Finding into death of Gary Jason Cramer

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 4679

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: GARY JASON CRAMER

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

Southbank, VIC 3006

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

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I, JACQUI HAWKINS, Coroner having investigated the death of GARY JASON CRAMER

AND haying held an inquest in relation to this death on 1 October 2014

at Melbourne

find that the identity of the deceased was GARY J ASON CRAMER born on 15 June 1969

and the death occurred on 15 October 2013

at Monash Medical Centre Clayton, 246 Clayton Rd, Clayton VIC 3168

from:

i (a) INFLUENZA B INFECTION

in the following circumstances:

ike Gary Cramer was born on 15 June 1969 and was 44 years old at the time of his death.

2. A coronial brief was provided by Victoria Police to this Court, It has wholly addressed the circumstances surrounding Mr Cramer’s death.

SUMMARY INQUEST

3. At inquest, a summary was read into evidence by Coroner’s Solicitor, Kate Hamilton. I am satisfied that the summary accurately reflects the evidence.

4, Mr Cramer was, immediately before death, a person placed under the care of the secretary to the Department of Human Services. Consequently, this matter is a mandatory inquest.’ Mr Cramer was born with cerebral palsy’ and for the majority of his life resided with his family at Mentone, Victoria, but ceased living in the family residence when his mother could no longer support his ‘physical, behavioural and health support needs. His diagnosis included intellectual disability, mental health issues and cerebral palsy?

5; On 26 March 2002 Mr Cramer began using the Occupational Therapy Service at Yooralla

Community Learning & Living. On 19 December 2002 he moved into Yooralla residential supported accommodation service, located at 16 Wordsworth Ave, Clayton South. Yooralla is

an organisation supporting people with disability, and is funded by the Department of Human

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

care’.

? A physical disability that affects movement and posture, due to damage to the developing brain either during pregnancy or shortly after birth. It can affect body movement, muscle control, muscle coordination, muscle tone, reflex, posture and balance.

3 Statement of June Godfree, Service Manager at Yootalla Wordsworth Ave, Undated,

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Services. The service provided staffing to support Mr Cramer’s needs, such as community access, health care, household support and personal care. The staff at Yooralla worked closely with Mr Cramer’s mother to support him, in accordance with his wishes and needs, and he was also assisted by Yooralla day support service, which helped him in accessing the community and a variety of activities.’ During his time at Yooralla, Mr Cramer had mumerous presentations to hospital for left lower lobe pneumonia, which on occasion included extended

stays.

On 8 October 2013 Mr Cramer was admitted to Monash Medical Centre Clayton (‘Monash Hospital’) with hypotension, productive cough and bibasal crepitations®, During admission he was given oral augmentation and doxycycline®, He deteriorated and had decreased oxygen saturation of arterial blood down to 77% on 16 litres of oxygen and tachypnoea’. He was transferred to the Intensive Care Unit (‘ICU’), switched to intravenous antibiotics and given bi-

level positive airway pressure®.’

On 11 October 2013 a meeting took place between treating clinicians at Monash Hospital and members of Mr Cramer’s family. It was decided that Mr Cramer was not for intubation, CPR ot inotropes/vasopressor!®, Nasopharyngeal aspirate found that Mr Cramer was Influenza B positive. He was administered Tamiflu''. Mr Cramer continued to deteriorate in ICU and was

provided palliative care before passing away on 15 October 2013,”

POST-MORTEM INSPECTION AND REPORT

4 Ibid.

A post-mortem inspection and report was undertaken by Dr Paul Bedford, Specialist Pathologist at the Victorian Institute of Forensic Medicine. Dr Bedford reported that the post-

mortem CT scan shows a left pleural effusion and prominent right lung changes,

Dr Bedford determined that the cause of death is 1(a) Influenza B infection.

• Crackles at the bases of both the left and right lungs.

5 Medication used to treat bacterial infections, including pneumonia and other respiratory tract infections,

7 Rapid breathing.

5 A small machine used to assist with breathing.

° e-Medical deposition Form for Gary Cramer, Monash Medical Centre Clayton, dated 15 October 2013, 3.

1° Agents used to enhance cardiac output or vascular tone that has been severely compromised by often life-threatening clinical conditions.

‘| An antiviral medication used to treat flu symptoms.

2 ¢- Medical deposition Form for Gary Cramer, above n 9,

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10. Dr Bedford reported that on the basis of the information available to him, the death is due to

natural causes.

FINDING

11, 1am satisfied, having considered ail of the evidence before me, that no further investigation is required.

12. The evidence satisfies me that the medical management and care provided by Monash Medical Centre Clayton and Yooralla was reasonable and appropriate in the circumstances, having

regard to the complexities involved.

13, I find that Gary Jason Cramer died on 15 October 2013 and that the cause of his death is 1(a) Influenza B infection.

I direct that a copy of this finding be provided to the following: The family of Gary Jason Cramer;

Investigating Member, Victoria Police; and

Interested parties

Signature:

; |

TACOUL HAWKINS

CORONER Date: 1 October 2014

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