Finding into death of Raymond John O_Brien

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 3874

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: RAYMOND JOHN O’BRIEN

Delivered On: 1 October 2014 Delivered At: Coroners Court of Victoria 65 Kavanagh Street

Southbank, VIC 3006

Hearing Dates: 1 October 2014 Findings of: CORONER JACQUI HAWKINS Coroner’s Solicitor Ms Kate Hamilton

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I, JACQUI HAWKINS, Coroner having investigated the death of RAYMOND JOHN O’BRIEN

AND having held an inquest in relation to this death on 24 September 2014

at Melbourne

find that the identity of the deceased was RAYMOND JOHN O’BRIEN born on 25 September 1941

and the death occurred on 31 August 2013

at Austin Hospital, 145 Studley Rd, Heidelberg VIC 3084

from:

1(a) ACUTE MYOCARDIAL INFARCTION 1 (6b) CORONARY ARTERY DISEASE

in the following circumstances:

Raymond O’Brien was born on 25 September 1941 and was 71 years old at the time of his death.

A coronial brief was provided by Victoria Police to this Court. It has wholly addressed the

circumstances surrounding Mr O’Brien’s death.

SUMMARY INQUEST

At inquest, a summary was read into evidence by Coroner’s Solicitor, Kate Hamilton. I am

satisfied that the summary accurately reflects the evidence.

Mr O’Brien was, immediately before death, a person placed in custody as a patient in an approved mental health service within the meaning of the Mental Health Act 1986 (Vic).

Consequently, this matter is a mandatory inquest.! Mr O’Brien was a forensic patient under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 (Vic). On 7 August 1973 he was acquitted of murder on the grounds of insanity and an order was made, by a Justice of the Supreme Court of Victoria, that he be detained under a Custodial Supervision Order at Thomas

Embling Hospital.? He was a resident of Canning Unit, a Continuing Care Rehabilitation Unit.

Mr O’Brien had a past medical history of hypertension, dyslipidaemia, paranoid schizophrenia,

obesity and abdominal aortic aneurysm. He also had a documented history of ischaemic heart

' See Coroners Act 2008 (Vic) s 52(2)(b); Coroners Act 2008 (Vic) s 3(i), definition of ‘person placed in custody of care’,

? Record Service Division Extract — File No. 144834/72 — Criminal Record of Raymond O’Brien, Coronial brief, exhibit 1; Governor’s Pleasure Order— Raymond John O’Brien.

Statement of Associate Professor Andrew Carroll, Consultant Psychiatrist at Forensicare, dated 25 September 2013, 1.

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disease.* From 18 to 20 August 2013 Mr O’Brien was admitted to the Austin Hospital after complaining of chest pain which he had been experiencing for two days.’ After medical review, it was determined that his chest pain was due to a non-ST elevation acute coronary syndrome. Mr O’Brien declined an angiogram and consequently a trial of medical treatment was commenced,® including aspirin, metoprolol’ and perindopril.2 On 21 August 2013 he declined his medications, except aspirin, due to a relapse of his schizophrenia. His non-

compliance continued ‘over the following week,’

On 27 August 2013 Mr O’Brien developed shortness of breath and requested oxygen. He was reviewed by an on-call registrar and covering consultant psychiatrist at Thomas Embling Hospital, who called an ambulance for transfer to the Austin Hospital. Mr O’Brien refused, and a second ambulance crew attended, with the option of coercive transfer to the Austin Hospital.

After weighing up the risk of Mr O’Brien staying at Thomas Embling Hospital without access to full medical treatment, against the risk of significant stress being caused by forcibly transferring him, potentially precipitating an acute cardiac event, the team and authorised psychiatrist decided not to transfer Mr O’Brien but rather monitor him very closely at Thomas Embling Hospital. Mr O’Brien declined his oral clozapine and, given his ‘very poor physical condition’, it was decided not to enforce injectable antipsychotic medication that evening. He

was placed on special nursing observations and was reviewed by the registrar, \°

On 28 August 2013 at 9.15am Mr O’Brien was assessed by Associate Professor Andrew Carroll, consultant psychiatrist, and general practitioner Dr Peter Enright. Associate Professor Carroll noted a further deterioration in Mr O’Brien’s mental state, and Dr Enright noted increasing shortness of breath, and made a provisional diagnosis of congestive cardiac failure with possible pneumonia. After discussions with Dr Enright, Mr O’Brien agreed to be transferred to the Austin Hospital. The Canning Unit Registrar at Thomas Embling Hospital liaised with the Austin Hospital Consultation Liaison Psychiatry Registrar to ensure that Mr

O’Brien’s psychiatric care remained optimal throughout his time at the Austin Hospital."

4 Statement of Dr Simon Lam, Consultant Physician and Rheumatologist, Coronial brief, 4.

5 Statement of Associate Professor Andrew Carroll, above n 2, 2-3.

© Statement of Dr Simon Lam, above n 3, 4.

T A beta blocker that affects the heart and circulation.

5 Medication to treat high blood pressure.

° Statement of Associate Professor Andrew Carroll, above n 2, 3.

"| Statement of Associate Professor Andrew Carroll, above n 2, 4-5.

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Ai;

Upon transfer to hospital, Mr O’Brien was found to have right basal crepitations in his lungs with associated widespread wheezes. A chest x-ray showed right lower lobe opacities which were not present on his x-ray taken on 18 August 2013. On ECG examination, Mr O’Brien had some lateral T-wave inversion which had been present during part of his previous admission.

He was treated with a combination of intravenous antibiotics, oxygen and IV therapy for hypotension. Serial cardiac enzyme testing was commenced to determine if he had experienced

a further cardiac event,'?

On 29 August 2013 Mr O’Brien had worsening dyspnea and diaphoresis. A medical emergency team call was made and he was commenced on Continuous Positive Airway Pressure (CPAP) ventilation, IV diuretics and a small dose of IV morphine with good effect.

He was transferred to the Critical Care Unit for ongoing CPAP and monitoring.

His Troponin levels were elevated but stable. He had ongoing hypotension and consequently anticoagulation was commenced, because of the possibility of pulmonary embolism. His CT

pulmonary angiogram was found to be negative.”

The hospital psychiatry liaison team was consulted to assist in the management of Mr O’Brien and his refusal to take some medications. He declined his clozapine medication but agreed to

take olanzapine instead.'*

On 31 August 2013 at approximately 10.30am Mr O’Brien lost consciousness and a Medical Emergency was called (Code Blue). He was found to be in Ventricular Fibrillation (VF) arrest and Cardiopulmonary Resuscitation (CPR) was immediately commenced. He received 25 minutes of CPR and 8 cardioversion shocks. His ECG rhythm progressed from VF to Pulseless Electrical Activity (PEA) to Asystole. A new coronary event was thought to be the likely cause of the arrest. Mr O’Brien was declared deceased at 11.15am on 31 August 2013.4

POST-MORTEM EXAMINATION

A post-mortem examination and report was undertaken by Dr Michael Burke, Senior Forensic Pathologist at the Victorian Institute of Forensic Medicine. Dr Burke reported that the postmortem examination showed no evidence of any injury that would have contributed to or led to death. There was no evidence of pulmonary thromboembolism or cerebral insult that would

lead to sudden death.

” Statement of Dr Simon Lam, above n 3, 5.

3 Ibid 5,

• Tid 5.

'S Statement of Dr Simon Lam, above n 3, 5.

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13. The examination confirmed significant ischaemic heart disease with organising acute myocardial infarction, and that there was underlying coronary artery disease. Dr Burke reported that the degree of heart disease would be consistent with causing sudden death as result of a cardiac arrhythmia’ and that there is no evidence to suggest the death was due to anything other than natural causes.

14. Dr Burke determined that the cause of death is 1(a) acute myocardial infarction and 1(b) coronary artery disease.

FINDING

1. Tam satisfied, having considered all of the evidence before me, that no further investigation is required.

uy The evidence satisfies me that the medical management and care provided by Thomas Embling Hospital and the Austin Hospital was reasonable and appropriate in the circumstances, having regard to the complexities involved.

3. I find that Raymond John O’Brien died on 31 August 2013 and that the cause of his death is 1(a) acute myocardial infarction and 1(b) coronary artery disease.

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

The family of Raymond John O’Brien; Investigating Member, Victoria Police; and Interested parties

Signature:

‘ KA equa tans

JACQUI HAWKINS CORONER

Date: 1 October 2014

'6 Heart attack,

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