Finding into death of PT

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2012 / 0236

REDACTED FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: PT

Delivered On: 23 August 2013

Delivered At: Coroners Court Melbourne Hearing Dates: 7 February 2013

Findings of: John Olle

Place of Death: Preston

Police Coronial Support Unit Kelly Ramsey

At the Coroners Court at Melbourne, I, John Olle, Coroner having investigated the death of PT

AND having held an inquest in relation to this death on 7 February 2013 at Melbourne find that the identity of the deceased was PT aged 57 and the death occurred on or about 19 January 2012 at Preston 3072 from: 1 (a) ASPIRATION PNEUMONIA IN AN HIV POSITIVE MAN ON METHADONE

in the following circumstances:

1. PT resided at Darebin Lodge, Preston’.

2. Achronic alcoholic and drug user, PT was HIV positive. His medications included

methadone.

3. Inthe days prior to his death, PT’s behaviour had become erratic, On 16" January 2012, he

was seen by General Practitioner Dr Bowles.

4, The summary of evidence accurately details:

“On 19 January 2012, the on site facility manager, Lawrence Thambu, noticed that PT was not quite normal and, when due to administer 100mg of methadone, hesitated and contacted Dr Bowles. Due to PT’s behaviour and sleepy state, an ambulance was called to the facility at about 4.00pm. After assessing PT, who at the time was lucid, conversant and refusing to go to a hospital, the ambulance officer Qulie Thorn, Northland 25 # 46523) advised staff (Thambu) to monitor PT and if his

condition changed, to call an ambulance again.

Communication then took place between Dr Bowles and the pharmacy (Medi Pharmacy in Preston) about the strength of the methadone dosage. It was

recommended to reduce the dose to 50mg, which was given to PT about 5.00pm.

' DHS managed care facility

Later in the evening, at about 8.30pm, Personal Care Assistants gave PT his medication: 7.5mg of Imovane; 1000mg of Valerian; 10mg of Bacio; and 2mg of Alprzolam. The care workers, Arun Sasioharan and Quentin Waters had to assist PT into bed. When checking PT’s jeans they located three unopened syringes. When

questioned about the syringes, PT did not answer.

At 10.00pm, Mr Waters and Mr Sasioharan checked PT and he was sleepy, but

otherwise appeared okay.

At 7.30am on 20 January 2012, Mr Sasioharan checked PT’s bedroom and attempted to wake PT, who did not move. He then shook PT’s leg but it was very stiff. There appcared to be vomit around his mouth and on the sheet. An ambulance was then called from the room. Ambulance officers attended and found that PT had passed

away.

Police attended the scene. A search of the room revealed no signs of drug use, of any struggle or anything out of the ordinary. PT was found in bed, covered with a

blanket, laying on his righthand side”.

Post Mortem Medical Examination

5. On25™ January 2012 Dr Gunawardena, Pathology Registrar performed an autopsy on the body of PT.

6. Dr Gunawardena found the cause of death be aspiration pneumonia in an HIV positive man on methadone.

7. Dr Gunawardena commented:

“Mr PT was known to be a chronic alcoholic and drug abuser who was diagnosed with HIV and Hepatitis C infection. He was residing at a managed care facility and had beon on inethadone. [He was found dead on 20/01/2012 at 0730 hours. On the day prior to his death the facility manager had found him to be abnormal and after consultation with the deceased doctor had given him half the normal methadone

dose. There had not been any signs of recent drug use.

At autopsy, he had evidence of bronchopneumonia involving the right lower lobe

with aspirated gastric contents. The left lower lobe also showed evidence of

? Summary of Police evidence

Under supervision of Dr Matthew Lynch, Forensic Pathologist

bronchopneumonia. His left anterior descending coronary artery showed 75% narrowing of the lumen with calcified atheromatous deposition.

His methadone levels in post mortem blood were 4mg/L and in addition he had Alprazolam and Zopiclone at levels consistent with therapeutic use. Methadone is a drug used therapcutically for the treatment of opiate dependence. A significant side effect of this drug is respiratory depression and sedation, which can lead to loss of protective reflexes of the airway and aspiration. Pneumonia is a common and expected complication of recurrent aspiration.

Autopsy did not reveal any evidence of AIDS defining illness.

There were no injurics to suggest any violence or trauma that could have caused or

contributed to death. * Finding

I find the cause of death of PT to be aspiration pneumonia in an HIV positive man on methadone.

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

PT’s Family Darebin Lodge, Preston Detective Sergeant Michael Wholohan, Darebin CIU, Preston Police Station

Signature:

/ of,

JOHN OLLE // CORONER /

Date: 2 a

“ Dr Gunawardena’s post mortem report

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