Finding into death of Angelo Pettolino

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR. 2012 000739

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of; ANGELO PETTOLINO

Delivered On: 14 JULY 2014

Delivered At: MELBOURNE

Hearing Dates: 14 JULY 2014

Findings of: CORONER ROSEMARY CARLIN

Place of death/Suspected death: NORMANBY UNIT, ST GEORGES HOSPITAL, 283

COTHAM ROAD, KEW, VICTORIA

Coroner’s Assistant LEADING SENIOR CONSTABLE STUART

HASTINGS

any se

I, ROSEMARY CARLIN, Coroner

having investigated the death of ANGELO PETTOLINO

AND having held an inquest in relation to this death on 14 JULY 2014

at MELBOURNE

find that the identity of the deceased was ANGELO PETTOLINO

born on 20 FEBRUARY 1920

and the death occurred on 25 FEBRUARY 2012

at NORMANBY UNIT, ST GEORGES HOSPITAL, 283 COTHAM ROAD, KEW, VICTORIA

from:

1(a) ISCHAEMIC HEART DISEASE in the following circumstances:

1. A summary inquest was held in relation to the circumstances of the death of Mr Pettolino in circumstances where he was in care. Although Mr Pettolino died of natural causes, the

holding of an inquest was mandatory due to his “in care” status.

2. Mr Angelo Pettolino was born on 20 February 1920 and he was 92 years old ‘at the time of his death. Mr Pettolino was widowed and is survived by his family, including his children

and grandchildren.

3. A brief was prepared by Victoria Police for the Coroner, including statements obtained from Mr Pettolino’s treating clinicians and from investigating officers. I have drawn on all of this

material as to the factual matters in this finding.

4. Mr Pettolino had previously been living alone at his home in Thombury, Victoria.

Consultant Psychiatrist, Dr Samantha Loi of the Aged Psychiatry Assessment and Treatment Team (APATT) at St Vincent’s Hospital visited Mr Peitolino at his residence on two occasions in late 2011 and early 2012. During her first home visit to Mr Pettolino on 28 October 2011, Dr Loi observed him to have difficulties adjusting to the ageing process and associated changes, including deterioration in his hearing, sight and stamina. He did not

appear depressed or anxious and he enjoyed the company of his family.

5. During her second visit with Mr Pettolino on 4 January 2012, Dr Loi noted that while he did

not appear to be depressed or anxious, his function appeared to have deteriorated. This was

—

evidenced by decreased self-care, not eating, increased smoking and forgetting basic

household tasks.

Mr Pettolino’s family became concerned for his wellbeing and together with his General Practitioner, Dr Bill McCubbery, they arranged increased support for him, He was placed in respite care at Assisi Nursing Home due to escalating behavioural and psychological symptoms of dementia. Mr Pettolino also had a history of gastro-oesophageal reflux,

vitamin D deficiency, vascular dementia and a history of throat cancer.

On 14 February 2012, following unmanageable behaviour at the nursing home, Mr Pettolino was transferred to Normanby House, a psycho-geriatric unit at $1 Georges Hospital in Kew,

Victoria, where he continued to receive treatment as an involuntary patient.

Approximately three weeks prior to his death, Mr Pettolino had a mechanical fall where he

fractured his fourth finger on his left hand.

On 25 February 2012, at approximately 4.00 a.m., staff observed Mr Pettolino having difficulty breathing. He was monitored by staff and appeared to improve. At approximately 6.25 a.m., Mr Pettolino was sitting in a chair in the dining room, near the staff office, when staff again observed him to become breathless and to deteriorate. At this time, staff placed him on the floor and attempted Cardiopulmonary Resuscitation (CPR) however he was

unable to be revived and was confirmed deceased at approximately 6.55 a.m.

An autopsy was undertaken by Dr Michael Burke, Senior Forensic Pathologist with the Victorian Institute of Forensic Medicine. Dr Burke reported that there was no evidence of any injury that would have contributed or led to death. The post mortem examination did not reveal evidence of pulmonary thromboembolism, however showed significant heart disease with cardiomegaly, myocardial fibrosis and associated coronary artery atherosclerosis, The degree of heart disease would be consistent with causing sudden death as a result of a cardiac arrhythmia. Dr Burke reported a teasonable medical cause of death

as 1(a) Ischaemic Heart Disease.

. Toxicological analysis of post mortem blood samples detected the sedative, Oxazepam

(0.05mg/L) and antipsychotic medications, Olanzipine (0.lmg/L) and Risperidone (4ng/mL).

12. Lam satisfied having considered all of the evidence before me that no further investigation is

required, There were no suspicious circumstances, I am satisfied that the clinical care

provided to Mr Pettolino was satisfactory.

13.1 find that Mr Angelo Pettolino died on 25 February 2012 and that the cause of his death

was Ischaemic Heart Disease.

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

The family of Angelo Pettolino; The Investigating Member; and

Interested parties.

Signature;

ROSEMARY CARLIN CORONER.

14 July 2014