Finding into death of Frank (Francesco) Sette

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2012 2713

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: FRANK (FRANCESCO) SETTE

Delivered On: 10 February 2014

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

Hearing Dates: 10 February 2014

Findings of: JOHN OLLE, CORONER

Police Coronial Support Unit Sergeant Sharon Wade

lof7

1, JOHN OLLE, Coroner having investigated the death of FRANK (FRANCESCO) SETTE

AND having held an inquest in relation to this death on 10 February 2014

at Melbourne

find that the identity of the deceased was FRANK (FRANCESCO) SETTE born on 19 June 1940

and the death occurred on 10 July 2012

at Western Health Sunshine Hospital, 176 Furlong Road, St Albans 3021

from:

1(a) CRANIAL FRACTURE AND INTRACRANIAL HAEMORRHAGE 1(b) FALL

in the following circumstances:

1. Frank Sette was aged 72 years at the time of his death.

Zs The coronial brief is comprehensive and has fully addressed the circumstances of death.!

3. An inquest has been conducted by virtue Frank was an involuntary patient at the time of his death.

Background

4. Frank’s sister Caterina Marino has provided a detailed statement which has provided valuable insight and background and assisted my investigation.

5. I note as a younger man Frank was a tailor. He returned to his home town Dasa to find a girl to marry. He was successful and subsequently married Elisabetta and the marriage produced two children Maddalena and Marisa born in 1969 and 1970 respectively.

6. Unfortunately the marriage could not sustain Frank’s jealous behaviour, Caterina explained

he started accusing his wife of things she simply hadn’t done. Catarina fully understood Elisabetta’s decision to take the children and move in with her mother. Frank initially saw

his daughters however when his parents died in 1991 he didn’t see them again.

"A copy of the coronial brief will remain with the court file

20f7

Mental Illness Diagnosed

Catarina explained that Frank’s schizophrenia was first diagnosed in the mid 1980’s. [note that Catarina visited Frank only days before his fall. Jt is clear that Catarina at all times

remained supportive of her brother despite the complexities of his mental health illness.

Menta] Health Treatment

My investigation has been assisted by reports from clinical staff from North Western Mental

Dr Sabah Khalid, Consultant Psychiatrist detailed the complex psychiatric history and the numerous contacts with Western Aged Psychiatric Assessment Treatment Team (APATT) over many years. Dr Khalid explained that Frank had several inpatient admissions mainly

with a psychotic relapse in the context of non compliance with treatment.

Dr Khalid explained that shortly that Frank’s marriage had broken down when he developed delusions of infidelity regarding his wife. He was diagnosed shortly after this with Paranoid

Schizophrenia.

Most recent admission to Sunshine Aged Person’s Mental Health Unit

Dr Khalid explained:

“His most recent admission to the Sunshine Aged Person’s Mental Health Unit occurred on the 7” of June 2012. He had been discharged off his CTO in recent months but was recommended for involuntary treatment on admission by the oncall psychiatry registrar, Dr Arup Dhar. 1 initially assessed him on the 8"" of June 2012 for a Stat review in which his involuntary status was upheld and he was then treated in hospital as a Section 12 patient under the Mental Health Act of Victoria. A full set of blood tests was organised which showed no abnormality, He was nursed in the High Dependency Unit under 15 minute visual observations mainly due to concerns regarding the safety of other patients and staff. He presented with a severe psychotic relapse in the context of recent bouts of physical illness with infective exacerbation of chronic lung disease and non compliance with treatment. At the time of admission Mr Sette was experiencing auditory hallucinations with persecutory, religioce and grandiose themes. He showed no insight into his condition insisting that he did not require treatment, Mr Sette did not express suicide

ideation, intent or plan at any time during his admission.”

3 of 7

Dr Khalid further explained:

“My last review of Mr Sette prior to his fall was on the 28"" of June. He presented with psychotic symptoms and persecutory themes around the staff and myself. His medications were progressively titrated up and he was no on Sodium valproate 200mg bd, risperidone Quickletts 2mg bd with additional use of prn Olanzapine 5mg upto a maximum of 10mg in a 24 hour period. At this point, I was increasingly concerned about the deterioration in Mr Sette’s mental state. I had a discussion with Consultant Psychiatrist Dr Louise Kerr who also works at Sunshine Aged Person’s Mental Health. I was considering the use of Depot Injection Zuclopenthixol Acetate that day for control of his acute psychosis and agitation. My concern was that he already had his depot medication Ripserdal Consta 50 mg on board and I did not want to over medicate him and risk the risk of cardiac side effects, excess sedation

and medication interaction.

On discussion with Dr Kerr we decided that giving his further. depot medication carlier than the due date was too risky, particularly given his cardiovascular history.

A decision was made to continue him on his current medication regimen, observe him very closely, maintain in HDU with no leave on 15 minute visual observations.

His next depot medication was due on the 4" of July. I conducted a file review on his treatment history and concluded that the medication he had demonstrated the most optimum treatment response to was depot Flupenthixol. It was decided that on

the date his next depot was due, he would be switched back to depot Flupenthixol.

I then returned to the ward in the morning of Friday 29" June and found that Mr Sette had a self inflicted fall on the evening of the 28" of June. This fall had resulted in an intracranial bleed and he had been transferred to a medical ward at Sunshine

Hospital where he was being treated palliatively.””

Dr Neil Wareing was present in the ward when Frank fell.

Dr Wareing explained:

“At approximately 16:30 on 28 June 2012 Mr Sette was observed by nursing staff to walk out of his bedroom, stand with arms outstretched to the sides, and throw

himself backwards onto the floor. It was not definitively clear whether he had struck

? Statement Dr Khalid

4of7

17,

his head in the fall, but this was the main concern. I was immediately notified of the event, spoke to and examined Mr Sette at this time. Her was alert, with a GCS of 15/15 and briefly complained of pain at the back of his head. He went on, in disorganised speech, to mention “God” and “Jesus” as he had done throughout the admission. He had no focal swellings or bony defects evident on palpation of his skull. He was helped back to bed by myself and three nurses, where he was able to obey simple commands. His pulse rate, blood pressure, temperature and respiratory rate were stable and within normal limits. I asked that neurological observations be continued. At approximately 16:55 I was informed by one of Mr Sette’s nurses that

he had started dry retching.””

Dr Wareing thereafter detailed his observations, conversations with fellow clinical staff and

tests performed, in particular the CT head scans which unfortunately

“showed a significant acute intracranial haemorrhage. Mr Sette was then sent to the

Sunshine Emergency Department for ongoing management.”*

Statements of nursing staff who witnessed the fall further assisted my investigation. In particular the statement of Sarah Adamek, Division 1 Nurse. She explained whilst with fellow nurses on the floor, Frank was observed to be responding to auditory hallucinations, he was rolling on the floor and appeared drowsy as he hadn’t slept the night before. She

stayed with Frank on a 1:1 basis to prevent him harming himself or others:

“At one point he grabbed a table and nearly pulled it on to himself. At one stage he appeared to be banging his head for less than 60 seconds, so by the time a pillow was placed under his head he had stopped. He explained that he had done something bad

and was repenting to God.”* Nursing staff assisted Nurse Adamek hoist Frank from the floor:

“Whilst in the hoist Frank was smiling and laughing as if he was enjoying being there. He maintained good eye contact with me and smiled at me when I greeted him. We assisted him back to bed and encouraged to get some sleep. We decided to

leave Frank alone as he looked like he was going to settle and get some sleep.

3 Report Dr Wareing

4 Report Dr Wareing

Statement Nurse Adamek

5S of 7

However, within 5 minutes at approximately 16:20 Frank was observed coming out of his bedroom. He pulled down his trousers and put his shirt over his head. At this point, Nurse Yadpreet and I approached Frank to try and protect his dignity but he put both arms out to the side of him as if to signify a cross and threw himself backwards onto the floor in the HDU lounge outside his bedroom. I did not witness him bang his head but the impact sounded severe. I telephoned our psychiatrist

registrar Dr Neil Wareing immediately, leaving a message on his mobile.”®

Thereafter, Nurse Adamek set out the neurological observations and the clinical course in

respect to Frank prior to his transfer as referred to by Dr Wareing.

I am satisfied that the incident which led to Frank’s fall could not have been reasonably

prevented,

Post Mortem Medical Examination

On the 13 July 2012, Dr Malcolm Dodd, Senior Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an external examination on the body of Francesco

Sette.

Dr Dodd found the cause of death to be cranial fracture and intracranial haemorrhage and fall.

Dr Dodd having noted that witnesses had observed Frank put his jumper over his head and

launch himself backwards landing on the side of his head commented:

“The deceased was admitted to hospital where a fracture was noted over the right parietal cranial area in tandem with a right subdural haemorthage and a midline shift

to the left.

The deceased was not amenable to surgery and died subsequent to his injuries.

Past medical history includes ischaemic coronary artery disease, schizophrenia,

hypertension, type II diabetes and an increase in blood cholesterol.”

Finding

I find the cause of death of Francesco Sette to be cranial fracture and intracranial haemorrhage and

fall.

® Report Nurse Sarah Adamek

7 Comments section Dr Dodd post mortem report

60f7

I direct that a copy of this finding be provided to the following: The Family of Francesco Sette Constable Luke Western, Investigating Member, Victoria Police NorthWestern Health

Signature:

7 of7