Finding into death of Krizan Vuksan

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2013 615

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, CAITLIN ENGLISH, Coroner having investigated the death of Krizan Vuksan

without holding an inquest:

find that the identity of the deceased was Krizan Vuksan

born on 1 April 1937

and the death occurred on 11 February 2013

at McLellan House, 2-6 Robinson Street, Jacana, Victoria, 3047

from: l(a) ISCHAEMIC HEART DISEASE 1(b) CORONARY ARTERY ATHEROSCLEROSIS

Pursuant to section 67(1) of the Coroners Act 2008, there is a public interest to be served in making findings with respect to the following circumstances:

1. Krizan Vuksan was 75 years of age at the time of his death. Mr Vuksan was born in Croatia

and moved to Australia in 1964 with his wife.

2. Mr Vuksane resided at McLellan House, 2-6 Robinson Street, Jacana, Victoria. McLellan House caters for the care of aged care low-level psychiatric patients. Mr Vuksan was made an involuntary patient under the Mental Health Act 1986 (Vic) at Sunshine Hospital on 10 September 2012 following an alleged physical attack on his wife. He was transferred to

McLellan House on 31 January 2013.

3. At the time of his death, Mr Vuksan was ‘in care’ pursuant to s 3 Coroners Act 2008 (the

Act). He was a patient in an approved mental health service within the meaning of the

Mental Health Act 1986. He was placed on a community treatment order, with a condition to

reside at McLellan House for duration of 31 January 2013 until 30 January 2014."

A coroner must hold an inquest if the deceased was, immediately before death, a person

placed in care, in accordance with section 52(2)(b) of the Act.

Pursuant to section 52(3A).of the Act, I am not required to hold an inquest in these

circumstances, if I consider that the death was due to ‘natural causes’.

In accordance with section 53GB) of the Act, a death may be considered to be due to ‘natural causes’ if the coroner has received a report from a medical investigator, in accordance with the rules, that includes an opinion that the death was due to ‘natural

causes’.

I have received a report in this case. I also note that no issues were identified regarding the health management of Mr Vuksan which impacted on his cause of death. Therefore, I make my findings with respect to the circumstances and do not exercise my discretion, in this

instance, to hold a public hearing through an inquest.

A police investigation was conducted into the circumstances of his death. A brief prepared by Victoria Police for the coroner includes statements obtained from; treating health practitioners and investigating police officers. I have drawn on all of this material as to the

factual matters in this finding.

Health History

Mr Vuksan had a medical history including; hypertension, bilateral hearing loss, gastroesophageal reflux, anaemia, right hip replacement, left inguinal repair,

cholecystectomy. Mr Vuksan also suffered from chronic paranoid schizophrenia.

On 10 September 2012, Mr Vuksan was admitted on an involuntary basis to Sunshine

Hospital with a primary diagnosis of chronic schizophrenia.

Consultant Psychiatrist Dr Louise Kerr, of North Western Mental Health stated that;

“His admission was precipitated by a very serious physical attack on his wife, occurring in the context of psychotic symptoms, mild multi domain cognitive impairment and a known

history of aggression, often in the context of attempts to dominate his wife-and family.’?

1 Coronial brief p 25.

2 Statement of Dr Louise Kerr, NorthWestern Mental Heatlh, 3 March 2015.

12. On 31 January 2013, Mr Vuksan was transferred from Sunshine Hospital to McLcllan House where he was admitted on a 12-month community treatment order. According to Dr Naser, Mr Vuksan was agitated and wanted to go home during his first week following

adtnission.’ Events Proximate to Death

13, On 7 February 2013 progress notes from McLellan House indicate that at 8.30am, Mr Vuksan “stated his chest was sore when he breathed in and had not slept overnight’. Staff

contacted Dr Basher Naser, the visiting general practitioner for McLellan House.

14. Dr Jennifer Torr was the visiting consultant psychiatrist to McLellan House. She met Mr

Vuksan once, in the week prior to his death. She stated that;

“Mr Vuksan was lying on the floor of his bedroom. He was extremely agitated and crying that he wanted to go home. He would not budge off the floor and it was exceedingly difficult to do a physical examination. I heard what could have been crepitation in one lung base, but could not be certain, I made arrangements for his medical care on the premise that he

may have had a chest infection.”

15. Mr Vuksan’s vital signs were within normal limits according to staff. A provisional diagnosis was made by Dr Naser, by telephone, that he was suffering from a lower respiratory tract infection. Dr Naser arranged for him to be commenced on Amoxicillin 500

mg three times a day and advised that he would visit soon to check on him.

16. Mr Vuksan developed a fever at 12.30pm on the same day. Amoxicillin was given at 3pm and staff contacted Dr Naser to advise that his temperature was 38.4 degrees, which Dr Naser considered consistent with his provisional diagnosis and further observation was advised.

17. On 10 February 2013, Dr Naser visited McLellan House to see Mr Vuksan. He was

advised by staff that Mr Vuksan “had improved, with resolution of his fevers, although a

cough still remained. *6 Dr Naser was unable to examine Mr Vuksan as he refused

3 Coronial Brief, 12.

4 Ibid, 33.

Email of Dr Jennifer Torr, 12 October 2014.

• Tid.

19,

consultation. Dr Naser observed that; “he looked well, but he was agitated.” Dr Naser assessed that “he was improving slowly with amoxicillin for lower respiratory tract infection. Given that I was unable to examine him, I decided to add another antibiotic (clarithromycin 250mg twice a day) to be on the safe side and ensure adequate antibiotic coverage of his infection.”® Dr Naser ordered routine blood tests and instructed staff to

notify him if he was not improving.

On 11 February 2013, Nurse Samantha McClintock was on night shift, conducting patient

rounds. At 3.30am, she checked Mr Vuksan and observed him asleep and snoring.

At approximately 6.15am Nurse McClintock attended Mr Vuksan’s room to administer Panadol. She located him in his bathroom slumped under the sink on his right side. It was

apparent to her, after an assessment of his vital signs, that Mr Vuksan was deceased.

Paramedics were contacted, who attended and confirmed he was deceased. Mr Vuksan was

moved back into his bed and police attended.

Review of Care

22,

Concerns were raised by Dr Torr regarding the manner of Mr Vuksan’s discharge from

Sunshine Hospital and transfer to McLellan House.

Dr Torr stated that;

“With regards to his agitation in the week prior to his death, it is my understanding that he was not this agitated when an inpatient at Sunshine Hospital. The plan had been for Mr Vuskan to be discharged to McLellan House at some time, but he remained an inpatient because he was awaiting a forensic assessment before facing trial. My understanding is that he was discharged to allow an admission from the emergency department. Discharge planning was incomplete and the discharge was precipitous, resulting in extreme distress

for Mr Vuksan.” ?

Dr Torr completed the e-Medical Deposition Form certifying time of death. Dr Torr noted

the possible cause of death to be:

T Ybid.

8 Ibid.

• Ibid

25,

“Pneumonia. Vascular risk factors, including hypertension so acute myocardial infarction or cerebrovascular events area also possible causes of death...Pneumonia could possibly be related to intramuscular sedation + shackling for transfer. There are issues regarding pressure on services to effect unplanned discharges, resulting in patient distress + need for intramuscular sedation to enable transfer. This may be something the coroner to address.

: . 1 Consequences of lack of funding + resourcing also shackled for transfer.””"°

Consultant Psychiatrist Louise Kerr was one of two consultant psychiatrists working on the inpatient unit at Sunshine Aged Persons Mental Health service during the period of Mr Vuksan’s admission from 10 September 2012 to 31 January 2013. Dr Kerr was requested to comment on the care provided to Mr Vuksan, including the use of intramuscular olanzapine

and the use of restraints when transferring him to McLellan House.

Dr Kerr explained the process for transfer from Sunshine Hospital to McLellan House. She

stated:

“It is usual procedure for patients to remain on the inpatient Hospital Unit until a room becomes available at McLellan Hostel, as there may be a waitlist. Transfer usually occurs within 24 hours of notification of an available room...Mr Vuksan was reluctant to go to his designated destination but came up with no reasonable alternatives...Mr Vuksan’s transfer had been planned and discussed within the ward following a forensicare assessment.

McLellan Hostel had information about him from the time of his official wait-listing. The decision for transfer was not based on pressure for alternative use of the Inpatient bed but was indeed felt to be the most appropriate option for the community care ...and thus a less

restrictive option for him than an inpatient Unit.’"'

With respect to his medication, Dr Kerr stated:

“Mr Vuksan had been tolerating Olanzapine 20mg oral for more than 4 weeks prior to discharge. The use of IM Olanzapine at 10mg, although not ideal, is often necessary at acute phases of illness or when there is an escalation of aggression. In elderly patients,

clinicians always have to weigh up the risk and benefit of any interventions. We can only

1° Coroners Court of Victoria, e-Medical Deposition Form, 11 February 2013, 3.

'l Statement of Dr Louise Kerr, North Western Mental Health, 3 March 2015

base these decisions on known medical co-morbidities. Mr Vuksan had previously tolerated

Olanzapine 5 and 10mg IM, without incident during this admission.”

27. With respect to the use of restraints on Mr Vuksan during transfer, she stated:

“The brief restraint for transfer is preferably avoidable, but in this case it was well known that unfortunately Mr Vuksan rarely responded to discussion or persuasion if he had a

different opinion and so delay was unlikely to have changed the process.”

28. Iam satisfied the response from Dr Kerr addresses the concerns raised by Dr Torr.

Post Mortem Examination

29. A post mortem autopsy was completed by Forensic Pathologist Dr Matthew Lynch at the Victorian Institute of Forensic Medicine on 21 February 2013. Dr Lynch formulated the

cause of death. I accept his opinion. Dr Lynch noted;

“there was significant natural disease in the form of ischaemic heart disease and an acute myocardial infarction. The heart was also markedly enlarged in keeping with the history of hypertension...there is no evidence to suggest that death is due to anything other than

natural causes.”

30. Toxicology results indicated the presence of the following; Ethanol (less than 0.01 g/100mL, Olanzapine (~0.2 mg/L), Temazepam (~0.06 mg/L) and Paracetamol (less than 5 mg/L)."4

Health and Medical Investigation Team Review

31. The Health and Medical Investigation Team!* (HMIT) reviewed the medical care provided to Mr Vuksan prior to his death, HMIT advice was that Mr Vuksan’s respiratory tract infection was appropriately managed and treated. Mr Vuksan had an unexpected death from

natural causes.

Finding

I find that Krizan Vuksan died from ischaemic heart disease secondary to coronary artery

atherosclerosis.

"2 Statement of Dr Louise Kerr, North Westcrn Mental Health, 3 March 2015 'S Statement of Dr Louise Kerr, North Western Mental Health, 3 March 2015.

M Olanzapine, Temazcpam and Paracetamol were within therapeutic range.

'S The Health and Medical Investigation Team (HMIT) is part of the Coroners Prevention Unit, which assists in the investigation and development of recommendations surrounding deaths occurring during the provision of healthcare.

HMIT also assists in identifying factors that may help improve paticnt safety and risk management.

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

Dr Jennifer Torr

Dr Louise Kerr

Detective Senior Constable Jason Connor

Pursuant to section 73(1B) of the Coroners Act 2008, I direct that a copy of this finding be

published on the internet.

Signature:

CAITLIN ENGLISH CORONER

Date: 18 May 2015