Finding into death of Anthony Ian Gaylard

IN THE CORONERS. COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2012 / 3970

FINDING INTO DEATH WITH INQUEST

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

Inguest into the Death of: ANTHONY IAN GAYLARD

Delivered On: 23 September 2013

Delivered At: Level 11, 222 Exhibition Street Melbourne 3000

Hearing Dates: 23 September 2013

Findings of: JOHN OLLE, CORONER

Police Coronial Support Unit Leading Senior Constable Tania Cristiano

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I, JOHN OLLE, Coroner having investigated the death of ANTHONY GAYLARD

AND having held an inquest in relation to this death on 23 September 2013 at Level 11, 222 Exhibition Street, Melbourne 3000

find that the identity of the deceased was ANTHONY JAN GAYLARD born on 10 August 1955

and the death occurred on 21 September 2012

at Monash Medical Centre, 246 Clayton Road, Clayton 3168

from:

1(a) HYPOXIC ISCHAEMIC ENCEPHALOPATHY FOLLOWING CARDIAC

ARREST

in the following circumstances:

1. Anthony Gaylard lived in care at 22 Rutherglen Street, Noble Park.

2. A mandatory inquest has been held this day.

33 I am satisfied the summary of evidence read by my assistant is an accurate reflection of the circumstances of death.

Background

4. Anthony had a lengthy medical history which included severe intellectual disability, depression, obsessive compulsive disorder and blindness secondary to glaucoma. He

received a variety of medications.

Circumstances

5. On 14 September 2007, Anthony was in a group outing in a bus with other members from his care facility. The diiver noticed him to be having a seizure, not breathing, had vomited and became unconscious. Ambulance personnel attended and transferred Anthony to the

Monash Medical Centre. The-initial CT image showed an hypoxic brain injury.

6. Anthony was transferred to the ICU. Over following days he suffered fevers, raised inflammatory markers and renal failure and showed no sign of meaningful neurological

recovery.

7. Following discussions with the family on 20 September 2012, the decision was made to

extubate Anthony and to provide palliative care. He died on the 21 September 2012.

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Post mortem medical examination

On the 26 September 2012 Dr Clare Hampson, Forensic Pathologist Registrar under supervision of Associate Professor David Ranson at the Victorian Institute of Forensic

Medicine performed an autopsy on the body of Anthony Ian Gaylard.

Dr Hampson noted the history and formulated the cause of death as hypoxic ischaemic

encephalopathy following cardiac arrest.

Dr Hampson commented:

“Post mortem examination revealed food matter in the larynx, myocardial fibrosis with mural thrombus, pulmonary thromboembolism, pulmonary fibrosis complicated by pulmonary hypertension and right ventricular hypertrophy, and cirthosis complicated by portal hypertension (splenomegaly and oesophageal varices).

Ischaemic necrosis within the ascending colon was present, likely secondary to

cardiac arrest.

Neuropathological assessment revealed global cerebral ischaemic injury. Please see

accompanying Neuropathology report for details.

In my opinion, the cause of death was hypoxic ischaemic encephalopathy following cardiac arrest. This is a condition that describes diffuse injury to the brain from a period of reduced cerebral blood flow and/or oxygen supply. In this case, the sequence of events leading to arrest is unclear; a primary cardiac arrhythmia may have caused a hypoxic seizure with aspiration of food matter, or alternatively a seizure may have been complicated by food aspiration and cardiac arrest. The findings of myocardial fibrosis (scarring of the heart) and mural thrombus (blood clot attached to the wall of the heart) indicate that the heart had sustained damage in the past and was not moving normally, which can predispose to cardiac arrhythmia.

Significant chronic liver and lung disease was present, which may have precipitated arrest or seizure due to metabolic derangement and/or low oxygen. There was no

clinical history of a primary seizure disorder such as epilepsy.

Toxicological analysis of blood detected medications that the deceased was known

to be taking and was non-contributory to death.

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On the basis of information available to me at this time, I am of the opinion that this

death was due to natural causes.”

Finding I find the cause of death of Anthony Ian Gaylard to be hypoxic ischaemic encephalopathy following

cardiac arrest.

I direct that a copy of this finding be provided to the following: The Family of Anthony Gaylard Senior Constable Joanne Thompson, Investigating Member, Clayton Police Station

Supervisor, aa Street, Noble Park

Signature:

fi

JOHN OLLE CORONER

' Post mortem report Dr Hampson

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