Finding into death of Luke Matthew Thomson

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2011 2174

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of LUKE THOMSON

Delivered On: Delivered At: Coroners Court of Victoria Level 11, 222 Exhibition Street, Melbourne 3000 Hearing Dates: 10 April 2013 Findings of: HEATHER SPOONER, CORONER

Police Coronial Support Unit Leading Senior Constable Nadine Harrison

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I, HEATHER SPOONER, Coroner having investigated the death of LUKE THOMSON

AND having held an inquest in relation to this death on 10 April 2013

at MELBOURNE

find that the identity of the deceased was LUKE MATTHEW THOMSON born on 28 February 1983

and the death occurred on 15 June 2011

at 11-13 Green Island Avenue, Mount Martha 3934

from:

1(a) ASPIRATION PNEUMONIA

2 CEREBRAL PALSY AND EPILEPSY

in the following circumstances:

1h,

Mr Thomson was aged 28 years when he died. He resided in a Department of Human Services (DHS) home situated at Green Island Group Home, 11-13 Green Island Avenue, Mount

Martha. Mr Thomson had a past medical history that included severe cerebral palsy.

A police investigation was conducted into the circumstances surrounding the death. Although Mr Thomson apparently died from natural causes his death was reportable as Mr Thomson was ‘in care’ at the time. His death was also subject to a mandatory inquest pursuant to section

52(2)(b) which states as follows:

‘.. Subject to subsection (3), a coroner must hold an inquest into a death if the death or cause

of death occurred in Victoria and —

(b) the deceased was, immediately before death, a person placed in custody or care; or...’ At the Inquest, a summary was read to the court by my assistant:

“Luke Thomson was born on 28" February 1983 and was 28 years old at the time of his death. For 14 years prior to his death, Mr Thomson resided at and was cared for at 11-13 Green Island Avenue, Mount Martha, which is a Department of Human Services Intellectually Disabled Care Facility. Mr Thomson was born with severe infantile cerebral palsy and epilepsy and had been unable to walk, talk or care for himself in any way. He also suffered

recurrent Aspiration Pneumonia.

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Events Leading up to Incident

On Tuesday 1 4" June 2011 at approximately 10.00am, Luke Thomson was observed by staff at the Green Island Group Home Mount Martha to be experiencing breathing difficulties. Mr Thomson was taken by ambulance to the Frankston Hospital Emergency Department where he was diagnosed with severe Aspiration Pneumonia. He was prescribed antibiotics Keflex,

Midazolam and Morphine.

At approximately 4.00pm, Mr Thomson was discharged from Frankston Hospital and

returned to the Green Island Group Home.

At approximately 4.00pm, Mr Thomson was discharged from Frankston Hospital and

returned to the Green Island Group Home.

At approximately 9.30pm, Dr Wise attended the Green Island Group Home where he reviewed

Luke Thomson situation and signed a treatment order.

At approximately 11.30pm, care assistant Kimberley Baines conducted a routine check on Mr Thomson and found him to have a temperature of 36.5 degrees and his breathing a bit shorter

than at the beginning of her shift, he was comfortable and resting.

On 15" June 2011, at approximately 12.20am Kimberley Baines conducted a routing check on Mr Thomson and found him not breathing, cold to touch with a slight blue complexion, she immediately called 00, requested an ambulance to attend and contacted the House Supervisor Gale Gault. Paramedics and the House Supervisor Gale Gault attended at the Green Island

Group Home at approximately 1.00am.

Medical Attention following Incident and Subsequent Death

Paramedics attended and were unable to detect any vital signs and Mr Thomson was pronounced deceased. No Cardiopulmonary Resuscitation (CPR) was conducted on Mr

Thomson.

A subsequent autopsy performed confirmed that Luke Thomson had died peacefully and primarily as a result of Aspiration Pneumonia and that Cerebral Palsy and Epilepsy were

?

contributing factors. '

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A statement from Mr Thomson’s mother contained in the brief indicated that she was satisfied with the quality of care provided to her son both in the Frankston Hospital and the DHS home.

There was also a statement from Dr Labattaglia, Emergency Consultant, in which he stated in

part:

“On 14" June 2011 at 1100 hours I treated Mr Thomson, of 11-13 Green Island Avenue Mount Martha, in the Frankston Hospital Emergency Department (ED). I was working as

one of the Senior Emergency Consultants in the ED on the day.

Mr Thomson presented to the ED with his mother. His presenting compliant was fever and increasing respiratory distress for approximately 6 hours. Whilst examining him, he had a short, self limited seizure. Mr Thomson was clearly in respiratory distress and had clinical

findings suggesting that he had moderate to severe aspiration pneumonia.

Mr Thomson had severe cerebral palsy resulting in him being non-verbal, requiring PEG feeds, having poorly controlled epilepsy and requiring high level care. According to his mother his condition had significantly worsened over the preceding 2 years and he was

having increasingly frequent episodes of aspiration pneumonia.

A long discussion between his mother, myself and his primary carer established an agreement that Mr Thomson had a very poor quality of life with significant and increased suffering secondary to his medical conditions. We also established that further active treatment was unlikely to result in any improvement in his quality of life and would likely result in increased suffering. This suffering would likely manifest as multiple attempts at resiting his intravenous

line, increasing ulcers on his heels, ongoing postural pain and recurrent infections.

A management plan for this presentention was a compromise between full palliative care and treatment of his aspiration pneumonia as requested by his mother. In order to return him to his residential care facility/home environment as soon as possible (where he is more comfortable) it was decided that a single dose of intramuscular antibiotics be administered

along with analgesia. Mr Thomson was to continue on antibiotics via his PEG feeding tube.

The palliative care team were contacted and agreed to review Mr Thomson once he returned to his residential care facility/home, to ensure he was comfortable. His mother understood

that he was very unwell and likely not to survive his current episode of pneumonia.”

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An Autopsy was performed by Dr Malcolm Dodd, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM). He formulated the cause of death and in his report

commented:

“The immediate cause of death in this case is one of aspiration pneumonia in a man with

cerebral palsy and epilepsy.

On 14th June 2011, the deceased was noted by nursing staff to be having difficulties breathing.

The deceased was transferred to Frankston Hospital Emergency Department where he was

diagnosed with severe aspiration pneumonia.

The deceased was prescribed antibiotics and analgesics and was discharged and returned to

the DHS Group Home.

A routine check at a later time disclosed the deceased to be comfortable and resting.

On 15th June at approximately 00:20 hours, a routine check found the deceased to be not

breathing and cold to the touch.

Ambulance officers were summoned; death was pronounced as a result of natural causes.

The external examination disclosed a PEG tube inserted above the umbilicus.

The remainder of the external examination was otherwise unremarkable in the context of the

past medical history.

An internal examination showed consolidation of the right and left lower lobes.

Histological examination confirmed confluent bronchopneumonia with zones of acute

inflammation and resolution.

In addition, foreign body giant cells were noted in keeping with past episodes of aspiration.

A lung swab produced a growth of Pseudomonas aeruginosa and Proteus mirabilis.

Additional examination disclosed a rounded heart, a bulky thyroid gland and a tense brain

showing aged changes.

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Toxicological analysis of body fluids disclosed elevated levels of glucose in vitreous humour

(approximately 36 mmol/L) and acetone bodies in blood and vitreous humour.

Biochemistry was otherwise non contributory.” Finding

It is apparent that Mr Thomson unfortunately died from aspiration pneumonia which had been a

recurrent problem in the context of his underlying cerebral palsy and epilepsy.

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

Ms Heather Thomson, Senior Next of Kin

Senior Constable Johann Meyer, Mornington Police Station, Investigating Member Department of Human Services

Interested Parties

Signature:

= Wa Sg eS

-HEATHER SPOONER CORONER Date: 15 May 2013

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