Finding into death of Geordie Rose Duguid

FORM 37 Rule 60(1)

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

Court Reference: 1548/2010 Inquest into the Death of Geordie Rose Duguid

Delivered On: 15 September 2011 Delivered At: Sale Coroners Court Hearing Dates: 22 July 2011

Findings of: HC Alsop

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court Reference: 1548/2010 Tn the Coroners Court of Victoria at Sale

1HC Alsop, Coroner having investigated the death of:

Details of deceased:

Sumame: Duguid First name: Geordie Rose Address: 26 Pearson Street Maffra VIC 3860

AND having held an inquest in relation to this death on 22 July 2011 at Sale Coroner's Court find that the identity of the deceased was Geordie Rose Duguid and death occurred on 25 April 2010 at 10 Boisdale Street, Maffra from

la Myocardial fibrosis (post myocarditic)

1. Geordie was 16 years old at the time of her death and lived with her family in Maffra.

2. As a young child she had been relatively healthy. When she was 3 years old she was diagnosed with a mild form of asthma, which evidenced itself usually after a cold and caused her “to get wheezy if she got chest infections.” It was her practice to carry ventolin if required.

3. Late in 2009 Geordie became unwell — in the words of her mother, “she was tired all the time and run down.” She sought medical assistance, underwent some tests and it was discovered that she had had glandular fever. More recently, she was tested for allergies and found to have a mild intolerance to some domestic animals. These allergy tests and their results are not relevant to this enquiry.

ll.

Geordie did not smoke cigarettes. There is no evidence of her ever being involved with illicit drugs, and on the rare occasions she consumed alcohol, she only drank alcohol in moderation.

On the evening of 24 April 2010, Geordie and some friends attended a 16th birthday party at 10 Boisdale Street, Maffra.

They arrived at about 9.30pm,

It appears she had a small amount of alcohol at the party - probably cask wine with fruit juice. Subsequent tests showed a very small blood alcohol reading, There is nothing before me to indicate that she was affected in any way by alcohol. These tests also confirmed there were no illicit substances or drugs in her system.

At about midnight, Geordie went to the toilet which was inside the home. The toilet door lock was faulty and it was necessary for someone to be outside the toilet with a key in case the door could not be opened from the inside.

Shortly after she entered the toilet Geordie was heard to vomit.

She did not respond to calls from outside the toilet so the door was opened to let Mrs Karen Willins into the toilet to check on Geordie, Geordie was found on the floor. Her clothing indicated she had collapsed either whilst still sitting on the toilet seat or immediately upon standing up. She was unresponsive and gasping intermittently, In the words of Mrs Wilkins, “her eyes were open, but she wasn’t seeing me,”

A 000 call was made almost immediately and instructions on CPR were relayed to both Mr and Mrs Wilkins and carried out.

Despite their efforts, Geordie did not respond.

Ambulance records show that the Ambulance Operations Centre received the 000 call from the party at 12.10am. This call was transferred by pager to the Maffra Ambulance Station at 12.11am. The ambulance arrived at the Boisdale Street address at 12,15am with paramedic David Booth on board.

Very shortly after his arrival, two police officers, Senior Constable Peverill and Leading Senior Constable Gloster arrived and commenced CPR with Mr Booth. Mr Booth placed cardiac monitor leads on Geordie, The monitor showed she was asystolic.

At this time, paramedic Debbie Ray was travelling from Latrobe Regional Hospital (Traralgon/Morwell) towards her ambulance base at Bairnsdale. She was east of Rosedale and heard radio traffic relating to Geordie. Being aware that Mr Booth was on his own at the scene, Ms Ray asked for instructions by radio as to whether she should assist Mr Booth — she was directed to do

so and arrived on scene fifteen minutes later to find Mr Booth and the two police officers conducting CPR on Geordie.

13. Further ambulance officers arrived some five minutes later.

14, The HELIMED helicopter ambulance arrived at about 1.00am with MICA Officer Davidson on board. He carried out further treatment but Geordie remained asystolic. Resuscitation was then discontinued.

15. The officers worked on Geordie for some 90 minutes. She was given adrenaline, absotine, sodium bicarbonate and 1800mls of fluids during this time. Despite these efforts, there was no change in the vital signs observed by Mr Booth and then Ms Ray on her arrival at the scene.

16. A post mortem examination was carried out by Doctor Melissa Baker on the 1 May 2010 at the Coronal Service Centre, Southbank. Her report concludes with the following comments:-

“The cause of death in this sixteen year old girl is myocardial fibrosis (scarring of the heart muscle), There are many causes of myocardial fibrosis, however in this case, the underlying cause appears to be a previous episode of myocarditis. Myocarditis refers to inflammation of the heart muscle and has many causes including infectious, toxic and immunologic. Infectious causes are the most common with viruses being by far the most common causative agent, Many viruses can cause myocarditis, including Epstein-Barr virus, the causative agent of infectious mononucleosis or glandular fever. It is noted that the deceased has serological evidence of past Epstein-Barr virus infection. It is possible that infection with this virus resulted in an episode of myocarditis, however it is not possible to prove this. Following an episode of myocarditis, there may be complete recovery, chronic heart failure or myocardial fibrosis resulting in risk of developing a fatal cardiac arrhythmia. This (ie fatal cardiac arrhythmia) is almost certainly the mechanism of death in this case. There was widespread myocardial fibrosis throughout both ventricles and in the region of the heart where the conduction system is present. There werc no features to suggest the presence of a familial condition.”

17. This case and that relating to 5 year old Rupert Rafferty (1534/2010) occurred within two days of each other. At the time there was substantial publicity as to whether there had been sufficient expert ambulance resources in the region, In both cases, the patient was found to be asystolic on the arrival of the first available ambulance, and there is no material before me on

18. which I could make a finding that the outcome would have been any different even if staffing had been increased and the level of qualification of staff had been raised.

Recommendations: 1, That the Minister for Health:-

(i) authorise a public advertising program raising awareness of the dangers of Glandular Fever; such program should be funded by the Health Department and must highlight the need for people with symptoms of the disease to seek medical advice as to the effects and the long-term dangers of Glandular Fever, specifically myocardial fibrosis.

(ii) investigate the adequacy of both currant and planned levels of ambulance services provided for those who choose to live away from more densely populated areas. The thrust of this recommendation is identical to that set out in the inquest hearing this date into the death of 5 year old Rupert Rafferty, (Case 1534/2010).

FLC.HAlsop -

CORONER