Finding into death of Kerry Anne Golley

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2012 1443

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: KERRY ANNE GOLLEY

Delivered On: 13 March 2014

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

Hearing Dates: 13 March 2014

Findings of: JOHN OLLE, CORONER

Police Coronial Support Unit Sergeant Wade

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I, JOHN OLLE, Coroner having investigated the death of KERRY ANNE GOLLEY

AND having held an inquest in relation to this death on 13 March 2014 at Melbourne j

find that the identity of the deceased was KERRY ANNE GOLLEY born on 19 August 1976

and the death occurred on 23 April 2012

at St Vincent’s Hospital, Fitzroy, VIC, 3065

from:

1(a) GLOBAL CEREBRAL ISCHAEMIC INJURY IN THE SETTING OF POST

CAECAL RESECTION FOR COLORECTAL CARCINOMA

in the following circumstances: 1 Kerry Golley was aged 35 years at the time of her death. She led an active community life.

Ms Golley is survived by her parents Ray and Cheryl, and two older brothers, with whom

she maintained a close relationship,

2 A brief was provided by Victoria Police to this Court. It has fully addressed the

circumstances surrounding Ms Golley’s death.

Background

3 Ms Golley was a registered client of Disability Accommodation Services, living in a group home at Wodonga. She resided in this home, with up to five residents, from December 2003 until 23 April 2012, She lived with her parents until she was 19 years old and continued to

return home for special family occasions, 4, Ms Golley had an intellectual disability and was also diagnosed with autism and epilepsy.

Summary Inquest

5 At inquest, a summary was read into evidence by Sergeant Wade. I am satisfied the

summary accurately reflects the evidence,

6. Ms Golley had been taken to her general practitioner or the emergency department at WDH on 12 occasions between December 2011 and February 2012 due to recurring bouts of vomiting. She was not admitted on these occasions, She was adinitted to WDH on 8 March 2012 for 5 days after vomiting and not having passed faeces for several days and on 21

Match for 2 days after more vomiting,

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Ms Golley attended a medical appointment on 27 March 2012 and was placed on a semi-

urgent (category 2) waiting list for a gastroscopy and colonoscopy.

Ms Golley was admitted to Wodonga District Hospital (“WDH”) surgical ward on 9 April 2012 after experiencing a vomiting, constipation and major epileptic seizures, She was transferred to the High Dependency Unit and on 13 April 2012 was diagnosed with a suspected bowel tumour, On 20 April 2012 she was admitted to Albury Base Hospital via accident and emergency. A left hemicolectomy was performed and she was then moved to

the intensive care unit.

On 22 April 2012 Ms Golley was admitted to St Vincent’s Hospital, Melbourne, after not regaining consciousness after what was thought to be a seizure in the High Dependency Unit at Albury Base Hospital on the evening of 21 April 2012, A CT scan suggested brain swelling and Ms Golley was referred to the Neurology and Neurosurgical service for opinion and ongoing treatment. The neurology unit reviewed Ms Golley and determined the most like diagnosis was brain injury following a period of brain hypoxia. The neurosurgery

unit did not think Ms Golley would benefit from intra cranial pressure monitoring.

Ms Golley’s MRI scan described a haemorrhagic 4" ventricular mass compressing the brain stem causing tonsillar herniation. There was some trivial intracranial arterial flow and subsequent minimal venous flow. The cerebral oedema was deemed irreversible. The radiologist thought the mass was most likely a primary tumour, such a glioma or medulloblastoma, A colon resection performed at Albury Base Hospital also demonstrated

colon cancer.

At 2.15pm on 23 April 2012 Ms Golley was declared deceased.

Post Mortem Medical Examination

12,

A post-mortem examination was undertaken by Dr Heinrich Bouwer, Forensic Pathologist at the Victorian Institute of Forensic Medicine, Dr Bouwer found the cause of death to be global cerebral ischaemic injury in the setting of post caecal resection for colorectal

carcinoma.

Dr Bouwer reported that post-mortem neuropathological examination showed evidence of | global cerebral ischaemic injury. There was herniation necrosis of the diencephalon and hippocampal tissue with herniated brain tissue within the 4" Ventricle. There was also cerebellar atrophy. The brainstem and 4"" ventricle demonstrated haemorrhagic necrotic non

neoplastic tissue in which areas of fibrinoid vascular necrosis were present. This appeared to

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represent herniated tissue likely from the hippocampal region and the diencephalon, There was no evidence of tumour infection. It was this herniated tissue that was seen on the antemortem MRI brain scan that raised the suspicion of a metastic lesion. This happened in the background of raised intracranial pressure with herniation of these structures into the

posterior fossa,

14. Dr Bouwer commented that the cause for the global cerebral ischaemia has not been indentified, He stated that it is possible that this was due to hypoxia/ischaemia in the setting of ongoing seizure activity and/or febrile convulsion in the post-operative period. There was no evidence to suggest there was bleeding in the post-operative period or at the autopsy, which may have caused hypoperfusion of the brain and cerebral ischaemia. Also, there was

no evidence of any cardiac disease that may explain this,

15. Post-mortem examination also revealed evidence of recent large bowel surgery with re-

anastomosis of the small bowel to the large bowel. There was no evidence of wound

dehiscence, haemorrhage or other abnormality seen on histological examination,

16. Post-mortem toxicological analysis detected drugs that may have been administered in a therapeutic setting, Analysis also detected a raised C-reactive protein level at 178mg/L (tange <Smg/L), which raises the possibility of a concurrent infection in the body. No focus of infection was identified at autopsy,

Finding

I find the cause of death Kerry Anne Golley to be global cerebral ischaemic injury in the setting of

post caecal resection for colorectal carcinoma.

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

The family of Ms Kelly Golley; Investigating Member, Victoria Police; and Interested parties

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Signature:

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