Finding into death of Argyrios Carras

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference:

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: ARGYRIOS CARRAS

Hearing Dates: 9 May 2013

Police Coronial Support Unit Senior Sergeant Jenny Brumby

Findings of: AUDREY JAMIESON, CORONER Delivered On: 9 May 2013 Delivered At: Coroners Court of Victoria

COR 2012 0986

Level 11, 222 Exhibition Street, Melbourne 3000

Lof4

J, AUDREY JAMIESON, Coroner having investigated the death of ARGYRIOS CARRAS

"AND having held an inquest in relation to this death on 9 May 2013 at MELBOURNE find that the identity of the deceased was ARGYRIOS CARRAS born on 5 February 1974 and the death occurred on 17 March 2012

at Austin Health, Heidelberg Repatriation Hospital, 300 Waterdale Road, Heidelberg West 3081 from:

1(a) ASPIRATION PNEUMONIA IN THE SETTING OF CEREBRAL PALSY

in the following circumstances:

1. Mr Argyrios Carras was 38 years of age at the time of his death. He lived at 79 Telopopea

Crescent, Mill Park, Share Supported Accommodation, Disability Services, North and West

Metropolitan Region (NWMR) — a Department of Human Services facility.

2. Mr Cartas had intellectual and ‘physical disabilities including Congenital Cerebral Palsy,

scoliosis and oesophagitis. He received all of his food and medication via a PEG tube. He

was wheel chair bound and required full assistance for all activities of daily living. He was

susceptible to Lower Respiratory Tract Infection and had a history of frequent chest infection.

Mt Carras was non verbal but had good comprehension skills and would indicate preferences

by smiling and frowning.

Surrounding Circumstances

3. In the two months leading up to Mr Carras’ death, he was noted to have increased spasms

and/or seizure activity.

4, On 10 March 2012, Mr Carras was administered Diazepam for increased spasms with little

effect. That evening staff contacted the on-call for a further Diazepam order reporting that Mr

Carras was having increased spasms, sweating and not breathing well. Staff were directed to

contact an ambularice service to transport Mr Carras to hospital.

5. On11 March 2012, Mr Carras was admitted to the Austin Hospital at approximately 8.20am.

He was subsequently admitted to Medical Unit 1 for investigations to explore potential causes

20f4

of his increasing spasm. An electroencephalogram (EEG) showed no obvious evidence of epilepsy — type electrical activity, A chest X-Ray identified changes which appeared to be consistent with pneumonia or aspiration. Mr Carras was treated with intravenous antibiotics and frequent suctioning for upper airway secretions. His condition however continued to

deteriorate.

6. On16 March 2012 active management was ceased and palliative care implemented following a discussion with Mr Catras’ mother. On 17 March 2012, Mr Carras was transferred to the

Palliative Care Unit. He died later that day with his mother in attendance.

INVESTIGATION Identity

7. The identity of Argyrios Carras was without dispute and required no further investigation.

Medical Investigation

8: Dr Matthew Lynch, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an external examination on the body of Argyrios Carras and reviewed a post mortem CT scan. Dr Lynch reported that in the absence of a full post mortem examination, and having regard to the circumstances, a reasonable cause of death could be attributed to

aspiration pneumonia in the setting of cerebral palsy.

Police Investigation

9, The police investigation and preparation of the coronial Brief of Evidence was prepared by

Constable Daniel Elliott.

INQUEST

10. An inquest was held in accordance with section 52(2) of the Coroners Act 2008 as immediately before his death Mr Carras was a person placed in custody or care as it is

defined in section 3 of The Act.

11. No issues were identified in the course of the investigation and a summary of the circumstances was provided to the Court by Senior Sergeant Jenny Brumby from the Police

Coronial Support Unit.

3084

Finding

I accept and adopt the cause of death as identified by Dr Matthew Lynch and find that Argyrios

Carras died from aspiration pneumonia in the setting of cerebral palsy.

AND I further find that there is no evidence of a relationship between the fact that Mr Argyrios

Carras was a person placed in custody or care and the cause of his death.

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

Mrs Shirley Carras Austin Health Constable Daniel Elliott, Greensborough Police Station

Mr Shane Beaumont, Disability Services, Department of Human Services

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

internet:

Signature:

Date: 9 May 2013

4 of 4