Finding into death of Luong Quang Nguyen

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 4159

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: LUONG QUANG NGUYEN

Delivered On: ; 17 July 2014

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

Hearing Dates: 17 July 2014

Findings of: Coroner John Olle

Police Coronial Support Unit Senior Constable Collins

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I, JOHN OLLE, Coroner having investigated the death of LUONG QUANG NGUYEN

• AND having held an inquest in relation to this death on 17 July 2014

at Melbourne

find that the identity of the deceased was LUONG QUANG NGUYEN born on 3 August 1967

and the death occurred on 17 September 2013

at St Vincent’s Hospital, 59 Victoria Parade, Fitzroy VIC 3065

from:

1 (a) COMPLICATIONS OF DIABETIC NEPHROPATHY

in the following circumstances:

Luong Nguyen was born on 3 August 1967 and was 46 years old at the time of his death. He

is survived by his mother, who currently resides in Vietnam.

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

circumstances surrounding Mr Nguyen’s death.

Summary Inquest

3,

At inquest, a summary was read into evidence by Senior Constable Collins. T am satisfied

that the summary accurately reflects the evidence.

At the time of his death, Mr Nguyen was, immediately before death, a person placed in care in-an approved: mental-health -service- within. the-meaning. of the Mdental.Health.Act 1986

(Vic). Consequently, this matter is a mandatory inquest,

On 13 November 2012 the Victorian Civil and Administrative Tribunal appointed the Office of the Public Advocate limited guardian of Mr Nguyen, with authority to make decisions about where Mr Nguyen lives, his healthcare and access to certain services, as Mr Nguyen was not complying with ‘treatment related to physical or mental health resulting in a

seriously compromised condition’?

In the time leading up to his death, Mr Nguyen was a patient of the Mental Health Service High Dependency Unit at St Vincent’s Hospital, alternating between involuntary treatment

when chronically unwell, and living in the community in a Ministry of Housing flat at

1 See Coroners Act 2008 (Vic) s $2(2)(b).

? Statement of James Doran, delegated guardian for Mr Nguyen, Office of the Public Advocate.

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Richmond under a Community Treatment Order (CTO) at other periods, Mr Nguyen had a 25-year history of schizophrenia, compounded by unstable and poorly controlled type 2 diabetes mellitus and polysubstance abuse.” He also had a medical history of untreated hepatitis C, hypertension, and hypercholesterolaemia. He was noted to substantially lack

insight into his endocrine issues and the requirement for insulin compliance.‘

On 15 August 2013 Mr Nguyen was admitted to St Vincent’s Hospital as an involuntary patient of the psychiatric unit. On 5 September 2013 he was transferred from the inpatient psychiatry unit to the acute general medical ward, still as an involuntary patient, for management of florid fluid overload secondary to congestive cardiac failure, worsening endstage renal failure and diabetic nephropathy. He was intended to be transferred on 4 September 2013, however he absconded from the psychiatric unit during transfer. He was reported missing by a staff member at St Vincent’s Hospital and was located by police at

Spm on 5 September 2013 and returned to hospital.

After discussion with the renal unit it was decided that Mr Nguyen was not a dialysis candidate, given his complex psychiatry co-morbidities, After consultation with the psychiatric team and general medical ward it was decided that Mr Nguyen would be transferred to the acute general medical ward for a trial of intravenous diuresis. During his acute admission his major medical issues included fluid overload, hypoglycaemia and renal impairment. Doctors at St Vincent’s Hospital maintained ongoing contact with James Doran, Mr Nguyen’s delegated guardian, regarding Mr Nguyen’s progress and poor prognosis. Mr Doran conveyed that he was happy for medical decisions to bé made by the

medical team.

Mr Nguyen had a poor response to aggressive diuretic therapy and it was determined by the medical team that he was unlikely to gain further benefits by its continuance, and that it may instead prolong his suffering and agitation. Consequently it was decided that the team would

focus purely on comfort care, with ongoing palliative care and psychiatry team input.

Mr Nguyen was transferred to the inpatient palliative care on 16 September 2013, On 17 September 2013 the palliative care registrar contacted the psychiatry unit to request that the

involuntary treatment order be revoked, as Mr Nguyen’s physical health had deteriorated

3 In particular, crystal methamphetamine, or ‘ice’ as it is commonly known, and alcohol.

• Toid.

5 Statement of Dr Ai-Ming Wong, physician at St Vincent’s Hospital, dated 16 December 2013.

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significantly. The psychiatry team had planned to complete the paperwork to revoke the involuntary order on 18 September 2013, however sadly Mr Nguyen passed away on 17

September 2013 at 7.50pm.

Post-mortem inspection and report

il.

A post-mortem inspection and report was undertaken by Dr Noel Woodford, Senior Forensic Pathologist at the Victorian Institute of Forensic Medicine. Dr Woodford reported that external examination of the body shows findings consistent with the history, Examination of a post-mortem CT scan shows the presence of a full bladder with fluid present within bowel loops. A small amount of fluid is present within the pericardial sac and

within the pleural cavities.

Dr Woodford determined that a reasonable cause of death in the circumstances is

complications of diabetic nephropathy.

Finding

15,

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

The evidence satisfies me that the medical management and care provided by St Vincent’s Hospital was reasonable and appropriate in the circumstances, having regard to the

complexities involved.

T find that Luong Nguyen died on 17 September 2013 and that the cause of his death is complications of diabetic nephropathy.

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

Signature: A

The family of Luong Nguyen; Investigating Member, Victoria Police; and

Interested parties

JOHN OLLE; CORONER ?

Date: 17 sy is

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