Finding into death of John William Macfie

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2014 1261

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: JOHN WILLIAM MACFIE Delivered On: 10 September 2014 Delivered At: Coroners Court of Victoria

65 Kavanagh Street Southbank, VIC 3006

Hearing Dates: 10 September 2014 Findings of: JOHN OLLE, CORONER Coroner’s Solicitor Kate Hamilton

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I, JOHN OLLE, Coroner having investigated the death of JOHN WILLIAM MACFIE

AND having held an inquest in relation to this death on 10 September 2014

at Melbourne

find that the identity of the deceased was JOHN WILLIAM MACFIE

born on 2 July 1940

and the death occurred on 7 March 2014

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

from:

1 (a) COMPLICATIONS OF LUNG CARCINOMA IN A MAN WITH MULTIPLE COMORBIDITIES

in the following circumstances:

SUMMARY INQUEST

John Macfie was born on 2 July 1940 and was 73 years old at the time of his death. A report was provided by the Department of Justice Office of Correctional Services to this Court. It has

fully addressed the circumstances surrounding Mr Macfie’s death.

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 Macfie was, immediately before death, a person placed in the legal custody of the Secretary to the Department of Justice. Consequently, this matter is a mandatory inquest.' Mr Macfie was received into custody on 26 May 2010, with his earliest eligibility date for parole on 18 May 2021.7

Mr Macfie had a past medical history of chronic obstructive pulmonary disease, hypertension, hyperlipidemia,’ ischemic heart disease, two coronary artery bypass graft surgeries performed in 1991 and 1996 and a cardiac stent inserted in October 2009 and January 2010. Mr Macfie

was also a chronic smoker.*

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

? Report: Department of Justice Review into the death of Mr John William MacFie at St Vincent’s Hospital on 7 March

2014, 4.

• High cholesterol.

‘ Department of Justice report, above n 2, 7.

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5. On 27 September 2011 Mr Macfie had a chest x-ray that noted a ‘mild prominence of the left hilar region’. A computerised tomography scan of his chest was recommended to exclude underlying lesions, however Mr Macfie refused any investigations until 17 April 2013. He also declined any further treatment and investigations following confirmation of his diagnosis of

lung cancer by CT scan, conducted on 17 April 2013.

6. Prior to 27 September 2011, Mr Macfie received comprehensive medical care, when required,” from health services contracted through Justice Health.° On 16 November 2011 an appointment was made for Mr Macfie to have a CT scan of his chest on 23 November 2011. On 23 November 2011 Mr Macfie attended the nurse clinic at Port Phillip Prison and refused to attend his scheduled CT scan. The nurse explained the importance of the CT scan to Mr Macfie, however he continued to refuse to undergo the scan. He also refused to discuss any potential risks associated with non-compliance with his treatment plan and medical appointments. Mr Macfie also made further refusals to have a CT scan on 1 December 2011 and 10 February

2012."

iA On 24 February 2012 a note was made in Mr Macfie’s medical records that he had complained of blood in sputum and a persistent cough. On 3 April 2012 he was prescribed antibiotics for his persistent cough. From 18 July 2012 to 24 September 2012 Mr Macfie refused to attend scheduled medical appointments on nine occasions, and made further refusals to attend between October 2012 and January 2013. Again, the impact and risks associated with his non-

compliance with medical appointments were discussed with him.’

8. On 17 April 2013, Mr Macfie had a CT scan of the chest which showed a ‘left upper lobe lung mass, with distal collapse compatible with bronchogenic carcinoma’. The CT scan results were discussed with Mr Macfie on 18 April 2013. Mr Macfie stated that he would not like further investigations and interventions. The medical notes recorded that Mr Macfie would require palliative management at some stage.’ From 30 April 2013 to 17 September 2013 Mr Macfie

was reviewed by nursing and medical staff on 20 occasions to manage symptoms of his chronic

Department of Justice Report, above n 2, 8-10.

6 Justice Health is a business unit of the Department of Justice responsible for the delivery of health services for persons in Victorian prisons, In Victoria, health services to persons in prisons are contracted out to health service providers.

Justice Health sets the policy and standards for health care in prison and contract manages the health service providers in the public prisons.

"Ibid 10.

5 Department of Justice Report, above n 2, 11.

*Thid 12.

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I.

obstructive pulmonary disease, ischemic heart disease and lung carcinoma. On 17 September 2013 he presented as frail, had difficulty swallowing food, had lost weight and was experiencing reflux. After medical advice, he was transferred to St John’s Ward at Port Phillip

Prison on 25 September 2013.'°

On 1 October 2013 Mr Macfie stated that he did not ‘want further investigations, ICU admission and CPR’, and he signed a ‘Not for Resuscitation’ form. From 1 October 2013 to 21 November 2013 he was accommodated at St John’s Ward and received symptomatic relief for his medical conditions. Between October 2013 and January 2014 he was transferred between St John’s Ward and St Augustine’s Ward on a number of occasions, in order to attend medical

appointments at St Vincent’s Hospital."

On 17 January 2014 at 2.50am Mr Macfie complained of chest pain. The nurse on duty administered glyceryl trinitrate spray to relieve the pain. At 5.15am Mr Macfie again complained of chest pain. The nurse called a code black!”. An ambulance was called and Mr Macfie was transferred to St Vincent’s Hospital emergency department and was later admitted

to St Augustine’s ward after initial treatment.!?

From 17 January 2014 to 7 March 2014 Mr Macfie was accommodated at St Augustine’s ward.

Due to symptoms relating to his lung cancer, Mr Macfie experienced ongoing chest pain and developed pneumonia. During this period his overall physical health continued to deteriorate, despite all treatment and interventions. On 28 January 2014 a decision was made to withdraw all active treatment for Mr Macfie’s medical conditions. He was commenced on palliative care, including ‘end of life care,’ and pain relief by way of Hydromorphine. On 28 J anuary 2014 Mr

Macfie re-signed his ‘Not for Resuscitation’ form.!*

On 7 March 2014 at 6.30pm Mr Macfie was found to be unresponsive, with no breathing, pulse

or respirations. He was pronounced deceased at 7.30pm.

POST-MORTEM INSPECTION AND REPORT

A post-mortem inspection and report was undertaken by Dr Yeliena Baber, Forensic

Pathologist at the Victorian Institute of Forensic Medicine. Dr Baber reported that external

‘© Department of Justice Report, above n 2, 12.

" Ibid.

'? Medical emergency.

'S Department of Justice Report, above n 2, 12.

“* Tid 13.

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examination of Mr Macfie’s body showed findings consistent with the clinical history.

Examination of the post-mortem CT scan showed emphysema, a left lung mass, satellite

lesions, sternal wires and cerebral atrophy.

Dr Baber determined that based on the information available to her, a reasonable cause of

death is complications of lung carcinoma in a man with multiple co-morbidities.

FINDING

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, Port Phillip Prison, Hopkins Correctional Centre, Metropolitan Remand Centre and Melbourne Assessment Prison was reasonable and appropriate in the circumstances, having

regard to the complexities involved.

I am satisfied that health staff discussed the issue of non-compliance of medical appointments with Mr Macfie, and that he was made aware of the associated risks on a number of occasions.

I am satisfied that Mr Macfie made an independent decision to not have further medical

investigation or intervention.

I find that Mr John William Macfie died on 10 September 2014 and that the cause of his death

is complications of lung carcinoma in a man with multiple co-morbidities.

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

Signature:

The family of Mr John William Macfie; and Interested parties

JOHN OLLE CORONER Date: \ September 2014 |

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