Finding into death of Nicola Spina

IN THE CORONERS COURT ‘OF VICTORIA AT MELBOURNE

Court Reference: COR 2010 2748

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: NICOLA SPINA

Delivered On: 24 October 2012

Delivered At: Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne 300 Hearing Dates: 24 October 2012 , Findings of: HEATHER SPOONER, CORONER

Police Coronial Support Unit Leading Senior Constable King ‘Taylor

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I, HEATHER SPOONER, Coroner having investigated the death of NICOLA SPINA

’ AND having held an inquest in relation to this death on 24 October 2012 at MELBOURNE find that the identity of the deceased was NICOLA SPINA born on 30 May 1947 and the death occurred on17 July 2010 at St Vincent’s Hospital, 41 Victoria Parade, Fitzroy 3065 from:

1(a) END STAGE ISCHAEMIC CARIOMYOPATHY AND CHRONIC RENAL

IMPAIRMENT

2 TYPE 2 DIABETES MELLITUS

in the following circumstances:

1. Mr Spina was aged 63 when he dicd. He was a prisoner at Port Phillip Prison situate at Corner Dohertys and Palmers Roads, Truganina. Mr Spina had been sentenced to life imprisonment on 14 August 2003. Mr Spina had a past medical history that included hypertension, angina, ulcerative colitis, left sided embolic ischaemic strokes, diabetes, mellitus, gastroesophageal

reflux, renal impairment, osteopenia and gout.

2. A police investigation was conducted and reports were obtained from the Office of Correctional Services Review (OCSV) which were attached to the Justice Health Report. A mandatory summary inquest was convened pursuant to section 52(2)(b) Coroners Act 2008 as

Mr Spina was ‘in custody’ immediately before his death.

-3. Asummary of the Investigating Member’s investigation was read to the inquest: “Nichola Spina was born on the 30" May 1947.

On the 22 December 2005, Mr Spina was sentenced on appeal to life imprisoninent for

murder.

Mr Spina remained in custody, imprisoned at Port Philip Prison until the 6" of July, 2010,

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Mr Spina had a past medical history of ischaemic heart disease, atrial fibrillation, type

2 diabetes mellitus, gout, chronic renal failure and ulcerative colitis.

On the 6" of July 2010, Mr Spina was conveyed by ambulance from Port Phillip Prison to the Emergency Department at St Vincent's Hospital with acute shortness of breath.

Mr Spina had been suffering this condition for two days prior and was worsening,

On arrival at Sit Vincent's Mr Spina was diagnosed with acute pulmonary oedema and

superimposed lung infection and was treated with antibiotics,

Mr Spina was admitted to the Intensive Care Unit (ICU) at approximately 1400 hours

where he was intubated and required inotropic support.

Mr Spina was subsequently extubated and discharged from ICU and transferred to St Augustines Ward at St Vincent's on the 7 of July 2010. On discharge Mr Spina was hypostensive and had to be re-admitted to ICU.

Mr Spina continued to be treated with antibiotics and received further inotropic support,

• On the 10" of July 2010, Mr Spina was discharged from ICU and admitted to St Augustines Ward, with end stage congestive cardiac failure and chronic renal failure,

Decision for palliative management was undertaken.

On the 17" of July, 2010, at approximately 0800 hours, Nurse Gary Delaney of St Augustines Ward found Mr Spina lying in bed with no signs of life.

Doctor Janko attended St Augustines Ward and confirmed Mr Spina deceased, Police attended St Augustines at approximately 0850 hours on I i July, 2010.

Police provided with Coroner’s case number 2748/10 and informed by Nurse Brent.

Next of Kin had been notified.

Undertakers from the Coroner's office attended at approximately 1323 hours on I ia July 2010.

A post mortem examination was conducted on the 1g July, 2010, with the cause of

death found to be end stage ischaemic cardiomyopathy and chronic renal impairment.

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There are no suspicious or negligent circumstances apparent surrounding the death,”’

4. In conclusion the OCSV report noted:

“At the time of his death on 17 July 201, Mr Spina aged 63 years was serving a term of imprisonment of Natural Life with a non-parole period of 25 years for the offences of murder (x2), unlawful imprisonment and threat to kill, Mr Spina had spent eight and a

half years in prison at the time of his death.

Individual Management File notes indicate continuous monitoring and oversight of Mr

Spina’s custodial case management,

Mr Spina’s death was not expected, after receiving ongoing medical treatment for several years at Port Phillip Prison and at St Augustine's ward at St Vincent's Hospital.

Justice Health noted that Mr Spina was provided with the same right to access, equity

and quality of health care as compared to community standards.

The review found that Mr Spina's custodial management during his imprisonment was appropriate and that the incident of his death was managed in accordance with procedures, other than the omission of a post-incident briefing in relation to St

Augustine's staff involved in the immediate response to the death,"

5. | The Justice Health report made the following findings:

“The Justice Health review of the death of Mr Spina identified the following:

Mr Spina was a 63 year old man who, at the time of his death presented with both

multiple and chronic medical conditions.

Based on the review of Mr Spina’s medical record, Justice Health is of the view that Mr ; Spina was provided with the same right to access, equity and quality of health care as

compared with community standards.’”

6. The Justice Health report also referred to the development of guidelines regarding ‘End of

Life Treatment Choices’ and ‘Not for Resuscitation‘ orders: “These guidelines are expected to

OCSR report, page 15 ‘Conclusion’ 2 Justice Health report, page 11 ‘Findings’

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provide clear policy and procedures for health staff within the justice system in instances

where advance planning is recommended/requested.”*

7. A-post mortem external examination was performed by Dr Linda Iles, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM). She formulated the cause of death and,

further to her Inspection and Report, commented as follows:

“The deceased, Nicola Spina, aged 63 years was a prisoner at Port Phillip Prison but had a past medical history of significant ischaemic heart disease, gout, chronic renal failure and ulcerative colitis along with diabetes. He was treated in St Vincent's Hospital for exacerbation of congestive cardiac failure and superimposed lung infection. Despite treatment his cardiac function did not improve and his renal function remained poor. Given that his course is well documented in the St Vincent's Hospital medical record, his cause of

death has been ascribed as above without performing a full postmortem examination,

I have examined the postmortem Cl' scan and interpreted it to the best of my abilities. I am

not a trained radiologist,

In the absence of a full postmortem examination, medicolegal issues that may arise al a

later date may be unable to be addressed

Whilst postmortem toxicological analysis can be undertaken, rational interpretation of the results can be difficult in the absence of a complete posi-mortem examination. This analysis

demonstrates evidence of the use of oxycodone and metoclopramide prior to death.”

I find that Mr Spina unfortunately died from natural causes whilst a prisoner and undergoing a term

of imprisonment.

COMMENTS

Pursuant to section 67(3) of the Coreners Act 2008, I make the following comment(s) connected with the death:

1. Following the Inquest into the death of Nicola Spina, Justice Health provided me with the

following four policics recently approved by the Secretary of the Department of Justice:

~ Refusal of Treatment

3 Justice Health Report, page 11.

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• Advance Care Directives & End of Life Care Plans

• Organ and Tissue Donation

• Petitions for Mercy

2. Justice Health advised that these policies are currently being distributed to their contracted health service providers for implementation. While 1 was not advised about the proposed implementation process of these policies by Justice Health, it will be prudent to ensure the relevant staff from the contracted health service providers are made aware of these new policies and receive adequate training on any neccessary changes to their current practice and to ensure adherence with these policies. I commend Justice Health for the development of these policies as a mechanism to improve the provision of health care to persons in

custody.

I direct that a copy of this finding be provided to the following: Mrs Lucy Cunico Senior Constable Kerryn Makin, Fitzroy Police Station, Investigating Mcmber Office of Correctional Services Review , Justice Health St Vincent's Hospital

Signature:

cs wey “Ny ye ogg

HEATHER SPOONER CORONER Date: 24 October 2012

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