Finding into death of Jonathan Mark Smith

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 3579

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(2)

‘Section 67 of the Coroners Act 2008

Inquest into the Death of:

Delivered On:

Delivered At:

Hearing Date:

Findings of:

Police Coronial Support Unit

JONATHAN MARK SMITH 20 May 2014 Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne 3000 20 May 2014

CAITLIN C ENGLISH, CORONER

Leading Senior Constable King Taylor

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1, CAITLIN CREED ENGLISH, Coroner having investigated the death of JONATHAN SMITH

AND having held an inquest in relation to this death on 20 May 2014 at MELBOURNI find that the identity of the deceased was JONATHAN MARK SMITH born on 28 October 1957

and the death occurred on 14 August 2013

at Wantirna Hospital

les)

from: 1 (a) RECURRENT ASPIRATION PNEUMONIA IN A MAN WITH SEVERE

INTELLECTUAL DISABILITY COMPLICATED BY SEIZURES

in the following circumstances:

1. Mr Smith was a 55 year old male who resided at 7 Tortice Avenue, Nunawading in a

supported residential services (SRS) unit managed by the Department of Human Services

(DHS). He had resided there for seven years prior to his death. Mr Smith was the only son of

Marjorie and Thomas Smith and had a sister Meredith.

2. Due to Mr Smith’s ‘in care’ status, his death is a reportable death to the coroner (s 11

Coroners Act 2008). Further, his ‘in care’ status mandates a coroner to hold an inquest into his

death (s 52(2)(b)).

3. Mr Smith had a documented past medical history of intellectual disability, seizures, left

hemiplaegia, hiatus hernia, asthma, gall stone pancreatitis and recurrent aspiration pneumonia.

Mr Smith contracted encephalitis at six weeks old which caused him to have a severe

intellectual disability. According to Dr Idris “{fJunctionally, he was non communicative but

was mobile and socially interactive.”

4. Mr Smith left home at 17 and moved into a residence in Sunbury for people with intellectual

disabilities. Mr Smith continued to return to his. family home on weekends and holidays,

continuing to be very much a part of his family. At 27, Mr Smith moved into Kew Cottages.

He developed pneumonia in his early thirties, which became a continuing health problem as

he grew older. Seven years prior to his death he moved into the Tortice Avenue SRS unit.

' Statement of Dr Adam Mohd Idris, Geriatrics Rogistrar, Eastern Health, 26/11/13.

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Police Investigation

A police investigation was conducted into the circumstances surrounding Mr Smith’s death.

During early 2013, Mr Smith’s condition deteriorated. On 31 May 2013 he was adinitted to Box Hill Hospital due to pneumonia for a day. He was again admitted on 9 June 2013 for the

same reason and received treatment and was returned home.

On 30 June 2013, Mr Smith was again admitted to Box Hill Hospital for pneumonia. He was also refusing oral intake. According to Mr Smith’s carer Emmanuel Vougiouclis, “Ct}his time instead of discharging Jonathan a meeting was held between myself, Jonathan’s doctor, his

mother and sister and other specialists from Box Hill.”

Mr Smith was transferred from Box Hill Hospital to Wantirna Hospital on 12 July 2013 with a diagnosis of aspiration pneumonia, Dr Adam Mohd Idris, Geriatrics Registrar, Eastern

Health, summarised the care provided to Mr Smith as per the notes from Box Hill Hospital:

“[H]e had been admitted there for aspiration pneumonia, with three aspiration episodes in the past year, associated with a steady functional decline (decreased mobility, less socially interactive, and decreased oral intake), He was initially treated with IV antibiotics with clinical improvement. It was also noted that Jonathan became distressed and agitated when medical care was being provided, including assessments, medication, blood tests and IV cannulas. He also had a further decline in his function,

refusing oral intake,

The medical team in Box Hill Hospital had extensive conversations with Jonathon’s mother, Marjorie Smith, as well as the carers from his SRS [Supported Residential Service]. It was decided that in Jonathan’s best interests, he would not be for escalation of treatment beyond oral antibiotics in case of further aspiration pneumonia. In the event of deterioration, he would be for comfort care only. He was transferred to Wantirna Hospital for discharge planning, as his care needs could not

be met by his SRS.

Jonathan was stable during his stay in Wantirna [ealth. He was noted to be

intermittently refusing his regular medications, oral intake and nursing care...

? Statement of Emmanuel Vougiouclis, DHS Carer, 6/10/13,

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On 12/8/13, Jonathan was noted to have decreased oral intake, as well as increased purulent sputum production. Lle was commenced on oral clindamycin empirically to cover aspiration pneumonia. He was noted to have deteriorated further on 13/8/13, and after further discussions with his mother, who reiterated her wishes as above, he was commenced on the Liverpool Care Pathway (LCP) and comfort care medications

(morphine, clonazepam, glycopyrrolate) were charted.

On 14/8/13, he was noted to be tachypnoeic despite receiving breakthrough medications, He was commenced on a syringe driver with 10mg of morphine and 2mg of mizazolam. This was relayed to his mother and SRS carers. He passed away

comfortably shortly therafter at 1405. 8

Health and Medical Investigation

9,

The matter was referred to the Coroners Prevention Unit, Health & Medical Investigation

Team (HMIT)! on 22 January 2014. They concluded that there were no issues with the

medical management of Mr Smith.

The Inspection Report

10,

Dr Jacqueline Lee Forensic Pathologist at the Victorian Institute of Forensic Medicine

conducted an inspection and examination of Mr Smith on 15 August 2013. In her report, she

made the following comments:

“Post mortem computed tomography scan showed pneumonia, absence of the head and neck of the head and neck of the right fenur and no acute changes within the head.

External examination of the body of the deceased showed no acute injuries.’”

Dr Lee concluded her report with a specific finding of the medical cause of death as recurrent

aspiration pneumonia in a man with severe intellectual disability complicated by scizures, In

all the circumstances, I accept that as the cause of Mr Smith’s death.

3 Statement of Dr Adam Mohd Idris, Geriatrics Registrar, Eastern Health, 26/11/13.

4 The role of the Health and Medical Investigation Team (HMIT) is to assist the Coroner's investigation into the nature and extent of deaths which occurred during the provision of healthcare, and identify potential system factors in healtheare related deaths. HMIT personnel comprise of practising Physicians and Clinical Research Nurses who draw on their medical, nursing and rescarch experiences, skills and knowledge to independently evaluate clinical evidence for the investigation of reportable healthcare deaths and to assist in identifying remediable factors that may assist in prevention and risk management in health services settings.

° Report of Dr Jacqueline Anita Lee, Forensic Pathologist, 21/8/13,

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

Mrs Marjorie Smith

Constable Christopher Anderson, Investigating Mcmber, Victoria Police Dr Yvette Kozielski

Signature:

CAITLIN ENGLISH CORONER Date: 20 May 2014

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