Finding into death of Carmel Vitalleri

IN THE CORONERS COURT OF VICTORIA _ AT MELBOURNE | ve eee ee _ bee ee

Court Reference: COR 2011 2075

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: CARMEL VITALLERI 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 CARMEL VITALLERI AND having held an inquest in relation to this death on 27 April 2012

find that the identity of the deceased was CARMEL MARIA (ALSO KNOWN AS MARY)

VITALLERI ‘ born on 8 March 1958

and the death occurred on 6 June 2011

at a community residential unit situate at 12 Dredge Street, Reservoir 3073

from: 1 (a) COMPLICATIONS OF POST-NATAL ENCEPHALITIS INCLUDING EPILEPSY

in the following circumstances:

1, Ms Vitalleri was aged 53 when she died. She was a resident in a community residential unit

for the intellectually disabled. Ms Vitalleri was deaf and blind with an unsteady gait.

2. Ms Vitalleri was in the care of the Department of Human Services so her death was reportable pursuant to s.4 (2) (c) and (e) of the Coroners Act 2008 (hereinafter referred to as ‘the Act’).

It is also mandatory that a coroner must hold an inquest if the deceased was immediately

before death, a person placed in custody or care (s.52. (2) (b) of the Act).

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

4. At the Inquest Leading Senior Constable Kennedy read the following summary to the court:

“The Deceased, Ms Carmel Maria Vitalleri was born on the 8" of March, 1958, at Red Cliffs

in Victoria,

Ms Vitalleri was a normal, healthy baby girl until falling ill at eighteen months of age, when: _ her parents took her to see their local doctor, who instructed that they take her to the hospital

at Mildura.

Doctors at the Mildura Base Hospital diagnosed that Ms Vitalleri was suffering from meningitis, however, after her condition failed to improve over the next ten days, her parents

decided to have her sent to Melbourne by ambulance.

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Doctors at the Fairfield Infectious Diseases Hospital. diagnosed Ms Vitalleri as actually suffering from encephalitis, Ms Vitalleri then fell into a coma at the hospital, not regaining

consciousness for nine months,

When Ms Vitalleri awoke from the coma she was deaf and blind.

Ms Vitalleri’s parents look after her at home for the next four years, however found it too difficult to properly care for her in the circumstances. Ms Vitalleri then moved into the care of the government at Kew Cottages, which was a specialised institution for people with

intellectual disability.

Ms Vitalleri remained in government care at Kew Cottages, later known as Kew Residential Services, until April, 2006, when she was moved into a new Community Residential Unit for intellectually disable persons located at 12 Dredge Street, Reservoir. This uew house accommodated up to five residents at any one time and staff are present twenty-four hours a

day to provide appropriate care.

After moving facilities, Ms Vitalleri’s case management plan remained much the same, as her physical and medical condition had remained relatively stable for some years. It was arranged for Ms Vitalleri to engage with a local general practitioner, pharmacy and day care *

Service provider,

Owing to being deaf and blind, Ms Vitalleri was unable to communicate with others, though she was able to partially navigate her way around the house, but would need assistance to go

anywhere else.

Ms Vitalleri also suffered from a number of other conditions — Epilepsy which was being successfully managed with medication so that she would have only one or two seizures a year; a mild left herniplegia which affected her mobility, for which she had special shoes made to assist her; a Vitamin .C and D deficiency which was managed with medication; and Osteoporosis which was managed with medication. The required medication was arranged in

blister packs and were dispensed by staff as required,

Ms Vitalleri had a history of constipation which was treated with a high fibre diet that kept

her bowel movements regular. She was also incontinent, to manage this she was ‘toilet timed’

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which meant she was put on the toilet at certain time, for instance after meals and snacks, and

for other times she wore an incontinence atd,

Staff at the house monitored Ms Vitalieri’s weight; as it was deemed to be ar the lower end of the healthy range, and in an attempt to increase her weight she was fed high energy food and

drink, but this was ineffectual.

To ensure that all relevant Department of Human Services policies were adhered to Ms Vitalleri had a number of management plans in place addressing her medical and health needs. A Health Support Needs Summary and a Comprehensive Health Assessment Program which were reviewed annually by her general practitioner and staff to ensure Ms Vitalleri’s

current needs were being met.

Each weekday from 9.00am to 3.00pm, Ms Vitalleri would attend Able North Day Services in Reservoir where she would take part in recreational activities such as musical activities, having massages and going on outings. Staff at the day services would complete entries in Ms Vitalleri’s communication diary detailing the events of the day. and whether there were any

issues with her, so that her residential care worker's would be aware of goings on,

Although her epileptic seizures were generally under control, in late 2010 after having suffered a nunber of seizures in relative. close proximity of each other. Ms Vitalleri was monitored in hospital for a number of days. Tests revealed nothing out of the ordinary and

she was referred to a neurologist and was placed on a waiting list,

In May 2011, Ms Vitalleri fell in the bathroom attached to her bedroom, and suffered bruising around her right eve. Two days later on the 20" of May, 2011, she was taken to see her General Practitioner Dr Daily who examined the injury and determined this was a superficial injury that did not require treatment. Dr Daily notes that Ms Vitalleri had been well in the

year before her death and had infrequent seizures.

At 8.00pm on the ia of June 2011, Disability Services Officer Ben Claessen commenced work at 12 Dredge Street, Reservoir, working alone at the house from 8.30pm onwards. There

were five residents in care at the unit.

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At about 10.00pm that night, Mr Claessen gave Ms Vitalleri her evening medication and snack before helping her into bed. Ms Vitalleri appeared to be her normal self, making

sounds from bed as she went to sleep.

In the early hours of the morning, Mr Claessen detected the smell of faeces in the unit and looked around the unit for the source, At about 12.40qm, Mr Claessen went to Ms Vitalleri’s open bedroom doorway, having worked out that was where the smell was coming from, and

saw her lying on the floor, initially thinking she had fallen from bed and gone to sleep on the

floor.

Turning the light on Mr Claessen realised that this was not the case, he saw that Ms Vitalleri’s eyes were wide open, her skin was off-colour. Checking for signs of life, Mr Claessen felt for a pulse, and did not locate one, but noticed her skin was still quite warm. Ms Vitalleri was located lying on the floor adjacent to the bed, on her back with her feet underneath the bed, her head was near the side of a dresser and her arms were bent at her

‘side. Mr Claessen called triple-zero for an ambulance and commenced CPR.

Ambulance officers attended and assessed Ms Vitalleri, pronouncing her to be dead and life ‘saving efforts were discontinued. Ms Vitalleri was moved from the floor into her bed and

covered with blankets.

At 2.10am police attended the address and inspected the scene and observed no_obvious signs of trauma on Ms Vitalleri or anything else at the scene to suggest there are any suspicious

circumstances in this matter.

At 2.55am Dr Andrew Gin of the Australian Locum Medical Service attended the address and signed a Certificate of Death in respect to Ms Vitalleri.

At 3.33am government undertakers attended the address and conveyed Ms Vitalleri to the

Coronial Services Centre.” Port Mortem Medical Examination

5. A post mortem autopsy was performed by Dr Jacqueline Lee, Forensic Pathologist at the Victorian Institute of Forensic Medicine. Dr Lee formulated the cause of death and in her

report she made the following comments:

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Information available to me at the time of this report is from the Victoria Police Report of

"Death Form 83, medical records from Dr Matihew Daly and medical records from Oakhill” ~

Clinic.

The 53 year old deceased had a history of post-natal encephalitis, which resulted in blindness, deafness, intellectual disability and epilepsy. Epilepsy was treated with 200 mg Carbamazepine three times a day, since August 2006, She experienced tonic-clonic seizures

lasting ~30 to 60 seconds, which were followed by post-ictal tiredness for ~1 day.

Two weeks prior to death, she fell in the bathroom. Bruising around the right eye was noted and she was cleared by the doctor. One week prior to death she experienced her first seizure

since February 2011,

She had lived in her current residence since April 2006. She required full time residential care and assistance with all activities of daily life. On 07 June 2011 she took her evening medications and went to bed around 10pm. Approximately 2 % hours later she was found on the floor next to her bed, Resuscitative measures by the staff of the residence and the

paramedics were unsuccessful and she was pronounced deceased.

Neuropathologic evaluation of the brain showed encephalomalacia in the distribution of the

posterior cerebral arteries and minor ongoing inflammatory changes of unclear significance.

The remaining autopsy showed a uterine leiomyoma and endometrial polyp.

Post-mortem carbamazepine concentration was within the therapeutic range.

Glucose and vitreous electrolytes were non-contributory, The significance of elevated urea concentration is unclear. It may reflect the degree of hydration, increased endogenous protein catabolism or hepatic synthesis. In this setting it may simply reflect endogenous protein catabolism, which is the degradation of muscle, in this woman with decreased mobility or

muscle damage following a tonic-clonic seizure.

Findings from the post-mortem computed tomography scan were. consistent with those at

autopsy,

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The most likely cause of death is sudden death in a person with epilepsy. In the setting of a break through seizure one week prior to death it is likely that she experienced another break

through seizure.

Often, there are no anatomic findings at post-mortem that are associated with a terminal seizure, In the absence of any other potentially fatal cause, and in light of her being found on

the floor next to her bed, a terminal seizure is likely,

The mechanism for sudden death following seizures is not clear. It is not related to anticonvulsant medication concentrations and is more common with seizures occurring

during sleep.

There was no post mortem evidence of any injuries which may have caused or contributed to

death,

There was some family concern expressed about Ms Vitalleri being too thin - “she wasn’t being fed enough’ — however, the evidence revealed that whilst Ms Vitalleri’s weight was low, it had apparently been stable for some time. The evidence indicated that Ms Vitalleri was regularly monitored. by a doctor and, according to the House Supervisor, she was given ‘sustagen drinks and extra foods, her weight was pretty stable, for as long as I’ve known her she was slightly under weight...’ According to a statement from her doctor, ‘.she was well in

the year before her death and had infrequent seizures.’

It is apparent that Ms Vitalleri unfortunately died from the complications of her postnatal

encephalitis including epilepsy.

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

The family of Ms Vitalleri

Senior Constable John Robertson, Investigating Member

Department of Human Services

Signature:

UN, xy Ape eg

HEATHER SPOONER CORONER Date::16 August 2012

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