Finding into death of Janice King

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2007 4576

FINDING INTO. DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of: JANICE KING

Delivered On: 16 August 2012

Coroners Court of Victoria -

Delivered At; Level 11, 222 Exhibition Street Melbourne 3000

Hearing Dates: 27 April 2012

Findings of: HEATHER SPOONER, CORONER

Police Coronial Support Unit Leading Senior Constable John Kennedy

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I, HEATHER SPOONER, Coroner having investigated the death of JANICE KING

AND having held an inquest in relation to this death on 27 April 2012 at MELBOURNE : find that the identity of the deceased was JANICE ANN KING born on 9 September 2007 + and the death occurred on 12 November 2007 at Northern Hospital, 185 Cooper Street, Epping, Victoria 3076 from: ) 1 (a) EPILEPSY

in the following circumstances:

1. Ms King was aged 45 when she died. She resided in a supported accommodation facility known as Cass House at 12 James Street Colac with three other permanent residents. Ms King

had a past medical history that included an acquired brain injury and epilepsy.

2. Ms King was in the care of the Department of Human Services so her death was reportable pursuant to s.49(2)(c) and (e) of the Coroners Act 2008 (hereinafter referred to as the Act). It is also mandatory for a coroner to convene an inquest where a deceased person was _

immediately prior to death placed in care (s.52(2)(b) of the Act)

3. A police investigation was conducted into the circumstances surrounding the death, At the

Inquest Leading Senior Constable Kennedy provided the following summary to the court:

“Ms King was a 45 year old female who resided at Cass House 12 James Street Colac, a

supported accommodation facility.

Ms King had a past ‘medical history that included epilepsy. This led to a disability that

required her to be in care at the supported accommodation at James Street, Colac.

Ms King also suffered an intellectual disability.

On the. 10" November 2007, Janice was found fitting by one of her carers. When the

fitting stopped Janice was found to be unresponsive and not breathing.

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Ms King was taken from her bed, placed on the floor and given CPR until the ambulance

arrived, Ms King was resuscitated with adrenaline, intubated and taken to the Colac Hospital.

Ms King was later air lifted to be Northern Hospital for intensive care treatment.

Ms King was placed in an induced coma, This was lifted on the I I" November, 2007 and it was détermined Janice had limited brain function and was only responding to extreme

pain.

Following a discussion with her family Ms King was extubated and given comfort

measures,

On the 12" November, 2007 Janice suffered another respiratory and cardiac arrest and

passed away.”

Post Mortem Examination

4, An autopsy was performed by Dr Katheriie White, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM). She formulated the cause of death and made the

following comments:

“According to the Victoria Police Report of Death Form, No. 83, the deceased was a 45-year- ~ old female who had suffered from a chronic intellectual disability and chronic epilepsy as a result of birth complications. She had spent the best part of her life in care facilities, On 10/11/07 she suffered an epileptic fit and subsequent cardiac arrest. She was transferred to Colac Hospital and airlifted to the Northern Hospital in intensive care treatment, She was intubated, ventilated and cooled to prevent any further brain damage, Her induced coma was” lifted on 11/11/07 and it was determined that the deceased had very limited brain function and was only responsive to extreme pain, On 12/11/07, she again suffered a respiratory and cardiac arrest and passed away, Her medications included heparin, esomeprazole, dilantin,

• sodium valproate, frisiim and lamictal.

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Review of the clinical notes indicates that the deceased had a history of recurrent seizures

• despite four anti-seizure medications. On 10/11/07, she was witnessed to have a seizure following which she was unresponsive with no cardiac output. The ambulance notes indicate that the deceased was found to be fitting by a carer and then stopped breathing and was in asystole, The length of seizure is not stated/known. It is estimated that the deceased had an arrest downtime of 20-25 minutes with effective cardiopulmonary resuscitation. On admission to the Intensive Care Unit (ICU), blood tests showed a subtherapeutic level of sodium valproate and phenytoin, In ICU she was treated with antiseizure medications, including loading with phenytoin, and was ventilated. No improved neurological functioning was noted in ICU. Following a discussion with family she was extubated and given comfort measures,

and passed away on 12/11/07,

The cause of death is epilepsy. According to ambulance records, the deceased was found to be “fitting”, following which she stopped breathing and was in asystolic cardiac arrest. The duration of the seizure is unable to be determined. Cardiac asystole (absent heart rhythm)

can be provoked by epileptic seizures.

Despite effective cardiopulmonary resuscitation, and subsequent admission to an intensive care unit, the deceased remained unresponsive with no improvement in neurological functioning. Ischaemic changes were seen within the brain and cerebellum at autopsy. It is likely that these are a sequelae of a recent hypoxic insult dite to seizure and asystolic cardiac

arrest.

It is not considered that this death should be classified as sudden wnexplained death in epilepsy (SUDEP) as the definition of SUDEP excludes death in association with status epilepticus. Status epilepticus has been defined as a seizure that “persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur”.

It is not possible to exclude the presence of status epilepticus prior to death and as such the

cause of death is given as epilepsy rather than SUDEP.

Bronchopneumonia was also identified at autopsy. It is considered that this is a sequela of

terminal events.

Microbiology of the pituitary fossa has cultured mixed flora. These are considered to be a

post-mortem contaminant.

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Toxicological analysis performed on antemortem specimens collected on 10/11/07 has not detected the presence of ethanol (alcohol). Free morphine was detected in the blood at a level of 0.06mg/L. Of note, the ambuldnce records indicate that the deceased was administered morphine, The toxicology results are consistent with this. Lamotrigine and phenytoin are both anticonvulsant medications and they have been detected in the antemortem samples, consistent

with therapeutic usage.”

5, The death was also reviewed by the Clinical Liaison Service! who found no identifiable

association between the cause of death and healthcare management.

6. It is apparent that Ms King unfortunately died from epilepsy.

I direct that a copy of this finding be provided to the following:

Senior Next of Kin L/S/C Tennyson, Whittlesea Police Station, Investigating Member

Signature:

che ree Ly ee

HEATHER SPOONER

CORONER Date: 16 August 2012

The CLS is part of the Coroners Prevention Unit (CPU) established in 2008 to strengthen the prevention role of the Coroner. The CPU assists the Coroner in formulating prevention recommendations and in monitoring and evaluating the effectiveness of recommendations, The role of CLS is to assist the Coroner’s investigation of deaths occurring in a healthcare setting. CLS is staffed with practising Physicians and Nurses independent of the health professions orinstitutions involved. They draw on their joint medical, nursing and research experience to evaluate the clinical management and care provided, and to identify areas of improvement so that similar deaths may be avoided in the fature,

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