Finding into death of John Manias

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: 104 t /08

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: JOHN MANIAS

Delivered On: 29 April 2015.

Delivered At: 65 Kavanagh Street Southbank 3006 Hearing Dates: 6 June 2011, 13 December 2011 Findings of: PETER WHITE, CORONER Representation: Mr P Bean on behalf of Ambulance Victoria on 6 June

2011, and Mr Halley on behalf of Ambulance Victoria on 11 December 2011

Ms D Foy on behalf of Southern Health

Police Coronial Support Unit Leading Scnior Constable Greig McFarlane

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I, PETER WHITE, Coroner having investigated the death of JOHN MANIAS

AND having held an inquest in relation to this death on at Melbourne find that the identity of the deceased was JOHN MANIAS born on 24 January 1945, aged 63 and the death occurred on 11 March 2008 at Dandenong Hospital, Dandenong, Victoria from: 1 (a) MULTISYSTEM ORGAN FAILURE, PNEUMONITIS AND SEPSIS

1 (b) COMPLICATIONS ARISING FORM A FALL RESULTING IN MULTIPLE RIB

FRACTURES

in the following circumstances:

1. John Manias died on 11 March 2008 at the Dandenong Hospital, after being admitted on 27 February 2008 with a number of fractures following a four-metre fall down a cliff. Mr Manias’ condition initially started to improve in hospital but he then deteriorated and passed

away in the Intensive Care Unit.

2. Dr Malcolm Dodd of the Victorian Institute of Forensic Medicine (VIFM) performed a post mortem medical examination. Dr Dodd found evidence of staphylococcus aureus and bronchopneumonia. He concluded that the cause of Mr Manias’ death was [(a) multi system organ failure, pneumonitis and sepsis and [(b) complications arising from a fall

resulting in multiple rib fractures.'

3. Idetermined to hold an inquest into Mr Manias’ death under section 52 (1) of the Coroners Act 2008 as it appeared, on the material before me, that Mr Mania’s death was uncxpected and that his cause of death was not anticipated. In particular, it appeared that the Dandenong Hospital staff were unaware that Mr Manias had developed staphylococcus at

the time of his death.

4. Lalso sought to investigate the circumstances around his ambulance transport to the

Dandenong Hospital and I will deal with that below.

Investigation and Inquest

See Exhibit 4.

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5. This finding is based on the totality of the material the product of the coronial investigation into Mr Manias’ death. ‘This material includes the inquest brief prepared by Constable Blair Wilkinson, statements of expert opinion provided by interested parties and the Dandenong Hospital’s medical records relating to Mr Manias and the testimony of the witnesses called.

This finding does not purpose to summarise all the evidence but will refer to it in only such

detail as is warranted by its forensic significance and its interest in narrative clarity,

6, At inquest, I heard evidence from Mrs Manias, her son Christopher Manias, Dr Yvonne

Kearley (ICU consultant) and Dr Malcolm Dodd (Pathologist) of VIFM.

7. Tnote that I received a lettcr from Southern Health before the commencement of the inquest, conceding that blood tests taken on 8 March 2008 demonstrated significantly raised creatinine levels and a high CRP level were not accessed until 10 March 2018 and that they should have been picked up by clinicians during 8 March 2008.7 This concession. negated

the need for me to call all the hospital staff involved in Mr Manias’ care.

Circumstances of the fall

8. Mr Manias was a 63-year-old man who is survived by his wife and two sons. le was employed by Holmesglen Tafe Property Services as a carpenter and was of good general

health with no ongoing medical conditions.

9. On 27 February 2008, Mr and Mrs Manias visited their son in Sunset Strip, Phillip Island.

After spending the day there, they commenced their return trip to Dandenong North, At approximately 7.20pm, they made a stop at Back Beach Road in San Remo. Mr Manias walked to the beach side of the road and then to the edge of an embankment. He slipped and

fell over the edge of the embankment, falling approximately four metres to the beach below.

10. Mrs Manias went looking for her husband who had not returned to the car and found him on the beach sitting on a log. He asked her to call an ambulance. Mrs Manias retrieved her

mobile phone from the car and called emergency services.

11. Paramedics Malcolm McCann and Kenneth Jones attended at the scene. They observed Mr Manias injured at the base of the cliff four metres below. Mr McCann accessed Mr Manias via a beach track. Mr Jones lowcred equipment down to Mr McCann by rope. The paramedics were concerned above the tide coming in, and that there were significant barriers

to accessing Mr Manias.

? See Exhibit 5

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Mr McCann conducted an assessment of Mr Mania’s vital signs. He had a heart rate of 70, blood pressure of 9OmmHg/palpication, his skin was pale, cool and moist. He rated his pain as 10/10, His Glasgow Coma Score was 15. Mr McCann determined that Mr Manias was in an ‘Actual Time Critical’ condition. Given the difficulties with accessing Mr Manias, it was ultimately determined that the safest way to remove him from the beach was to request an ocean rescue boat from Newhaven. A rescue boat arrived at approximately 9.30pm and he was transferred to the Newhaven Marina and then in to an ambulance. ‘They originally contacted the Wonthaggi Hospital but were told that that hospital did not have the resources

to manage Mr Manias so they headed to the Dandenong Hospital.

Dandenong Hospital

14,

15,

On admission to Dandenong Hospital (part of Southern Health as it was then known), he was assessed to have sustained a fracture of the Left Anterior Superior fliae Spine, fractured 6ht, 9" and 10" ribs with associated small pneumothorax and a fractured left acetabulum, He was admitted under the care of Professor Bruce Waxman, the General Surgeon on call on the day of his admission, He was reviewed by the Orthopaedic Registrar of 28 Tebruary.

Mr Manias was to be managed with strict bed rest, a Zimmer Knee splint to avoid hip flexion and to remain non-weight bearing. He was further reviewed by the ColoRectal Registrar and a further plan of treatment by intravenous fluids, analgesia, chest physiotherapy and orthopaedic review was made. He was transferred to the Surgical Unit

that day.

Physiotherapy treatment commenced on 29 February 2008. He was reviewed by the Occupational Therapist on 3 and 7" of March. The physiotherapy notes in the medical record from 3 March 2008 state that he was safe for discharge home, pending input from the

Occupational Therapist. From 5 March his observations had been decreased to datly.

Dr Mikhail Fisher reviewed Mr Manias on Saturday 8 March 2008... In his statement he recalled Mrs Manias raising the left leg swelling and the possibility of internal haemorrhage.

His clinical assessment was that leg swelling was consistent with the fractured pelvis and that DVT was more likely. Dr Fisher’s assessment was that internal haemorrhage was

unlikely. [note that this assessment was born out al autopsy.

See statement of Wendy Jupp, Nurse Unit Manager, at page 36. Ms Jupp outlined in detail Mr Manias’ clinical

course,

• See statement of Dr Mikhail Fisher at page 41 A of the Inquest Brief

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16. Dr Fisher was concerned about Mr Mania’s tachycardia and febrile episode the night before and ordered blood tests to be taken on 8 March 2008.° The blood tests were taken but the

results were not accessed until Mr Manias deteriorated on 10 March 2008.°

17. The blood tests showed that as at 8 March 2008, Mr Manias has a low sodium level of 130 mmol/L, an elevated creatinine level of 229mmol/L (the reference range is 40-120), and C

Reactive Protein level of 401.3 (reference range is 0-5).!

18. On 10 March 2008, Mr Manias was noted to be distressed with pain in his left hip. Te was diaphoretic, tachycardic at 123 and hypotensive at 62/40. A Medical Emergency Team call

was made and he was transferred to the Intensive Care Unit.

Mrs Manias

19. Mrs Manias testified that, in the days after admission to hospital, Mr Manias started to improve.® She was told that Mr Manias needed to eat and drink more so she brought in food for him and monitored his fluid intake.” He was seen on 5 March 2008 by the rehabilitation registrar and found to be suitable for rehabilitation at home. At this time, Mrs Manias noticed that her husband was feeling ill and weak. Mrs Mantas noted a deterioration from that point on. By Thursday 6 March, she was worried for her husband and thought he was getting worse instead of better. On 7 March, Mrs Manias thought that her husband appeared

to be getting weaker and expressed her concems to nursing staff.

20, On 8 March, Dr Mikhail Fisher reviewed Mr Manias as part of his ward round along with two other doctors. Mrs Manias told the doctors that Mr Manias had swelling particularly in his left foot but that she did not think Dr Fisher was very concerned.'® She then took him

out for some fresh air and noted he was quiet and sweating. |'

5 Ibid.

6 Ibid. Dr Fisher stated that when he reviewed Mr Manias on the ward round on 10 March 2008, there was no handover that the blood tests had not been followed up.

7 See Exhibit 6C 8918:15-17 °710:25-31 7 13:17-31

'' One of Mrs Manias’ concerns raised after her husband’s death was the lack of communication with the family in relation to her husband and what she felt was a failure to take her concerns in to account. I understand that Southern Health has taken these concerns on board and now endeavour to communicate more fully with family members.

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21, Mrs Manias’ felt that Mr Manias did not improve over the next two days and he remained weak and had difficulty breathing. Mrs Manias was present when a MET call was made on

the afternoon of 10 March 2008 and he was transferred to ICU.

Dry vonne Kearley

22, Dr Kearley attended the inquest to give evidence. Dr Kearley first saw Mr Manias in ICU when he was acutely unwell.'* Dr Kearley treated Mr Manias until his death on 1 L March

2008. Dr Kearly made a diagnosis of septic shock secondary to pneumonia based on clinical examination, reduced air cntry at the left base, chest x-ray, hypothermia, raised white cell count and a C reactive protein of 307.9. Hc was noted to have acute renal failure, secondary to septic shock, abnormal liver function and hypoglycacmia. His condition deteriorated over night and he required cardio pulmonary resuscitation at approximately 1.20pm. Dr Kearlcy made the decision to thromholyse Mr Manias as pulmonary embolus was a possibility.

After three hours of CPR, Dr Kearley and Dr Waxman had a meeting with the family and

the decision was made to cease active treatment. Mr Manias passed away soon after.

23. At the time, the treating doctors thought Mr Manias’ diagnosis was one of massive pulmonary embolism with acute renal failure. Dr Dodd, pathologist at the VIFM, did not find any evidence of pulmonary embolism. Mrs Manias was unaware (hat her husband had

contracted a staphylococcus infection until she received the medical examiners report,

24, I note here that 1 do not make any criticisms of Mr Manias’ treatment in TCU and I do not intend to outline in detail the treatment he received in ICU. There was a line of questioning at inquest about the decision to use a ceftriaxone and azithromycin over Vancomycin given his acute renal failure. I do not consider that this had any bearing on Mr Manias death and I accept Dr Kealey’s evidence that by the time Mr Manias arrived in ICU he was not able to

be saved, ?

25. Dr Kearley further testified about the significance of the blood tests results and proccsses in

place to report abnormal results to the ordering doctor.

26. As noted above, Southern Health conceded that the blood tests should have been accessed on 8 March 2008. Dr Kearley’s evidcnce was that the blood tcst results could not show the

presence of the staphylococcus and the only way to diagnose staphylococcus is by way of a

2 T60:9-11 8-175:14-16

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blood or sputum culture. '" In addition, there are no physical symptoms to diagnose staphylococcus aurcas,!> However, she further testified that the CRP result from 8 March 2008 was markedly elevated and tells her that he had a serious infection. The elevated

creatinine level indicated acute renal failure,'®

27, At the time of Mr Mania’s death, pathology services were required to call the doctor who ordered the test, if there was a critical abnormal test result. Dr Kearlcy stated that the creatinine level recorded on 8 March 2008 was high but ‘not a range that would require someone to have treatment for dialysis’ ,'7 The policy in place in 2008 relating to critical biochemistry results and therapeutic drugs notification protocol did not contain creatine or CRP levels as results that needed to be notified to doctors when at a critical tevel.!" Dr Kearley’s view was that these indicators should be added to the list of results that require a

phone call to the doctor.'°

28. Dr Kearley stated that the infection likely started in Mr Manias’ IV line.” The nursing notes from 4 March 2008 noted that ‘the IV site [is] slightly inflamed’,”? Again on 9 March 2008, nursing notes from 14.30 state that ‘TV site L forearm slightly read and swollen. Pl monitor for infection’.”” There is no further references to the IV site on the ward, Counsel for Southern Health tendered a document titled Junior Medical Officer Checklist. This checklist has come in to operation since Mr Manias’ death. Included on that checklist is a reminder to check IV sites. Dr Kearley stated that it is possible that if the check list was

used, the 1V site would have been picked up.” Ambulance Victoria

29. I note briefly here, that my investigation caused me to seek an expert report from Associate

Professor Mark Fitzgerald, Director of Trauina Services at the Alfred Mospital in relation to

"'774:22-24

'5-174:26-29

1617 1:22-25

7-180:20-28

'8 See Exhibit 6E.

° 1:93:17-19

9 T87:17-19

2 See page 160 of the medical records ” See page 166 of medical records 3-789:2-5

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the appropriateness of Mr Manias’ transfer to Dandenong Hospital. I was subsequently provided with a statement from Professor Anne-Maree Kelly, Professor and Academic Head of Emergency Medicine at Western Health addressing issues raised in Professor Fitzgerald’s report. I am satisfied that the issues raised in these reports do not need to be commented

upon further. These reports remain on the inquest brief.

30. Given the time delay between Mr Manias’ fall and his death, the paramedic’s conduct and

decisions made by them, cannot be said to have had a bearing on his death.

FINDINGS

31. Under section 67(1) of the Act, I am required to find the identity of the deceased, the cause of death and the circumstances in which the death occurred. The identity of the deccased is not in issue and I am satisfied, based on the statement of identification, that the identity of

the deceased is John Manias.

32. Mr Manias’ cause of death is also not in dispute and I am satisfied, based on Dr Dodd’s post

mortem examination report that the cause of death was: 1(a) multisystem organ failure, pneumonitis and sepsis {(b) complications arising form a fall resulting in multiple rib fractures

33. I find that Mr Manias contracted staphylococcus aureus whilst in the Dandenong Hospital being treated for his injuries sustained on 27 February 2008. 1 further find that it is likely that the staphylococcus infection started in the IV line and that, although redness and swelling was noted in the nursing records, further investigation was not undertaken as to this possibility.

34, I find that, had medical staff followed up on the blood test results taken on 8 March 2008 prior to 10 March 2008 that it is likely that further investigations would have been undertaken and that Mr Manias would have been treated according to those results. | am further satisfied that had such a course been followed, it is likely to have led to a favourable

outcome."

4 soe transcript page 94:5-9,

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I direct that a copy of this finding be provided to the following: Ambulance Victoria Mr Manias’ family Monash Health

Signature:

OA. (hic

PETER ee

CORONER Date:29 April, 2015

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