Finding into death of Vishna Mary Damke

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 001080

FINDING INTO DEATH WITH INQUEST _

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

Inquest into the Death of: VISHNA MARY DAMKE

Delivered On: 14 JULY 2014

Delivered At: MELBOURNE

Hearing Dates: 14 JULY 2014

Findings of: CORONER ROSEMARY CARLIN

Place of death/Suspected death: McCULLOCH HOUSE, CLAYTON, VICTORIA

Coroners Assistant : LEADING SENIOR CONSTABLE STUART

HASTINGS

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I, ROSEMARY CARLIN, Coroner

having investigated the death of VISHNA MARY DAMKE

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

find that the identity of the deceased was VISHNA MARY DAMKE born on 29 JANUARY’ 1959

and the death occurred on 13 MARCH 2013

at McCULLOCH HOUSE, CLAYTON, VICTORIA

from:

l(a) PREUMONIA 1(b) RADIATION INDUCED BRAIN INJURY

in the following circumstances:

1, A summary inquest was held in relation to the circumstances of the death of Mrs Damke in

circumstances where she was in care, The holding of an inquest was mandatory due to her

“in care” status.

. Mrs Damke was 54 years of age at the time of her death. She was born on 29 January 1959 and is survived by her husband, Craig and her daughter, Amelia. At the time of her death she resided in McCulloch House, the Palliative Care Unit at Monash Medical Centre in

Clayton, Victoria,

. In 1993, Mrs Damke was having mini seizures which involved her “freezing up”. She was initially diagnosed with delayed post-natal depression however in March 1994, she was

diagnosed with an inoperable brainstem tumour.

. Mrs Damke was treated at the Alfred Hospital initially, She had a “VP shunt’ inserted to relieve pressure in her brain and then a craniotomy. She also received radiotherapy on her brain and her coccyx. Following the radiotherapy, Mrs Damke became quite frail and was admitted to a rehabilitation facility at Caulfield Hospital for approximately six weeks.

Following her discharge, she developed stomach pains and approximately two weeks later,

she underwent an appendectomy and remained in hospital to recover, for a period of around

four weeks.

Mrs Damke was then discharged home, however she was sttll unwell and developed a stomach infection and meningitis. She went back to the Alfred hospital for treatment and then spent some time at a rehabilitation facility, Florence Nightingale in Brighton. Mr Damke reported that his wife’s condition improved and although cognitively impaired, she

was well enough to go on a holiday, which she enjoyed.

In January 1995, Mrs Damke underwent another course of radiotherapy. For the next five years, she did not have any further hospital admissions for surgery however her mobility, speech and hearing deteriorated. Her family were unable to care for her and she was moved to a unit in Glenhuntly, close to the family home, where she was attended to by care workers. As her condition worsened, she was admitted to the Caulfield Hospital rehabilitation unit and then moved to Sunnyhurst Gardens, a Supported Residential Service

(SRS) facility in Brighton.

Mrs Damke’s condition further deteriorated and she was transferred back to Caulfield Hospital before being moved to Caulfield House, another SRS. She remained there for 12 months before being transferred to Yooralla SRS, a Department of Human Services facility.

She remained there for the majority of her time prior to her death and was treated by Dr Qasim Hamimi. During her time at Yoralla, she moved into palliative care on a few

occasions however would become better and transfer back to Yoralla.

On 12 March 2013, at around 1.00 p.m., Mrs Damke was transferred from Yoralla SRS to McCulloch House, as the staff at the facility were unable to manage her end of life care. On admission to McCulloch House, Mrs Damke was treated by Dr Leeroy William, Palliative

Medicine Specialist.

Dr William noted that Mrs Damke presented with clinical signs of pneumonia with pyrexia, tachycardia, semi-consciousness and bilateral pulmonary crepitations. She was known to

have expressive and receptive dysphasia, lower limb contractures, pressure areas from bony

3 0f4

prominences (resulting from cachexia) and a sacral pressure area.! During her admission,

Mrs Damke received morphine and glycopyrrolate for comfort.

10. Mrs Damke’s family were aware that her passing was imminent and stayed with her until around midnight, when they thought she would probably last the night. She died at 2.40 aim. on 13 March 2013.

11. Dr Paul Bedford, forensic pathologist with the Victorian Institute of Forensic Medicine, reported that the cause of the death was l(a) Pneumonia and 1(b) Radiation Induced Brain Injury. Dr Bedford commented that Mrs Damke died from clinically identified pneumonia with associated fever, which was a consequence of long term brain injury associated with

radiation therapy on a brain stem tumour. There were no issues in relation to toxicology.

12.1 find that Vishna Damke died as a result of pneumonia and radiation induced brain injury.

13.1 direct that a copy of these findings be provided to the family of Mrs Vishna Damke, the

Interested Parties and to the Investigating Police Officer.

Signature:

ROSEMARY CARLIN CORONER 14 JULY 2014

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' Statement of Dr Leeroy William dated 14 November 2013.

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