenchymal brain injury with lacerations, subarachniod, intraventricular and intraparenchymal haemorrhage, as well as multiple rib and limb fractures. Dr Lynch noted the results of postmortem toxicological analysis which showed the anticonvulsant phenytoin and paracetamol at levels consistent with normal therapeutic use. He attributed Mr Bishop’s death to injuries sustained in fall from height.

1 “Duodopa contains levodopa and carbidopa, a common combination of medicines used to treat Parkinson's disease, It is available in a gel formulation which is administered via a tube direclty into the intestive. It is intended for patients with advances idiopathic Parkinson’s disease with severe motor fluctuations despite optimised alternative pharmacological treatment," Excerpt from response to request for information from the Therapeutic Goods Administration dated 18 January 2010. See following footnote,

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8. This finding is based in part on the brief of evidence compiled by one of the police officers who attended the scene, Leading Senior Constable Paolo Cabai from Camberwell Police.

The statement of Mr Andrew Hughes, Consultant Neurologist, refers to a syndrome which occurs in Parkinson’s disease called Rapid Eye Movement Sleep Behaviour Disorder (REMSBD) - “where patients can act out their dreams during sleep and become physically quite active including, being ambulant, and where patients have in fact injured themselves.” He also noted that Mr Bishop had not previously been known to have this syndrome nor had this been reported to him on any review and that there was no indication that Mr Bishop was depressed, The absence of any indication of depression was consistent with the statement of Dr Tony Michaelson, a General Practitioner who had treated Mr Bishop from 1985, but less frequently since his move to Camberwell in 2004.

9, The possibility that REMSBD, whether arising from Parkinson’s disease or the Duodopa treatment, may have contributed to Mr Bishop’s death was investigated. The Therapeutic Goods Administration (TGA)2 was asked to advise about any known correlation between Duodopa and REMSBD. They advised that -

"Levodopa, a component ef DUODOPA is known to be assaciated with somnolence and episodes of sudden sleep onset in patients with Parkinsons’ disease but not specifically with disturbances in REM sleep. Levodopa may cause mental disturbances. These reactions are thought to be due to increased brain dopamine following administration of levodopa...It’s possible that abnormal sleep behaviour may be a presentation of mental disturbance due to the increased brain dopamine. These reactions are relatively common in patients with advanced Parkinson’s disease."

10. ‘In response to a similar request, Solvay Pharmaceuticals Australia? outlined its researches and advised that -

"In summary, there have not been any cases of REM Sleep Behaviour Disorder associated with Duodopa treatment and there is no indication of a correlation between this condition and Duodopa treatment specifically from the currently available data,"

11. An independent expert report was sought from Professor Olaf Drummer, Head (Forensic Scientific Services), Victorian Institute of Forensic Medicine (VIFM). He also searched the literature and found no reports associating REMSBD and the use of Duodopa. He added that:

“However, it is known that patients with Parkinson’s disease do experience sleep disturbances as well as other autonomic symptoms such as restless legs syndrome and rapid eye movement sleep behaviour disorder."

Part of the federal Department of Health and Ageing.

Response dated 18 January 2010 from Dr Sophie Glover-Koudounas, Medical Director and Head Medical & Regulatory Affairs ANZ, Solvay Pharmaceuticals Australia.

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12, Based on the totality of the material available to me, I find that Mr Bishop died as a result of injuries he sustained when he fell from his third floor balcony to the ground below. There is insufficient evidence to support a finding that he fell or jumped from this height with the intention of taking his own life, although the possibility cannot be excluded, Similarly, there is no evidence that his Duodopa treatment caused or contributed to his death. The possibility that REMSBD associated with his Parkinson's disease may have caused or contributed to his death also remains open.

Signature:

PARES ANTONIADIS SPANOS CORONER

Date: 20th May 2011

ce: The family of Mr Alan Bishop The investigating member, LSC Paolo Cabai c/o Camberwell Police

Mr Andre Hughes, Consultant Neurologist c/o Movement Disorder Clinical, Austin Health

Dr Sophie Glover-Koudounas, c/o Solvay Pharmaceuticals Australia

Mr Pio Cesatin c/o Office of Prescription Medications, Therapeutic Goods Administration, Commonwealth Department of Health and Ageing

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