Finding into death of Robert Edward Curry

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference:

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1)

Section 67 of the Coroners Act 2008

Inquest into the Death of: ROBERT EDWARD CURRY

Delivered On:

Delivered At:

Hearing Dates:

Findings of:

Police Coronial Support Unit:

10 September 2012

‘ Coroners Court of Victoria

Level 11, 222 Exhibition Street Melbourne 3000

8 August 2012

Coroner Paresa Antoniadis SPANOS

COR 2009 005057

Leading Senior Constable Amanda MAYBURY,

assisting the Coroner

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I, PARESA ANTONIADIS SPANOS, Coroner, having investigated the death of ROBERT EDWARD.CURRY

AND having held an inquest in relation to this death on 8 August 2012

at Melbourne

find that the identity of the deceased was ROBERT EDWARD CURRY

born on 23 January 1971, aged 38

and that the death occurred on 24 October 2010

at Community Residential Unit, 7 Lara Crescent, Mount Evelyn, Victoria 3796

from: : .

1(a) END-STAGE RESPIRATORY FAILURE

1 (b) KYPHOSCOLIOSIS

CONTRIBUTING FACTORS

2 CEREBRAL PALSY, INTELLECTUAL DISABILITY6

in the following circumstances:

1. Mr Curry was a 38 year old single man who resided at’? Lara Crescent, Mount Evelyn, a Community Residential Unit, managed by Melba Residential Services (Melba), on behalf of the Department of Human Services. Mr Curry had a significant past medical history that included profound intellectual disability, cerebral palsy with severe scoliosis, rickets, cataracts, asthma, aspiration pneumonia, recurrent chest infections and depression. He required full time high level care and assistance with all the activities of daily living. Mr Curry had been in care since he was about seven years old and had resided at Lara Coutt for

about twelve years before his death. His mother Vivian took an active interest in his life and

visited him regularly until her death some nine years ago.

2, Mr Curry’s medical care was provided by Dr Gurcharan Singh Ubhi, from Lilydale Medical Centre, who gave him a full medical check-up once a year and attended to any illnesses as they arose. Mr Curry’s health had been stable for many years, with no particular medical issues in the months immediately preceding his death, except conjunctivitis of the left eye which responded to eye drops and washes. His regular medications were administered: by

Melba staff, from a “Webster” pack prepared by the pharmacy. They were Caltrate, Colfen,

Losec, Iron Plus, Megatrol and Zyprexa.

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On 23 October 2009, after he had left for his day placement, one of the Melba staff members noticed that Mr Curry’s Webster pack still contained that morning’s medications, The medications were taken to the day placement centre and administered to Mr Curry. Upon reflection, the staff member thought it was possible that she had administered another resident’s medications to Mr Curry at about 7.00am that morning by mistake, prior to his departure for the day placement centre. The other resident’s medications were Kepra, Tegretol, Rivotril, Aldactone and Coloxyl/Senna. The incident was reported but Melba were

unable to verify whether the mistake had in fact occurred.

There was nothing about Mr Curry’s behaviour to raise concerns for his welfare or safety. He

appeared a little sleepy on his return from-day placement but this was not uncommon for him.

Mr Curry had-dinner and was put to bed at about 8.00pm as usual, He was checked later in the evening and appeared to be sleeping peacefully, as he was when last checked at 12,15am on 24 October 2009. At about 12.45am, however, one of the nightshift carers checked on Mr Curry and found he wasn’t breathing, She called “000” and commenced: cardiopulmonary resuscitation until ambulance officers arrived a short time later. Mr Curry was table to be

revived.

The coronial investigation of Mr Curry’s death included a mandatory inquest, as he was a person placed in custody or care as defined in section 3 of the Coroners Act 2008.1. The Act recognises that some people. are more vulnerable than others, and affords them protection by requiring that the circumstances of their death are investigated by a coroner, irrespective of the medical cause of death, and by mandating that as part of that investigation there should be an

inquest or formal public hearing.

An autopsy was conducted by Senior Forensic Pathologist Dr Shelley Robertson from the Victorian Institute of Forensic Medicine (VIFM), who reviewed the circumstances as reported by the police to the coroner and considered the available medical records. Dr Robertson

attributed the cause of Mr Curry’s death to end-stage respiratory failure secondary to

kyphoscoliosis and noted as indirect contributing factors cerebral palsy and intellectual -

disability. Dr Robertson made the following comments in her autopsy report regarding her findings and the toxicologist’s report — “Robert Curry, died from natural causes with

evidence of end-stage respiratory disease. He had a past history of intellectual disability,

! See also sections 52(2) (b) & (3) of the Act.

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cerebral palsy and gross kyphoscoliosis. This had produced severe compromise of his respiratory system with gross distortion of thoracic cavities. Toxicological analysis showed the presence of drugs at levels consistent with therapeutic usage. These would not have

contributed to death.”

Toxicological analysis of post-mortem samples revealed Carbamazepine (“Tegretol”, an anticonvulsant) ~6mg/L, Olanzapine (“Zyprexa”, an antipsychotic also used for mood stabilisation) ~0.7mg/L and a trace of J-aminoclonazepam, a matker for Clonazepam (“Rivotril”, a benzodiazepine with sedative and anticonvulsant properties), These results

confirm the medication error suspected by Melba staff to have occurred on 23 October 2009.

I asked Professor Olaf Drummer, Head of Forensic Scientific Services at VIFM and a Toxicologist, to comment on the likelihood that the medication error, which occurred on the morning of 23 October 2009, caused or contributed to Mr Curry’s death. He advised that the levels of Carbamazepine and Clonazepam detected, while consistent with normal therapeutic use, would cause at the very least significant sedation in Mr Curry if he was not accustomed to them and potentially could contributed to his death given that his compromised underlying medical condition. Professor Drummer could not be more precise, but indicated that Mr Curry's clinical state in the hours following the medication error would be important in

assessing the impact on the drugs.”

In Dr Robertson’s absence, Professor Stephen Cordner, Director of VIFM, provided a supplementary report addressing the medication etror outlined above confirmed by the results of post-mortem toxicological analysis. He agreed with Professor Drummer’s advice to the effect that it was “possible that drowsiness associated with the ingestion of the drugs has tipped an already quite ill man over the edge...that it cannot be reasonably excluded that the ingestion of the drugs may have played a contributory role in this man’s death, I do not think

it can be concluded that the drugs necessarily contributed to.this man *s death.”

The records provided by Melba indicated that Mr Curry was sleepy on arrival at the residence after his day placement on 23 October 2009, which was not unusual for him. Relevantly, observations made on 22 October 2009, were consistent, that is, he had returned from his day

placement sleepy, indeed “very sleepy” that day as well,

? Email report to Coroner dated 29/1 1/2011.

3 Email report to Coroner dated 03/08/2012.

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At the inquest, Ms Penny Kendall,’ Manager, Community Living Support Services, Melba Residential Services, gave evidence about Mr Curry’s general level of functioning and confirmed that their records indicated no appreciable change in his behaviour following the medication error. She also explained how the medication error had occurred on the morning of 23 October 2009 and its significant impact on the staff member involved. It should be noted that the staff member involved had been employed at the residence for several years and that unfamiliarity with Mr Curry or with the procedures at the residence appeared to have

played no part in the error occurring.

Ms Kendall testified that there are no “minimum qualifications” for. staff employed at the residence, although some have a Certificate 4 qualification. What Melba Jook for is a person who has a good attitude for working with people with disabilities.° Apart from orientation and induction, after they had been employed for some time, staff members were expected to attend one of the half day training session in the administration of medication which were held up to

three times a year. In the event that a training session is not scheduled for some time, or if

_agency staff are employed, they are instructed in the administration of medication on the job,

and are required to accompany another trained/expetienced staff member on four medication

rounds before being allowed or required to administer medication independently. 6

I find that Mr Curry died from end-stage respiratory failure secondary to kyphoscoliosis and note as indirect contributing factors cerebral palsy and intellectual disability. While I am satisfied to the appropriate standard of proof that the medication error occurred on the morning of 23 October 2009, the evidence does not support a positive finding that the medication probably contributed to his death. Neither does the evidence support exclusion of this as a possibility, that is that the medication error may have contributed to death by increasing Mr Curry’s drowsiness thereby compromising his already compromised respiratory

function.

4 No relation to the police investigator LSC Darren Kendall.

5 Transcript page 15.

§ Transcript pages 16-17.

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COMMENTS

Pursuant to Section 67(3) of the Coroners Act 2008, I make the following comment(s) connected

with the death:

1, Mr Curry was a person under the control, care of custody of the Secretary to the Department of Human Services, and as such a person placed in custody of care as defined in the Coroners Act 2008, He had profound physical and intellectual disabilities and required assistance with all the activities of daily life, including assistance in accessing medical attention and

treatment. He was entirely dependent on his, carers for the administration of medication.

4. While I have made no finding that a medication error probably contributed to his death, the

evidence allows of this possibility.

4. The circumstances surrounding Mr Curry’s death and the medication error in particular, highlight the need for carers in a Community Residential Unit setting to be competent in the administration of medication, for there to be carefully enforced procedures around

administration of medication, and ongoing training in this regard.

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

The family of Mr Curry

Leading Senior Constable Darren Kendall (22800) c/o O.LC. Mooroolbark Police

Dr Gurcharan Singh Ubhi c/o Lilydale Medical Centre, 351 Main Street, Lilydale “Ms Penny Kendall, Melba Residential Services ,

Office of the Senior Practitioner, Disability Services Division, Department of Human Services ‘

Signature:

Fawr

PARESA ANTONIADIS SPANOS CORONER Date: 10 September 2012

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