Finding into death of Rodney David Keegan

IN THE CORONERS COURT - OF VICTORIA AT MELBOURNE

Court Reference: COR 2011 2543

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: RODNEY DAVID KEEGAN Heating Date: 10 October 2012 Findings of AUDRBY JAMIRSON, CORONER Police Coronial Support Unit — Leading Sonior Constable Nadine Harrison

Delivered On: , 26 October 2012

Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne 3000

Delivered At:

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I, AUDREY JAMIESON, Coroner having investigated the death of RODNEY DAVID KEEGAN AND having held an inquest in relation to this death on 10 October 2012

At Melbourne

find that the identity of the deceased was RODNEY DAVID KEEGAN

born on 13 August 1969

and the death occurred on 12 July 2011

at Maroondah Hospital, Davey Drive, Ringwood Hast 3135

from: 1(a CARDIOMYOPATHY IN A MAN WITH AN ACUTE ABDOMEN

in the following circumstances:

1. Mr Rodney Keegan was 41 years of age at the time of his death. He had a history of

. intellectual disability, epilepsy and psychosis, He had undergone cardiac surgery in the past

for a congenital heart condition. and had right sided paralysis subsequent to a stroke. He was

treated with a number of medications including the anticoagulant, Warfarin. Mr Keegan lived

in a Department of Human Services Community Residential Unit (CRU) at 5 Mitchell Road, Mount Albert North.

2. On6 fuly 2001, Mr Keegan-was admitted to Maroondah Hospital following a fall at the CRU.

On admission he was found to have an elevated INR! of 7.5 which was treated and reversed to

1.8. ACT scan of the brain showed no evidence of haemorrhage.

4. On 9 July 2011, Mr Keegan developed abdominal pain, distension and tachycardia. A CT

Scan of the abdomen identified free fluid but no cause was found. At 8.00pm a Code Blue was

' The target range for INR in anticoagulant use (e.g. warfarin) is 2 to 3. In some cases, if more intense anticoagulation is thought to be required, the target range may be 2,5-3.5. .

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called for an episode of apnoca. He was transferred to the Intensive Care Unit and later suffered an electro-niechanical dissociation (BMD)? attest. He was intubated and Cardiopulmonary Resuscitation (CPR) was performed for 13 minutes before the return of

spontaneous circulation. It was suspected that he had aspirated during intubation attempts.

4. Mr Keegan’s condition failed to improve in the following days. The possibility of abdominal sutgery was discussed with Mr Keegan’s family, however, a decision was made not to prolong

his suffering.

5, Onl July 2011, Mr Keegan was extubated, He died at 12.08am on 12 July 2011.

6, The death of Rodney David Keegan was reportable as immediately before his death he was @

person placed in custody or care as it is defined in the Coroners Act 20087 Investigation

7. Dr Noel Woodford, Forensic Pathologist at the Victorian Institute of Forensic Medicine, "performed a preliminary examination of the body of Rodney Keegan, reviewed a post mortem _ CT scan and the medical records and reported to the Coroner that the cause of the intra- :

‘abdominal fluid identified on the ante mortem CT scan was not entirely apparent. He advised

that only a full post mortem examination would provide clarity to the acute medical issues

sutrounding Mr Keegan’s death, However, as Mr Keegan’s family had expressed an objection

to an autopsy being performed and having regard to Mr Keegan’s significant medical issues

over a prolonged period, Dr Woodford stated that a reasonable cause of death that accounted

for the terminal circumstances could be attributed to cardiomyopathy in a setting of acute

abdomen.

8. The Police investigation did not identify any suspicious circumstances. No issues with regard

to the care or medical management of Mr Keegan were identified.

9. An Inquest was held pursuant to section 52(2)(b) Coroners Act 2008,

2 pulseless Electrical Activity (or Electro-Mechanical }issociatian - EMD) is present when the ECG shows a rhythm normally associated with an output but with no detectable central pulse,

3 Section 3 — person placed in custody or care means — (d) a person under the control, care or custody to the Secretary to the Department of Human Services or the Seerctary to the Department of Health

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10, Leading Senior Constable Nadine Harrison provided a summary of the circumstances to the

Coroner. No witnesses were called to give evidence,

Finding accept and adopt the medical cause of death as identified by Dr Woodford and find that Rodney David Keegan died from natural causes being cardiomyopathy ina setting of an acute abdomen.

The exact cause of the acute abdomen was not however identified.

AND I further find that that there is io causal relationship between the cause of Mr Keegan’s death

and the fact that he was a person placed in custody or care.

Pursuant to section 73(1) of the Coroners Act 2008, I order that the Finding be published on the

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

Mrs Anne Keegan Secretary to the Department of Human Services

Constable Samara Jones, Ringwood Police Station, Investigating Member Eastern Health Signature: -

AUDREY CnaESON CORONER orn, _ Date: 26 October 201

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