Finding into death of Ralph Graeme Keat

FORM 37 Rule 60(1)

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

(Amended pursuant to s76 of the Coroners Act 2008 on the 21st October, 2011)

Court reference: 1395/10

Inquest into the Death of RALPH GRAEME KEAT

Place of death: Kingston Centre, 400 Warrigal Road, Heatherton, Victoria 3202 Hearing Dates: 18 April 2011

Appearances: Sergeant Tracy Weir, Police Coronial Support Unit (PCSU) Findings of: CORONER AUDREY JAMIESON

Delivered On: 17 May 2011

Delivered At: Coroners Court of Victoria

Level 11, 222 Exhibition Street Melbourne Victoria 3000

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 1395/10 In the Coroners Court of Victoria at Melbourne I, AUDREY JAMIESON, Coroner having investigated the death of: Details of deceased: Surname: KEAT Firstname: RALPH Address: 71 Blackwood Avenue, Mentone, Victoria, 3194

AND having held an inquest in relation to this death on 18 April 2011 at Melbourne

find that the identity of the deceased was RALPH GRAEME KEAT and death occurred on 14 April 2010 at Kingston Centre, 400 Warrigal Road, Heatherton, Victoria 3202

from: la. UNASCERTAINED NATURAL CAUSES

in the following circumstances:

1. Mr Ralph Keat was born on 24 November 1945. He was 64 years of age at the time of his death. He lived with his wife of 38 years, Marie Keat, in Mentone. The couple have two (2) children, Mr Keat retired in 2002 after 40 years working as a Bank Officer at the National

Australia Bank,

2. Mr Keat’s medical history included a motor vehicle accident in 1968 in which he sustained a

frontal lobe injury which rendered him unconscious for approximately three (3) weeks and

resulted in loss of memory. He also had a history of hypertension, depression and insomnia. In

September 2009, he was diagnosed with frontal lobe dementia. Around the same time, while an

involuntary patient at Monash Medical Centre on 24 hour leave, he presented to the Emergency

Department with multidrug overdose. His medications at the time of his death included

Temazepam, Carbamazepine, Amiodarone, Oxazepam and multivitamin.

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3. On 12 April 2010, Mr Keat was admitted to the Biala Unit, Kingston Centre as an involuntary patient. His admission was precipitated by gradual worsening of his dementia observed by Mrs Keat to include bizarre and obsessive behaviour, withdrawal and possible hallucinations, odd eating and drinking habits associated with poor appetite and loss of weight, and insomnia. On admission his vital signs and blood tests were all within normal limits. Neurological examination showed some frontal lobe signs. His admission was for management of his frontal lobe dementia and possible psychoses.

4, On 13 April 2010, Mr Keat was visited by his wife. He appeared happy and settled into the unit. Mrs Keat left the Centre at approximately 4:00pm at which time Mr Keat was in bed. Over night Mr Keat was observed by nursing staff on an hourly basis. On each occasion up 5:45am he was observed in his bed asleep.

5. On 14 April 2010, at 6:50am, nursing staff entered Mr Keat’s room for a routine check. Mr Keat was not in his bed. The ensuite bathroom door was closed. The attending nurse assumed Mr Keat was using the toilet or shower and decided not to disturb him. At 7:50am, another member of the nursing staff entered Mr Keat’s room and discovered Mr Keat still absent from his bed, The bathroom door was locked and Mr Keat did not respond to his name being called. The member of staff unlocked the bathroom door and discovered Mr Keat sitting on a chair in front of the bathroom sink, slumped forward with his head in the basin and his arms hanging below. He was unresponsive. A Code Blue was called and cardio-pulmonary resuscitation commenced however, Mr Keat was unable to be revived. He was declared deceased at 8.05am by Dr Vanita Agarwal.

Investigation:

6, Dr Sarah Parsons, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed a full post mortem examination and ancillary tests but was unable to ascertain a medical cause of death. Toxicological analysis detected carbamazepine and temazepam at levels consistent with therapeutic usage. Post mortem electrolytes were considered non-contributory.

There were no signs of trauma. Dr Parsons commented:

Possible causes of death in cases where there is negative autopsy include cardiac arrhythmias, metabolic disturbances or seizures.

7. The Police investigation did not identify any suspicious circumstances.

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8. Mr Keat was a person placed in custody or care as defined in section 3 Coroners Act 2008!.

An Inquest was held in accordance with section 52(2)(b)2 of the Act. The Inquest was held by way of summary from Sergeant Tracy Weir, PCSU, Assisting the Coroner. No issues regarding the medical management of Mr Keat have been identified,

Finding:

In the absence of suspicious circumstances, evidence of self harm or abnormal toxicological analysis results, I find that Ralph Graeme Keat died from unascertained causes which in all probability, are related to natural causes. The cause of death has been re-recorded with Births,

Deaths and Marriages to reflect the same.

And I further find no relationship between the cause of Mr Keat’s death and the fact that he was immediately before his death, a person placed in custody or care.

Signature:

CORON: 21st October, 2011

Distribution of Finding: Mrs Marie Keat

The Chief Psychiatrist Southern Health

I person placed in custody or care means- (4) a patient in an approved mental health service within the meaning of the Mental Health Act 1986; or...

2s, 52(1) A coroner may hold an inquest into any death that the coroner is investigating.

(2) Subject to subsection (3), a coroner must hold an inquest into a death if the death or cause of death occurred in Victoria and-

(a) the coroner suspects the death was the result of homicide; or

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