Finding into death of Mary Una Barnett

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 004781

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: MARY UNA BARNETT

Delivered On: 14 JULY 2014

Delivered At: MELBOURNE

Hearing Dates: 14 JULY 2014

Findings of: CORONER ROSEMARY CARLIN

Place of death/Suspected death: ST AUGUSTINE’S WARD, ST VINCENTS HOSPITAL,

; 41 VICTORIA PARADE, FITZROY, VICTORIA

Counsel Assisting SENIOR CONSTABLE PAUL COLLINS

I, ROSEMARY CARLIN, Coroner

having investigated the death of MARY UNA BARNETT

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

find that the identity of the deceased was MARY UNA BARNETT born on 1 SEPTEMBER 1942

and the death occurred on 23 OCTOBER 2013

at ST AUGUSTINE’S WARD, ST VINCENTS HOSPITAL, 41 VICTORIA PARADE, FITZROY,

VICTORIA : ‘

from: 1(a) DIFFUSE LYMPHOID MALIGNANCY

in the following circumstances:

1. A summary inquest was held in relation to the death of Ms Barnett in circumstances where she was in custody. The holding of an inquest was mandatory due to her “in custody”

status.

2. Ms Barnett was born on | September 1942 and was 71 years of age at the time of her death.

At the time of her death she was receiving treatment at the St Augustine’s Ward at St

Vincent’s [Hospital in Fitzroy, Victoria.

3. Ms Barnett had an extensive medical history which included ischaemic heart disease, hypertension, type 2 diabetes, peripheral vascular disease, stroke, chronic back pain, renal impairment and chronic obstructive pulmonary disease. She was also on a range of

medication for these conditions.

4, On 9 June 2011, Ms Barnett was sentenced to five years and three months for two offences to be served at the Dame Phyllis Frost Centre (DPFC). She had been granted parole which

was due to commence on 28 October 2013.

5. Upon entering into custody, Ms Barnett underwent routine health assessments by the medical officer and nursing staff which noted her extensive past medical history but were

otherwise unremarkable.

On 28 June 2011, Ms Barnett presented with shortness of breath, lower leg swelling and chest tightness, She was assessed by the medical officer and transferred to St Vincent’s Hospital by ambulance where she was diagnosed with chronic heart failure, a chest infection, high blood pressure, hyperparathyroidism and renal artery stenosis. She was scheduled for a heart ultrasound, respiratory function test and an outpatient renal clinic

review before being returned to the DPFC on 6 July 2011.

From 6 July 2011 to 3 October 2011, Ms Barnett was regularly reviewed by medical and nursing staff and her health remained stable. On 3 October 2011, she complained of right sided abdominal pain and flank pain. She was reviewed and a blood test requested, which

returned normal results,

On 10 October 2011, Ms Barnett complained of worsened abdominal pain and was transferred to St Vincent’s Hospital where she was reviewed and booked in for an outpatient upper abdominal ultrasound. She was returned to the DPFC the next day. Over the next few days, Ms Barnett continued to complain of pain and was assessed by the medical officer

and on 14 October 2011, she was transferred again to St Vineent’s Hospital for review.

At St Vincent’s Hospital, results suggested resolving pancreatitis and directions were given regarding her medication. She was booked in for an outpatient renal review in early

November and returned to the DPFC on 15 October 2011.

From 15 October 2011, Ms Barnett was regularly reviewed by medical and nursing staff and treatment was administered in consultation with staff at St Vincent’s Hospital. During this period, she presented with high blood pressure, weakening of the heart and back pain. On 25 September 2012 it was noted that she needed to start dialysis following a review by the

renal team at St Vincent’s Hospital.

.On 2 October 2012, Ms Barnett presented with chest pains and was transferred to St

Vincent’s Hospital, An assessment ruled out a cardiac cause for her chest pain however a new right sided rib fracture was observed. It was noted that she had sustained a fall in her cell two weeks prior and that this was the likely cause of the fracture. She was then

transferred back to the DPFC. |

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From 2 October 2012 to 8 September 2013, Ms Barnett was continuously reviewed and treated for her various health conditions. Her kidney disease was noted as being stable however upon review at the renal clinic at St Vincent’s Hospital on 27 August 2013, staff were unsure why she had not been reviewed earlier despite plans to do so. Formal planning

for dialysis was deferred until her release, given her imminent release date.

.On 8 September 2013, Ms Barnett was having difficulty rising from her bed and was

hypoglycaemic. An emergency code was called and she was transferred to St Vincent’s Hospital for review. She was treated and assessed by a dietician and returned to the DPFC

on 11 September 2013.

. From 11 September to 4 October 2013, Ms Barnett’s back pain continued to worsen and her

health deteriorated, During this period, the medical officer discussed end of life measures with her and she expressed her wish that all reversible causes of death be treated including

the use of dialysis for her kidney disease and CPR in the case of an emergency.

On 4 October 2013, Ms Barnett’s haemoglobin level was noted to be low and she was transferred to St Vincent’s Hospital for management. The following day, she was admitted to the St Augustine’s Ward. A scan revealed widespread marrow disease, most likely high

grade lymphoma, a fast growing blood cancer.

On 21 October 2013, Ms Barnett’s condition deteriorated rapidly and following a review by the renal team and a discussion with her daughter, a ‘Not for Cardiac Resuscitation’ order was put in place. Ms Barnett was pronounced deceased at approximately 2.24 a.m. on 23

October 2013.

An inspection of Ms Barnett’s body was undertaken by Dr Noel Woodford, Senior Forensic Pathologist at the Victorian Institute of Forensic Medicine. Following an external examination of the body and a review of Ms Barnett’s clinical records, Dr Woodford concluded that the death was due to natural causes and that a reasonable cause of death was

l(a) Diffuse Lymphoid Malignancy,

18. GEO Care Australia Pty Ltd (GEO Care) is the organisation responsible for providing healthcare to inmates at the DPFC. A report prepared by Justice Health for the Coroner made recommendations that contracted health service providers such as GEO Care develop systems and processes to‘avoid reliance on external providers and to monitor the provision

of external appointments so that patient omissions do not occur in the future. I have

reviewed GEO Care’s action plan and agree with the proposals it has advanced to improve

the processes for chronically ill patients attending specialist appointments.

19.1 find that Mary Barnett died as a result of Diffuse Lymphoid Malignancy. Whilst she should not have missed an earlier renal review, I am satisfied it did not contribute to her

death.

20.1 direct that a copy of this finding be provided to the family of Ms Barnett, the Interested

Parties and to the Investigating Member, Victoria Police.

Signature:

ROSEMARY CARLIN CORONER 14 JULY 2014

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