Finding into death of Colin Frederick Toogood

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2012 4513

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: COLIN TOOGOOD

Delivered On: 12 June 2013

Delivered At: ’ Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne 3000

Hearing Dates: 12 June 2013

Findings of: JOHN OLLE, CORONER

Police Coronial Support Unit Set David Dimsey

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I, JOHN OLLE, Coroner having investigated the death of COLIN TOOGOOD

AND having held an inquest in relation to this death on 12 June 2013 at MELBOURNE find that the identity of the deceased was COLIN FREDERICK TOOGOOD born on 16 September 1946 and the death occurred on 23 October 2012 at 17 Loch Street, Cranbourne 3977 from: 1 (a) UNDETERMINED

in the following circumstances:

1. Colin Toogood was born on 16 September 1946.

2. A mandatory inquest has-been conducted into the circumstances of Colin’s death due to his ‘in-care’ status. Colin lived in residential care under the supervision of Department of Human

Services (DHS) for about 40 years.

3. The coronial brief has fully addressed the circumstances of Colin’s death. |

4. [note the following summary: “Colin Toogood (16/9/1946) died whilst in residential care unit.

Colin Toogood had been living residential care units for over 40 years. Colin had a right

side Hemipligia. Colin kept in close contact with his sister and brother in law.

On the 23" of October 2012 Colin was eating soup for dinner and was complaining that it was too hot. After a while he ate this soup and drank his cup oftea. Colin complained he had a sore neck as he sat and watched tv. During this time he requested three glasses of water, At approximately 6.55pm Colin was aided to the toilet, which was a general

‘from the toilet and entered after knocking.

Colin was slumped over, whilst still sitting on the toilet seat. He appeared to be blue in

the face and not responsive. The carer then placed him on the floor to clear airways and

' Copy of brief remain in court file.

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begin resuscitation, The other workers called 000 and Gerard Wyers was assisted by —

000, talking through the resuscitation process.

Ambulance members attended and continued resuscitation. Colin did not regain

consciousness and the ambulance members declared him deceased.

Police attended and observed a male on the ground in front of the toilet bowl, covered by a blanket. The care unit was kept in a clean and orderly manner. Staff were very approachable and helpful in the investigation of the deceased, and Police had no

suspicions of foul play”?

‘Post mortem examination

On 29 October 2012 Dr Linda Iles Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM) performed an autopsy on the body of Colin Frederick Toogood.

Dr Iles noted the circumstances surrounding death and was unable to determine a cause of death.

Dr Iles commented:

“The deceased, Colin Frederick Toogood aged 66 years reportedly had a history of epilepsy, intellectual disability, brain shunt, hearing impairment and lack of vision in his right eye secondary to a stroke around the time of his birth, He was under DHS care. On the evening of his death, he complained of a sore neck and requested a glass of water.

He then asked a staff member to assist him to the toilet. He was subsequently found slumped forward on the toilet and sideways. Attempts at resuscitation were

unsuccessful.

After complete post-mortem examination, no definitive cause for Mr Toogood’s death has been identified, Post mortem examination demonstrates significant remote brain injury (see below), an incidental carcinoma of the left kidney but does not demonstrate any cardiac pathology capable of causing this man’s death. In addition, there is no

evidence of pulmonary thromboembolism or features of anaphylaxis.

’ Neuropathology exainination demoistrates significant gliosis involving the left middle

cerebral artery territory along with prominent thalamic gliosis in keeping with remote

stroke. There is significant corresponding atrophy of descending white matter tracks. In

Summary Inquest Brief.

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Finding

addition, there is gliosis and residual haemosiderosis about the inferior, temporal and frontal lobes, This change is more in keeping with remote traumatic brain injury. I am unaware of the full details of Mr Toogood’s medical history since birth, I do note that a shunt is referred to in the medical records. No shunt was identified at post mortem , examination, Likewise on review of post mortem CT scans no shunt is seen. Whilst no acute skull fracture is evident, there is evidence of a defect to the right temporoparietal

skull which may represent remote traumatic head injury.

As a result of previous cerebral insults, Mr Toogood had a well documented history of epilepsy. Whilst sudden deaths in the setting of epilepsy are well described (SUDEP),

the circumstances surrounding Mr Toogood’s death are not typical of a SUDEP type

' death and thus I am reluctant to ascribe Mr Toogood’s death as SUDEP.

The circumstances surrounding Mr Toogood’s death are most in keeping with a cardiac mechanism of death. No significant cardiac pathology was identified anatomically.

However, there is a significant possibility that Mr Toogood suffered a sudden cardiac arrhythmia. The substrate for this is not clear at autopsy. The presence of a channelopathy cannot be excluded thus it is recommended that consideration be given to

this man’s next of kin undergoing a review of their cardiovascular health.

Toxicological studies performed after death demonstrate evidence of the use of the anticonvulsants carbamazepine, lamotrigine and phenytoin and levetiracetam. A small

amount of diazepam is also present.

There is no post mortem evidence of violence or injury contributing to death.

This case has been subject to the Institute’s technical review process.

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

death is due to natural causes”, ?

Tam satisfied that Colin died of natural causes. -

I find the cause of death is undetermined, oe ~ . . .

3 Comments section Dr Iles post mortem report.

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I direct that a copy of this finding be provided to the following: Mrs Sandra Wenn, Senior next of kin

Senior Constable J. Malec, Investigating Member

Signature: & my A Ne

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