Finding into death of Sean Raymond Adams

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2012 001042

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, PARESA ANTONIADIS SPANOS, Coroner,

having investigated the death of SEAN RAYMOND ADAMS

without holding an inquest:

find that the identity of the deceased was SEAN RAYMOND ADAMS born on 10 June 1960

and that the death occurred on 20 March 2012

at the Alfred Hospital, 55 Commercial Road, Melbourne Victoria 3004 from:

1(a) MULTIORGAN FAILURE IN A MAN WITH CORRECTED CONGENITAL

COARCTATION OF THE AORTA AND VALVULAR DISEASE.

Pursuant to section 67(2) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Mr Adams was a 51-year-old male who lived with his partner in Elwood. His medical history included chronic obstructive pulmonary disease, asthma, urge incontinence, paroxysmal atrial fibrillation, mitral valve repair, coarctation of the aorta, mitral valve regurgitation,

biventricular heart failure and schizophrenia.

2. Approximately four weeks before his death, Mr Adams presented to The Alfred Hospital Emergency Department (ED) with chest pain, nausea, vomiting and decreased appetite. Blood pathology, echocardiography, computered tomography (CT) pulmonary angiogram, pelvis and abdomen CT, hepatobiliary iminodiacetic acid scan and an ultrasound of the abdomen were all

conducted, none of which were able to diagnose a cause for Mr Adams’ abdominal pain.

3. On13 March 2012, Mr Adams attended The Alfred ED again complaining of chest pain, increasing dyspnoea for three weeks, intermittent left sided chest pain, diapohoresis

(sweating) and persistent right upper quadrant pain. He was diagnosed as having had a non-

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ST elevation myocardial infarction (NSTEMI)! and biventricular heart failure. There was no evidence of palpitations or syncope and acute renal failure; however, his presentation was complicated by a persistent elevated white cell count, ongoing right upper middle quadrant

pain, deranged liver function, acute renal impairment and persistent tachycardia.

Mr Adams was admitted to The Alfred as an inpatient. On 20 March 2012 he was taken to the cardiac catheter suite at approximately 10.30am for an angiogram. However, his International Normalised Ratio (INR)’ was 2.2 seconds placing him at increased risk of bleeding, and so the cardiologist cancelled the angiogram. When Mr Adams returned to the ward at about 12.30pm, he was hypothermic, tachypnoeic and cyanosed, and an Atrovent nebuliser was administered to assist with his tachypnoea. Mr Adams then collapsed with no obvious signs

of life, and a ‘code blue” was called.

An anaesthetist who responded to the call intubated Mr Adams, however, this was somewhat delayed due to appropriate equipment being unavailable to the anaesthetist on the ward. Mr Adams was ventilated by nursing staff as instructed by the anaesthetist, and had a prolonged resuscitation with no return of spontaneous cardiac circulation. After discussion of Mr Adams’ poor prognosis with his family, a decision was made to withdraw active treatment and he died

shortly afterwards at approximately 2.30pm.

An autopsy of Mr Adams’ body was performed by Forensic Pathologist Dr Heinrich Bouwer from the Victorian Institute of Forensic Medicine (VIFM) who reviewed the circumstances as reported by the police to the coroner, the medical deposition and medical records from The Alfred and provided a detailed written report of his findings. Dr Bouwer attributed death to multiorgan failure in a man with corrected congenital coarctation of the aorta and valvular disease and stated that the postmortem examination showed a markedly enlarged heart weighing more than double the expected for a man of Mr Adams’ height and weight. In addition, all four cardiac chambers were dilated and there was evidence of congenital cardiac failure with heavy and congested lungs, bilateral pleural effusions, congested liver and mild ascites. There was a well-healed scar in the anterior wall of the left ventricle of the heart, and

no evidence of pulmonary embolism or sepsis.

"In a NSTEML the blood clot only partly occludes the artery and, as a result, only a portion of the heart muscle being supplied by the affected artery dies.

? INR is a standardised test used to check how well anti-coagulant or ‘blood thinning’ tablets are working.

The hospital emergency code usually used to indicate that a patient requires resuscitation or is otherwise in need of immediate medical attention.

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Toxicological analysis revealed the presence of Haloperidol, Metoclopramide, Olanzapine and Paracetamol within therapeutic ranges. No alcohol or other commonly encountered drugs

were detected.

In correspondence with the court, Mr Adams’ family raised a number of concerns about the

clinical management and care provided to him at the Alfred, including:

e the management of Mr Adams’ psychiatric condition

e the seriousness of his heart condition

e Mr Adams’ comfort in the ward

e his leaving the Alfred after his first presentation in 2012 without a diagnosis and whether there was any follow-up care

e the hospital’s communication with Mr Adams’ family.

It is understandable that Mr Adams’ family were concerned that medical staff were unable to diagnose the cause of his continued abdominal pain. In light of the range of their concerns, I requested that the Court’s Health and Medical Investigation Team (HMIT) review the overall clinical management and care provided to Mr Adams at The Alfred. The HMIT review was based on the medical deposition and medical records, the pathologist’s report and the investigation and brief of evidence compiled by the police. The HMIT concluded that the

overall clinical care and management provided to Mr Adams was reasonable and appropriate.

More specifically, it appears that Mr Adams was in poor health at the time of his death with progressive organ failure and severe biventricular heart failure. HMIT noted that resuscitation for his cardiac arrest was undertaken in accordance with the Australian Resuscitation Council (ARC) guidelines. This included the administration of chest

compressions whilst other causes for pulseless electrical activity were considered and treated.

Also, HMIT advised that Mr Adams’ symptoms and underlying condition were managed carefully during his admission, and were investigated comprehensively, in the setting of a

complex medical history.

Some of the concerns raised by Mr Adams’ family concerning the quality of communication between the family and The Alfred staff, fall outside the reasonable scope of the coronial investigation of his death, and the family have been advised to directed to the appropriate staff

at the Alfred Hospital of the Health Services Commissioner.

I find the cause of death of Mr Sean Raymond Adams to be multiorgan failure in a man with

corrected congenital coarctation of the aorta and valvular disease. The evidence does not

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support a finding that any want of clinical management or care on the part of the staff of

Alfred Hospital, caused or contributed to his death.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected with

the death:

Signature:

Given the current emphasis by the ARC on chest compressions rather than the establishment of an advanced airway or rescue breaths during a cardiopulmonary arrest, I can make no definitive causal connection between the apparent delays in establishing intubation and Mr

Adams’ death.

However, the documentation of the perceived airway difficulties experienced by Mr Adams and need for advanced airway equipment does suggest a lack of communication amongst the staff attending his cardiac arrest, and a need for the staff and management of Alfred Hospital

to discuss these issues further.

Whist the resuscitation appears to have been appropriate and well managed despite the lack of airway equipment, I encourage the Alfred Hospital to address the anaesthetist’s documented

comments about the lack of airway resuscitation equipment on the ward.

I direct that a copy of this finding be provided to the following: Mr Dean Paynter Ms Sharon Adams Ms Vanessa Adams Mr Anthony Adams Dr Matthew Skinner, The Alfred Hospital Ms Jacqui Brown, Alfred Health Clinical Governance Unit Constable Igor Rusmir, St Kilda Road Police Station.

PARESA ANTONIADIS SPANOS CORONER

Date: 18 November 2013

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