Finding into death of Cameron Yeates

IN THE CORONERS COURT OF VICTORIA AT SHEPPARTON

Court Reference: COR 2007 000434

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1)

Section 67 of the Coroners Act 2008

Inquest into the Death of CAMERON YEATES

Delivered On: Delivered At: Hearing Dates:

Findings of:

Representation:

Police Coronial Support Unit

24 August 2012

Shepparton Coroners Court

Monday 22 August 2011 — Wednesday 24 August 2011 Stella Stuthridge, Coroner

Mr D. Hancock — Yeates Family

Mr S. Reid - Goulburn Valley Health

Mr A. Clements — Dr Lee and Dr Coulthard

Ms F Ellis — Office of Public Advocate

L/S/C Greig McFarlane

I, Stella Stuthridge, Coroner, having investigated the death of Cameron Kenneth Yeates

AND having held an inquest in relation to this death on Monday 22™ August 2011 ~ Wednesday 24" August 2011

at Shepparton Coroners Court

find that the identity of the deceased was Cameron Kenneth Yeates

born on 20 August 1975

and the death occurred On 2 February 2007

at Goulburn Valley Base Hospital, Graham Street Shepparton, Victoria 3630

from:

lal in the following circumstances:

Introduction: The Coroners Act 2008 (Vic) prescribes my functions as a Coroner. The primary purpose of the coronial investigation of a reportable death! is to ascertain, if possible, the identity of the deceased

person, the cause of death and the circumstances in which the death occurred.”

My secondary role, if appropriate, is to comment on any other matter connected with a death including public health or safety or the administration of justice. In the Supreme Court of Victoria in the matter of Harmsworth v State Coroner [1989] VR 989, Justice Nathan broached the subject matter of the limits of a Coroner’s power and observed that the power of investigation is not ‘freeranging’. Coroners are also empowered to make recommendations in relation to public health and

safety or the administration of justice."

As a Coroner | am not permitted to include in a finding any statement that a person is or may be guilty of an offence. Similarly, it is not my role to make any specific findings on whether there has

been any negligence-giving rise to the death, which I am investigating.

' Coroners Act, 2008 (Vic) s. 4 ; Coroners Act, 2008 (Vic) s. 67 ° Coroners Act, 2008 (Vic) s. 72(1),72(2) and 67(3)

A coroner is not bound by the normal rules of evidence.* Where findings of fact are made, the test is whether there is sufficient evidence to be satisfied on the balance of probabilities. When a coroner is considering issues of causation, in relation to individuals or entities, acting in their professional

capacity, a higher standard of proof applies.” | have applied this standard in these proceedings.

Inquests are difficult for families and often do not resolve the many issues that have arisen because of the death of a loved one. It is an opportunity to question and to enquire if the circumstances could have been different. As such, the focus of the inquiry here is the cause of the tragic death of Cameron

Kenneth Yeates and whether his death could have been prevented.

From the evidence in this case, I have no doubt Mr and Mrs Yeates; especially Mrs Yeates, supported their son unfailingly for 31 and a half years: they advocated continuously on his behalf; often in

difficult circumstances and that dedication should be recognised.

Background

Cameron Kenneth Yeates was born on the 20 August 1975. It quickly became apparent to his parents that Cameron had a disability. Up until approximately 2002, Cameron was slightly over weight. His diet was not optimal. A Department of Human Services, Psychological Assessment was completed of Cameron on the 21 August 2000. The assessment found Cameron had an IQ of 64. He was eligible to be registered as a client of Disability Services. The assessment report notes that Cameron had a ‘poor ability to see relationships between two objects.’® The report recommended that any instructions be given in ‘simple, clear language and with a small amount of steps’.’ During the period 23 September

2005 — 14 December 2006 Cameron was subject to a Guardianship Order.

In 2002, his mother describes Cameron as becoming pale, lethargic and with unexplained weight loss. A blood test taken in July 2002 revealed his red blood cells were enlarged, with low B12 and folate deficiency. He was commenced on a regime of B12 injections and iron tablets. Dr Harry Lee was his treating doctor at the time and diagnosed Cameron with Coeliac. Cameron’s health continued to decline over the following years. In a series of photos provided by the family to the Court, this

decline is clearly visible. Cameron’s bowel function also declined.

4 Coroners Act, 2008 (Vic) s. 62 5 Coroner’s Case No 2912/01, Coroner Byrne; Briginshaw v Briginshaw (1938) CLR 336

Pe3

Circumstances & Chronology®

In approximately June 2006, Cameron’s condition seemed to deteriorate markedly, His ankles and lower legs became swollen. Investigation found Cameron had very low iron levels and protein deficiency. A CT scan was performed and faecal loading in his rectum and sigmoid colon was found.’ On the 31 July 2006, Cameron was admitted to Goulburn Valley Hospital (GV Hospital) until the 8 August 2006. During this admission he received transfusions of whole blood in order to increase his iron and albumin (protein) levels. He was treated with enemas and oral laxatives to try to obtain normal bowel function. Dr Nanayakkara, Consultant and Dr Coulthard, his general

practitioner, were treating Cameron conservatively.

On the 26 September 2006, Cameron had a gastrocopy. There was a plan to perform a colonoscopy but this could not be done. At this time, Cameron and his family were advised Cameron did not have

Coeliac Disease.

Cameron’s family raised extensive concerns about the mis-diagnosis of Cameron with Coeliac.

During evidence Mrs Yeates provided a newspaper article about Coeliac she had been given by Dr Lee. This mis-diagnosis does not appear to have caused his death." In the event Cameron had adopted a diet consistent with Coeliac treatment, it is likely that many of his subsequent difficulties

would have been avoided. A follow up x-ray was performed on the 26 October 2006.

In October and November 2006, both Dr Nanayakkara and Dr Coulthard expressed the view to Cameron and his mother that there was little that could be achieved in improving Cameron’s overall

health unless he improved his diet.

At this time, medical professionals describe Cameron’s diet as very poor. There was very little protein, fruit or vegetables, Mrs Yeates in her submissions dated 13 January 2012 disagrees. She makes the point that while living with her, Cameron ate proper evening meals consisting of meat and vegetables and fruit. In the last 6 months of his life, Cameron ate very little. Mrs Yeates believes this was due to his concerns about weight gain and discomfort due to his distended abdomen and bowel

problems,

7 Pg5

5 Mrs Yeates has provided a very detailed history of Cameron from birth. I have considered that history in preparing this matter. This chronology does not reflect all the medical events that occurred for Cameron, it is a short guide to assist in understanding the finding. Mrs Yeates chronology and submissions shall remain on the court file for future reference.

° Lower bowel

' Transcript pg 194

In late November 2006, Cameron was referred to Dr Elliot, Gastroenterologist. Dr Elliot observed severe malnutrition, with a huge amount of swelling of the legs right up into his abdomen and his

abdomen was distended." Dr Elliot said the abdominal x-rays showed marked faecal overloading.”

On the 14 December 2006, Cameron was admitted to St Vincent’s Hospital under the treatment of Dr Wilson. Shortly after admission, Cameron was diagnosed with Deep Venous Thrombosis in his right leg and he commenced Warfarin treatment. He was suffering from severe chronic constipation with

mega colon, Cameron’s diet was described as poor with little high fibre foods or protein.'* Dr Wilson

noted Cameron’s very poor nutritional state and evidence of malnutrition.

Dr Wilson explained there were two treatment options. A conservative medical approach; increasing Cameron’s fibre and fluid intake together with a regime of enemas and laxatives in order to restore normal bowel function. At the same time, Cameron’s diet needed to include protein and high fibre foods to effect long-term improvements and address his malnutrition. Secondly, a surgical approach with removal of the large part of the colon, This surgical approach having substantial risks, especially

considering Cameron’s malnourished state and deep vein thrombosis.”°

During Cameron’s admission he meet with a dietician who tried to improve his diet. Unfortunately, Cameron failed to have sufficient protein when unsupervised. As such, his protein level remained low through out this period.’® Cameron was discharged from St Vincent’s on 22 December 2006, and

re-admitted on 4 January 2007.

During Cameron’s second admission, Dr Wilson continued with the conservative medical treatment i regime. Dr Wilson gave evidence that during both admissions, he consulted with the surgical team to

discuss possible surgical solutions but the decision was made not to pursue this. Dr Wilson took into

account that there was some slow improvement in Cameron’s bowel function and the significant risks involved in the surgical approach. ? Dr Wilson did note that during the period from December 2006

to January 2007, Cameron’s malnutrition got worse and this was a serious problem.'® On 10 January |

| Transcript pg 147

® Transcript pg 147

'S Depositions, pg 72

'4 Transcript pg 67

'S Transcript pg 67-68

‘6 Transeript pg 69

'T Transcript pgs 67-68, 76, 80-83 ® Transeript pg 86 - 98

GOR

2007, Cameron was discharged home with follow up arranged with the local nursing service to

continue with a treatment regime aimed at improving Cameron’s bowel movement and dict.

At the Inquest, each of the Doctor’s who gave evidence agreed that Cameron was suffering from a chronic long-term problem.” His exceptionally poor diet had caused malnutrition.”° The dict had also severely affected his bowel function resulting in a grossly enlarged lower bowel (mega-colon).”" It is likely this affected the absorption of nutrients in the bowel. The malnutrition had created chronically low levels of protein.” The low protein resulted in fluid problems in Cameron’s blood and the

swelling of his legs.”

There is a strong likelihood that as Cameron’s bowel slowed and became loaded with faeces his bowel was unable to properly absorb nutrients, and thus malabsorption was potentially a contributing factor.”4

Each of the Doctors, and Professor Dudley, the independent expert, agreed with the above analysis of Cameron’s diagnosis.”° Further, they all agreed that there were only two forms of treatment, medical of sutgical."* Each Doctor and Professor Dudley confirmed that from December 2006 to J anuary 2007, the continuation of the medical treatment was appropriate and it was not appropriate to

: . 2 consider a surgical response, at that stage.?”

In particular, Professor Dudley noted that surgical removal of the bowel would not have solved

Cameron’s problems, without a dramatic improvement in Cameron’s diet.7* Pp

On the 29 January 2007, Cameron was admitted to GV Hospital. When he was admitted he was severely bloated and in pain. A CT Scan on the 31 January 2007 revealed his bowel was full of faeces. A regime of oral laxative was commenced. Until the morning of his death, Cameron’s vital signs were stable, he was able to care for himself and a conservative approach to treatment was

adopted.” Due to Cameron’s low protein levels, regular transfusions were administered.

° Transcript pgs 36-67,70-71,73,99,197 20 Ibid, and pgs 67, 69, 118, 152-153 21 Thid, and pgs 64, 148 ® Transcript pgs 112-116 33 Thid, and pg 122 4 Dr Elliot, Transcript pg 148 > Transcript 197, see also footnotes 16-20 26 Transcript 195, 206, see also footnotes 16-20 7 Transcript 212, see also footnotes 16-20 8 Transcript pg 216 ? GV Hospital Medical Records; Statement of Dr Geaboe, pg 2

On 2 February 2007 at 4.45 am, there was a change in Cameron’s vital signs. Nursing staff felt the changes may have been due to postural hypotension™ and were not alarmed, Further, Cameron did

not appear to the Nurse as more unwell*!

At approximately 7.55 am, Cameron was scen to be walking unsteadily and appeared sweaty. He told

the Nurse he wanted to go to the toilet. As the Nurse tried to assist him, he collapsed to the floor.

Staff immediately called for assistance and commenced resuscitation. Cameron was unable to be

revived and passed away.

A full post mortem was performed on Cameron. The post mortem found no natural disease. Dr Shelly Robinson, Forensic Pathologist, found the cause of death to be acute colonic pseudo-obstruction, During the inquest, various Doctors gave evidence of the chronic nature of Cameron’s problems and his malnutrition. Dr Robertson explained in evidence she did not have access to Cameron’s medical file at the time of the post mortem. Further, she was not aware and did not observe that Cameron had been suffering from malnutrition. Accordingly, after the inquest I requested a review of the cause of

death.

The review was undertaken by Dr Micheal Burke, Senior Forensic Pathologist. Dr Burke is of the view that Mr Yeates malnourished state had contributed to his death, but it is impossible to determine

exactly how. This is supported by the evidence of all the Doctors and Professor Dudley.

Dr Burke is of the view that from a purely pathological point of view the death is unascertained, that is we do not know exactly what caused the death. He is of the view it is likely Cameron died form a

cardiac arrhythmia associated with a metabolic disturbance.

Disimpaction

There was a great deal of evidence and cross-examination about whether during Cameron’s treatment manual dis-impaction of his bowel should have occurred. Detailed explanations were given by several Doctors.”? Their evidence was that manual disimpaction was not necessary, as there was no blockage of Cameron’s lower rectum. Further, there was evidence that despite Cameron’s chronic

constipation, some bowel movement did occur.

• An alteration in blood pressure and heart rate caused when a person moves from lying still for along time to sitting or standing.

3! GV Hospital Medical Records; Statement of Dr Geaboc, pg 4

Colonoscopy

The inquest heard evidence about the difficulties of preparing Cameron for a colonoscopy. Further, Cameron’s intellectual disability may have had some impact on the difficulties in preparing him. The evidence in this matter establishes that ultimately the failure to perform a colonoscopy did not contribute to Cameron’s death as the post mortem established there was no underlying disease that

would have been detected during the colonoscopy.

Small Intestinal Bacterial Overgrowth

In the family submission, they have raised the possibility that Cameron suffered from a small intestinal bacterial overgrowth. This issue was not canvassed in evidence in the inquest. I note Dr Wilson gave evidence in his statement that he had prescribed Aprofloxcin due to the possibility that

Cameron had a bacterial overgrowth.?

Dict and intellectual disability

Cameron had an assessed 1Q of 64. Several Doctors gave evidence that it was sometimes difficult to

get Cameron to agree to medical treatment.** This was especially the case if the treatment was | invasive. Cameron’s family noted in their statement to the Court that Cameron was not always able to

make the best choices or decisions for himself.

Dr Nanayakkara had concerns that Cameron did not fully comprehend or retain information about his treatment.** Dr Lee felt that Cameron understood most of what he was discussing with him, but still would not stick to a good diet>° Mrs Yeates commented to the Coroner, “Had we been consulted in relation to Cameron’s intellectual disability, his lack of cooperation, his in-ability to understand the potential seriousness of his situation etc we may have been able to assist doctors to successfully treat him”?

The evidence throughout the inquest supports the proposition that Cameron had an extremely poor diet for many years. Some improvements occurred in his diet when his mother supervised his meals.

He had consultations with dieticians at both St Vincent’s Hospital admissions and whilst at GV Hospital. It appears unlikely the dieticians had access to Cameron’s intellectual assessment report prepared in 2000, quoted above. Access to that report may well have assisted them in teaching Cameron the importance of changing his diet and assisting in implementing procedures that could

result in sustained change.

2 Transcript pg 73-79

33 Statement of Dr Wilson, pg 71 ff

4 Transcript pg 58, 222 ; Depositions pg 72 % Transcript pg 222

• Transcript pg 33-38

Tnote that Dr Coulthard made a referral to the St Vincent’s Hospital Adult Development Clinic on or about the 17 January 2007.

Research undertaken by the Coroner’s Prevention Unit was unable to locate any dieticians specifically trained to deal with persons with intellectual disabilities. Dieticians working with persons with an intellectual disability should have access to relevant assessments, Such information is necessary to ensure the patient is able to comprehend and make sustained changes allowing the

dietician to create an education program suited to the particular individuals’ cognitive abilities.

Where a patient is a registered client of Disability Services, medical personnel should have a process to access relevant assessments that can assist in assessing a persons intellectual functioning and the

delivery of medical information to the patient.

Families understanding

Material filed with the Coroner’s Court in this matter by the family and the evidence during the Inquest established that there were periods when Cameron’s family struggled with understanding which doctor was responsible for treating him and what treatment goals were, This experience increased the families distress. During the last 7 months of Cameron’s life, his mother was extremely concerned about her son’s deteriorating health and the apparent failure of medical staff to

comprehend how ill her son appeared to her. In hindsight, her concern was not misplaced,

Mrs Yeates in her statement to the Coroner comments “There was a constant underlying assumption from him and other professionals that Cameron’s problems were brought about because of his diet, and if he would just address his

diet he would be OK.”*®

Sadly, the wealth of medical evidence and the post mortem report confirm that this assumption was correct. There was no evidence of an underlying undiagnosed disease or aetiology causing Cameron’s problems, The effects of years of a chronic poor diet resulted in severe malnourishment, malabsorption, gross muscle wasting, low protein levels, chronic constipation, mega-colon and

severe oedema of the lower legs and abdomen.

Medical Emergency Response Teams (MET)

7 Depositions pz 22 8 Depositions pg 50

Tn Professor Dudiey’s report, he expressed the view that a Medical Emergency Response Teams

(MET) call has been shown to have improved outcomes for hospital inpatients.? ” There was extensive

evidence throughout the Inquest about MET calls.*° I am satisfied that GV Hospital had a MET call system in place.” | am satisfied that Cameron’s vital signs on the morning of this death were not sufficient to have warranted the making of a MET call. Further, | am satisfied that even if such a call

was made it would not have prevented Cameron’s death.

Guardianship

During the period, 27 September 2005 to 14 November 2006, James Doran was Camerons’ appointed Guardian.” During this period, Dr Nanayakkara was treating Cameron. Cameron was to have a gastroscopy, a colonoscopy and an iron infusion on 12 September 2006. Due to issues around the

proper provision of consent by the Guardian, this treatment was delayed until the 29 September 2006.

Ultimately, the colonoscopy could not be undertaken due to difficulties in preparing Cameron for the procedure. The delay did cause distress for Cameron’s family, in particular his mother. I am satisfied

this delay did not contribute to Cameron’s death.

Family Submission

Mrs Yeates on behalf of the family provided the Court with extensive and detailed submissions. The family raised extensive concerns about the lack of information provided to them, the failure of medical staff to consult with them and that they were not advised of how serious Cameron’s

condition was.

Cameron was 31 years old, he had an intellectual disability. Apart from the period 27 September 2005 to 14 November 2006, he was not subject to a guardianship order. At the Inquest, various Doctors gave evidence that they felt Cameron understood their discussions with them. The Doctors who gave evidence at the Inquest were not extensively questioned about Cameron’s ability to consent

to medical treatment.

If a family member had been appointed, as Guardian for Cameron then his treating doctors would

have been legally obliged to consult with his guardian, Sadly, this was not the case.

» Statement of Professor Dudley , 18 December 2009 “° Transcript pgs 187 £f:258 ff, 199 — 206; ' Statements of Dr Geobuc dated 22 August 2011 and 19 august 2011 and attachments.

Conclusion

In all the circumstances it appears that the effects of years of a chronic poor diet resulted in severe malnourishment, malabsorption, gross muscle wasting, low albumin levels, chronic constipation, mega-colon and severe oedema of the lower legs and abdomen. These processes contributed to Cameron’s death. T am not able to determine exactly what pathological process caused Cameron’s death and I find the cause of death is unascertained and order that the death certificate be amended to

reflect this.

Signat

Stella Maria Stuthridge

Coroner Date: 24 August 2012

” Statement to the Coroner of James Doran