Finding into death of Angela Murray

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2009 1833

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: ANGELA MURRAY Delivered On: . 25" June 2012 Delivered At: . Level 11, 222 Exhibition Street Melbourne 3000 Hearing Dates: 29 May 3012

Findings of: AUDREY JAMIESON, CORONER

Police Coronial Support Unit Leading Senior Constable Amanda Maybury

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I, AUDREY JAMIESON, Coroner having investigated the death of ANGELA MURRAY

AND having held an inquest in relation to this death on 29 May 2009 at MELBOURNE

find that the identity of the deceased was ANGELA FAY MURRAY born on 8 July 1956

and the death occurred on 23 September 2008

at Monash Medical Centre, 246 Clayton Road, Clayton 3168

from:

1 (a) ASPIRATION PNEUMONIA IN A FEMALE WHO HAD UNDERGONE A

LAPAROSCOPIC CHOLECYSTECOTMY FOR CHOLANGITIS AND CHOLELITHIASIS WHO ALSO SUFFERED FROM PANCREATITIS AND RECENT HAEMATEMESIS :

in the following circumstances:

1, Ms Angela Fay Murray was 52 years of age at the time of her death, She had an intellectual disability and was diagnosed with cerebral palsy and epilepsy. She lived in a group home located at 1139 Dandenong Road, Hast Malvern, a facility under the auspices of the

Department of Human Services, Disability Services.

2, On30 August 2008, staff at the home observed that Ms Murray required greater assistance to get up and was unsteady on her feet. Further changes in her condition were noted over the following day prompting requests for attendance by her treating general practitioner, Dr Psaradellis. Investigations were subsequently performed at Cabrini Hospital, On 10 September 2008, Ms Murray vomited a large amount of fluid which was reported to Dr Psaradellis. . She vomited again that evening after eating a small meal and then’ at approximately 9.20pm, vomited a large amount of brown coloured liquid which was also reported to Dr Psaradellis,, An ambulance was subsequently requested and Ms Murray was

transported to the Monash Medical Centre with suspected aspiration.

3. On 11 Sepember 2008 Ms Murray was reviewed by the surgical registrar and was found to have a number of medical concerns including acute cholecystitis with multiple immobile stones in the gallbladder, cholangitis with raised white cell count, pyrexia and acute pancreatitis. She subsequently underwent a laparoscopic cholecystectomy with an

intraoperative cholangiogram. Postoperatively Ms Murray’s condition did not substantially

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improve and she experienced seizure activity and decreased oxygen saturation levels requiring MET calls on two occasions. By 23 September 2008, Ms Murray had developed significant respiratory distress, In consultation with her next of kin, it was decided that there should be

no further escalation of treatment. Ms Murray died on 23 September 2008.

At the time of her death, Ms Murray was considered a person in custody or care as defined in the Coroners Act 2008' her death was reportable,” however, a death certificate was issued and

this did not occur. °

On 1 April, 2009, the Department of Human Services reported Ms Murray’s death to the

Coroners Court.

Investigation

Associate Professor (A/Prof.) and Forensic Pathologist, Dr David Ranson, was requested to review the documentary material available in relation to Ms Murray’s death, including the death certificate and the medical records from Monash Medical Centre. A/Prof. ‘Ranson commented that the medical certificate of death appeared to be correct, however, it failed to mention some of the predisposing medical conditions which led to her final period of hospitalisation. Accordingly, A/Prof, Ranson reformulated Ms Murray’s causc of death to be that of aspiration pneumonia in a female who had undergone a laparoscopic cholecystecotmy for cholangitis and cholelithiasis who also suffered from pancreatitis and recent

haematemesis. No suspicious circumstances were identified.

Sergeant David Dimsey of the Police Coronial Support Unit undertook additional investigation on behalf of the coroner and obtained a statement from Ms Cathie Ceroloni, Disability Accommodation Serviccs Manager for Disability Services for the inner part of southem region. No issues were identified as specific to the care that Ms Murray received at

her group home or Monash Medical Centre.

} Person placed in custody or care "person held in care" means—

(a) aperson under the control, care or custody of the Secretary to the Department of Human Services; or the Secretary of the Department of Health ,

2 Gpeportable death” means a death—

(a) a person under the control, care or custody of the Secretary to the Department of Human Services; or the Secretary of the Department of Health .

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8. An inquest was held in accordance with Section 52(2)(b).

Finding

IT accept and adopt the medical cause of death as identified by A/Prof. David Ranson and find that Angela Fay Murray died from aspiration pneumonia in circumstances where she had undergone a laparoscopic choleeystecotmy for cholangitis and cholelithiasis on a background of pancreatitis and

recent haematemesis,

AND I- further find that there is no relationship between Ms Murray’s cause of death and the fact

that she was a person in custody or care as defined in the Act.

I direct that a copy of this finding be provided to the following: Ms Carolyn Felix, sister of Ms Murray

Ms Cathie Cerolini, Department of Human Services

Signature:

AUDREY JAMIESON

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