Finding into death of Mohammed Tartourssi

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2003/2073

FINDING INTO DEATH WITHOUT INQUEST

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

I, JUDGE IAN L. GRAY, State Coroner having investigated the death of Mohammed TARTOUSSI

without holding an inquest:

find that the identity of the deccased was Mohammed TARTOUSSI born on 29 July 1999

and the death occurred on 28 Junc 2003

at Royal Childron’s Hospital, Parkville Victoria

from:

1, UNASCERTAINED

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

circumstances: Background

1. Mohammed Tartoussi was the sccond of five children of Maria and Malek Tartoussi.

Mohammed was born on 29 July 1999 and dicd on 28 June 2003, aged three years

11 months old. Mr and Mrs Tartoussi have two surviving children.

2. Mrs Tartoussi has TAFE qualifications in nannying and pathology for blood collectors, and was previously a Registered Division II Nurse. Her family medical history includes

asthma and she has siblings who suffer from myotonic dystrophy.’

A chronic, slowly progressing, highly variable, inherited mulli-systemic discase characterised by wasting of the muscles (muscular dystrophy), cataracts, heart conduction defects, endocrine changes, and myotonia.

1 of 10

3. Mr Tartoussi stated that his family history includes a sister who has lost three children to SIDS at the ages of six months, four months and two months, respectively, and who has

a child with a form of genetic dystrophy.

4, Mr and Mrs Tartoussi’s first-born child, four and a half year old daughter, Yasmine died on 2 ‘August 2001, from multiple injuries from an unwitnessed fall from an eighth storey balcony in Lebanon, where the family had been visiting Mr Tartoussi’s relatives.

Yasmine is buried in Lebanon. Mohammed was two years old at the time.

5. On 27 November 2002, Mr and Mrs Tartoussi’s third child, Zakaria, died aged 43 days old from respiratory insufficiency and interstitial fibrosis and low grade pneumonitis of probable viral aertiology, some seven months before Mohammed’s death. Zalcaria’s

death is described in the related finding without inquest?

6, Paediatric Forensic Physician Dr Terence Donald provided a report regarding the Tartoussi children. In relation to Zakaria, Dr Donald’s report, dated 7 June 2005 opined that: :

“it is reasonable to conclude that even though Zachariah (sic) was presented for medical attention five times in his short life there was likely to be present during this period a significant disease process, namely developing pneumonitis. No record was made of any health professional recognising the presence of any respiratory distress or examining Zachariah’s (sic) chest. Chest examination is likely to have revealed

anormulities, particularly in the last week or so of Zachariah’s (sic) life.’” Mohammed

7. Mrs Tartoussi pregnancy with Mohammed was complicated by several occasions of bleeding and intra-uterine growth retardation and reduced foetal movements. During the pregnancy, Mohammed was diagnosed via ultrasound as having bilateral renal pelvis

dilation.

8. Throughout his life, Mohammed was presented to 179 medical consultations with 36 medical professionals at 16 locations. Mrs Tartoussi acknowledged that she increased the frequency of medical presentations following the deaths of her other two children,

Yasmine and Zakaria. Significant presentations include:

? Coroners Cour! of Victoria case number COR 2002 3670.

3 Dr Terence G, Donald, Paediatric Forensic Physichian, tartoussi Paedianic Review, 7 Jane 2005.

2 of 10

Mohammed was admitted to the Royal Children’s Hospital (RCH) at one month old for a urinary tract infection (a common condition related to the

bilateral renal pelvis dilation);

. on 22 February 2000, Mohammed was taken to the RCH after falling out of a shopping trolley. Mohammed lost consciousness briefly and vomited

multiple times. He was diagnosed with a concussion;

on 2 May 2000, Mohammed was noted by the Maternal Child Health Nurse

as having been taken to the RCH following two cyanotic episodes;

. on 11 May 2001, Mohammed was referred to the RCH Emergency

‘ Department with a possible head injury a weck carlier, followed by vomiting;

on 12 November 2001, Mohammed woke with blue hands and lips and was

taken to the RCH where a heart murmur was diagnosed;

in November 2001, following a number of presentations to the RCH with no abnormalities detected on physical examination, Mrs Tartoussi and Mohammed were referred to a consultant paediatrician, Dr Robert Sloane.

Dr Sloane reported that Mohammed played and interacted well and that Mrs Tartoussi was warm and appropriate with Mohammed. Dr Sloane

reported no abnormality in their relationship;

on 2 May 2003, Mrs Tartoussi presented Mohammed to the Bell Street

Family Medical Centre where he was diagnosed with viral gastroenteritis;

. on S May 2003, Mrs Tartoussi presented Mohammed to the Bell Street

Family Medical Centre where he presented with a cough and runny nose;

on 8 May 2003, Mrs Tartoussi presented Mohammed to the RCH stating that he had been unwell and vomiting for five days. Mohammed was admitted overnight and diagnosed as having an acute exacerbation of asthma, vomiting and an upper respiratory tract infection. Mohammed was treated with

Ventolin and Prednisolone and was discharged the following day;

on 14 May 2003, Mrs Tartoussi presented Mohammed to the Bell Street Family Medical Centre regarding an asthma attack; ,

3 of 10

k. on 30 May 2003, Mrs Tartoussi presented Mohammed to the Bell Street Family Medical Centre where he was diagnosed with a viral upper

respiratory tract infection; and

l. on 3 June 2003, Mrs Tartoussi presented Mohammed to the Bell Street Family Medical Centre.regarding a runny nose and cough but no abnormality

was detected on examination.

9, On 28 June 2003, Mrs Tartoussi presented Mohammed to the Bell Street Family Medical Centre at 11.00am regarding a complaint of chest pains. Dr Youssef Khoury examined Mohammed and diagnosed very mild symptoms of an upper respiratory tract infection. Mohammed presented with no signs of severe asthma such as tracheal tags or rib recessions and only mild wheezing. Dr Khoury added Prednisolone to Mohammed’s regular medications (Seretide and Ventolin), and scheduled a follow-up appointment

with Mohammed’s family doctor, Dr William on the following Monday.

10. Mrs Tartoussi stated that on 28 June 2003: a. Mohammed was not his normal self the rest of that day, being ‘off-colour and clingy’; b. she gave Mohammed a dose of the Prednisolone between 12.30-1.00pm;

c. she took Mohammed to the local shop on his bicycle later that afternoon, but

that she had to carry his bicycle home as he was unwell;

d, on their return home from the shops, Mohammed told her that he was not

feeling well and had some chest pain; e. Mohammed put himself to bed early (at approximately 8.30pm); and

f. when he put himself to bed, Mohammed told her to “tell dad T love him more than anything in the world, as much as the world, because | won’t sec him

again”.

11. Mrs Tartoussi was on the phone to a relative when she heard Mohammed’s apnoea alarm (which Mrs Tartoussi had purchased after Zakaria’s death and following a number of cyanotic episodes that Mohammed had apparently suffered) going off. She ran into his toom to find him unresponsive. Mrs Tartoussi ended the phone call and phoned 000 immediately, reporting that Mohammed was unconscious and not breathing. When the

Mobile Intensive Care Ambulance (MICA) paramedics arrived at the home, they found

4 of 10

Mrs Tartoussi performing cardiac compressions on Mohammed. Paramedics noted that Mohammed may have had an asthma attack and continued cardio pulmonary resuscitation (CPR) for 30 minutes on the scene and a further 30 minutes during

transportation to the RCH.

12, On arrival at the Emergency Department of the RCH, Mohammed was observed to be asystolic with fixed and dilated pupils. Resuscitation attempts were continued for a further 20 minutes, unsuccessfully, and Dr Starr pronounced Mohammed dead at 11.5lpm.

13. On 2 July 2003, Associate Professor David Ranson of the Victorian Institute of Forensic Medicine (VIFM) performed a post-mortem examination on Mohammed. Mohammed’s

cause of death was unable to be asccrtaincd.* Investigations

14. In August 2004, following Mohammed’s death, being the only surviving Tartoussi child, the Homicide Squad took over investigation of Zakaria and Mohammed’s deaths.

Following the birth of Mr and Mrs Tartoussi’s fourth child (“A”) in October 2004,

16 months after Mohammed’s unexplained death, the Department of Human Services

Child Protection Unit also commenced an investigation into the Tartoussi family.

15, In October 2004, nine days after birth, A was admitted to the Emergency Department of the RCH following an apnoeic episode (cessation of breathing) at the family home.

During A’s hospital admission, two further apnocic cpisodes were observed by hospital

staff. Epilepsy was considered as an explanation for these episodes. Extensive

investigations were undertaken during A’s period of hospitalisation and, in 2005, it was

confirmed that no metabolic disorder had been diagnosed.

16. On release from the RCH, A was placed on a Children’s Court order, A remained in foster care for 14 months before returning to Mr and Mrs Tartoussi’s care on a Children’s Court supervision order for 12 months, While in foster care, A had twocpisodes requiring hospital attendance. On one occasion, A expcricnced respiratory difficulties which triggered the apnoea moniter and A was admitted to the RCH with a

diagnosis of bronchitis, On the other occasion, A’s carer noticed that A was not

• Assoc, Prof. David Ranson, Victorian Institute of Forensic Medicine, Document detailing) the nature and results of the medical investigation into the death of Mohammed tartoussi.

5 of 10

breathing properly and called an ambulance. A was diagnosed with an acute allergic

reaction.

17. Mrs Tartoussi gave birth to another child (“S”) in November 2007. Within four months of birth, 5 was also admitted to the RCH following an apnoeic episode. The apnoeic episodes continued in hospital and no cause was detcrmined. Pacdiatric Forensic

Physician, Dr Terence Donald, conducted a review in relation to S. Dr Donald opincd:

a. that nothing in the materials ‘raised a suspicion that any of S's episodes of

collapse were induced by another person, in particular (the) mother’, and

b. that tt would have been appropriate for each (of S’s) episode(s) of collapse to have been systematically discussed and investigated from a forensic perspective by forensic paediatricians, DHS Child Protection and the police’?

18. DHS Child Protection involvement with this family ceased in July 2010.

19. Clearly at the time of Mohammed’s death, there was no medical history of epilepsy in the Tartoussi children. In further discussion with Associate Professor David Ranson, the forensic pathologist who performed Mohammed’s post-mortem examination, he advised that:

a. even if epilepsy is part of a cause of death there is often little to find at

autopsy in such cases; and

b. itis possible, however, as a result of the clinical information obtained in relation to epilepsy in subsequent Tartoussi children, that this could have

been part of the mechanism of Mohammed’s death.®

20. I find that Mohammed Tartoussi died on 28 June 2003 of unascertained causes.

COMMENTS

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

with the death:

Dr Terence Donald Paediatric Forensic Physician, Report in relation to ‘S', dated 16 July 2012.

® Report by A/Prof David Ranson dated 19 June 2014.

6 of 10

Multiple medical presentations

24,

During their lifetimes, Mrs Tartoussi presented all five of her children for medical

attention numerous times, ‘The deceased Tartoussi children were presented as follows:

a. Yasmine: During her nearly four and a half years, Yasmine had 179 medical presentations with 41 health professionals in 24 locations, including three

hospitalisations for minof respiratory problems.

b, Mohammed: During Mohammed’s nearly four years, he was presented to 179 medical consultations with 36 medical professionals at 16 locations, including 11 admissions to the RCH generally for vomiting, diarrhoca and asthma. Mohammed’s presentations increased markedly following Yasmine and then Zakaria’s deaths. On the day he died, Mrs Tartoussi presented Mohammed to the Bell Street Family Medical Centre stating that he had complained of chest pains. He was diagnosed as having very mild signs of

an upper respiratory tract infection, but no signs of severe asthma.

c. Zakaria: Zakaria was presented to five medical consultations during his six weeks of life. Complaints included a runny nose, cough, being ‘snuffly’ and

becoming bluc while feeding.

Unfortunately, in Zakaria’s casc, Mrs Tartoussi’s multiple medical presentations regarding his apparent illncss and congested nose appear to have been missed opportunities to identify the respiratory infection that claimed his life. Indced,

Mrs ‘Tastoussi’s concerns appear to have been warranted.

. The two surviving Tartoussi children have also had numerous medical presentations,

including for episodes of turning bluc in the lips, face and extremities,

Mrs Tartoussi, herself, averaged onc attendance at a doctor every fortnight over a 14year period, for a variety of symptoms including chest pains, asthma, upper respiratory infections, pregnancy and headaches. Mrs Tartoussi stated that she would often sce the doctor to seek reassurance that there was no more serious problem. Mrs Tartoussi described herself as an anxious mother who was overprotective of her children.

Mrs ‘Tartoussi stated that her own mother was also anxious and would often take her and her siblings to the doctor. In October 2010, Mrs Tartoussi was diagnosed with epilepsy,

which is now controlled with medication.

7of 10

25,

Mrs Tartoussi acknowledged that her frequency of attending doctors increased following Yasmine and Zakaria’s deaths, but denied ever fabricating any symptoms in Mohammed or Yasmine to get medical attention. Dr Donald surmised that although unable to find evidence that Mrs Tartoussi induced any symptoms or illnesses in her three deceased children, he was “convinced that she did exaggerate or over interpret their symptoms”, behaviour which he found “is not necessarily harmful but nonetheless it is inappropriate

and potentially compromises normal growth and development in children.”

In November 2001, following a number of presentations of Mohammed to the RCH with no abnormalities detected, Mrs Tartoussi was referred to a consultant paediatrician,

Dr Robert Sloane, with a query regarding: Factitious Disorder by Proxy (formerly called ‘Munchausen by Proxy’), Dr Sloane indicated that in his observations of Mrs Tartoussi

and Mohammed, he felt there was no abnormality in the maternal-child interaction,

Medicare reporting system and multiple presentations

29,

As part of the police investigation, the then State Coroner requested that police also

investigate: a. the current system of reporting medical consultations in Victoria; and

b. whether any safeguards are possible to prevent multiple medical

presentations of a child from going undetected in the future.

. Medicare Australia (Medicare) has a system to identify excessive access to medicines

listed under the Pharmaceutical Benefits Scheme (PBS), known as the ‘Prescription Shopping Program’. This system allows providers to identify ‘prescription shopping’ in

patients and make informed decisions about patients’ medication levels.

The police investigation into the Tartoussi sibling deaths identified that a Medicare system enabling recognition of significant numbers of presentations to medical practitioners may have provided an opportunity for the health professionals to investigate Mrs Tartoussi’s over-presenting of her children. Such a system may have alerted medical professionals that there was a problem within the family that required

further testing, including genetic, metabolic or otherwise.

Apart from identifying a need for further investigation or family support, a program that identifies multiple medical presentations may cause a medical practitioner to form a

belief that a child is in need of protection. Victorian medical practitioners are now

8 of 10

—

34,

obliged to report any suspicious activity which creates in them a belief of reasonable

grounds that a child is in need of protection to the Department of Human Services.’

. The basic framework and infrastructure is already in place to allow a similar program to

be created to enable the identification of persons who present on multiple occasions at general practitioners and various health professionals. However, two issues would

constrain Medicare’s ability to create such a program, being:

a. the inability of the system to capture data from within public hospital facilities, as they do not technically bill against Medicare (because they are

funded by the State governments); and

b. legislative amendment would be required relating to privacy considerations and information dissemination beyond the primary purpose for which it was

obtained.’

The first constraint could be overcome by hospitals scanning or storing patients’ Medicare details and registering hospital visits with Medicare. This may require further consideration of changes to the centralised computer/recording programs and

implementation costs would surely follow.

The second constraint comes under the public and private medical sectors’ regulatory instruments. The Health Privacy Principles’ within the Health Records Act 2001 (Vic) regulate use or disclosure of personal and health information for purposes other than the primary purpose for which it was collected. However, several specific categories allow for dissemination of medical information in limited situations and a new category could be included to cover cases of multiple presentations of children within a limited time period, Alternatively, the system need not identify details of treatments or identifying

medical information other than frequency of attendances.

If health professionals could easily access the number and frequency of previous presentations of a child, they could make reasonable and appropriate inquirics to inform

themselves of the child’s circumstances. This could potentially benefit the welfare of

? Children, Youth and Families Act 2005 (Vic), s182(1)(a)-(e), 8184 and s162(c) and (d).

& Health Records Act 200] (Vic) (Health Privacy Principles) and Health Services Act (1988) (confidentiality of a patient’s personal information).

° Health Records Act 2001 (Vic) schedule 1, Iealth and Privacy Principle 2,

9 of 10

children with an undiagnosed problem within the family requiring further testing, or

children at risk.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendations

connected with the death:

1. ifit has not already occurred, that the Tartoussi family consider consulting specialist

genetic services for diagnostic, family health, and/or disease prevention advice; and

2. that the Minister for Health consider improvements in the way data regarding presentation for medical care can be accessed/shared by medical professionals to assist with patient evaluation and care, and that this consideration takes into account the

Comments at paragraphs 27-35 above.

I convey my sincere condolences to Mr and Mrs Tartoussi and their families on the tragic losses of

Mohammed and their other young children, Yasmine and Zakaria.

Pursuant to rule 64(3) of the Coroners Court Rules 2009, I order that this finding be published on

the internet.

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

D/L/S/C Leigh Smyth, Victoria Police Investigating Member Ms Kirsty McIntyre, Department of Human Services

The Hon. David Davis, MP, Victorian Minister for Health

Dr Terrance Donald, Paediatric Forensic Physician

Signature:

DEF nny

JUDGE IAN L. GRAY STATE COR yy Date: 29, (a 6

10 of 10