Finding into death of Margaret Teresa O'Donnell

IN THE CORONERS COURT OF VICTORIA .

AT MELBOURNE Court Reference: COR 2013 001327

FINDING INTO DEATH WITHOUT INQUEST

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

I, ROSEMARY CARLIN, Coroner having investigated the death of MARGARET TERESA

O’DONNELL

without holding an inquest: find that the identity of the deceased was MARGARET TERESA O’DONNELL born on 28 August 1943 and that the death occurred on 28 March 2013 at Austin Hospital, Victoria from: l(a) CONGESTIVE CARDIAC FAILURE

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

1. Ms O’Donnell was born on 28 August 1943 and she was 69 years old at the time of her death. She is survived by her family. At the time of her death she resided in Kew Cottages,

a residential service managed by the Department of Human Services.

2. Ms O’Domnell had a complex medical history including intellectual disability, type 2 diabetes, obesity, hypertension, valvular heart disease, heart failure, iron deficiency, asthma, recurrent bronchitis, vitamin B12 deficiency and recurrent cellulitis of the legs.' She was frequently seen by her GP and had received treatment from specialists at Austin Hospital

and Box Hill Hospital for her heart, leg cellulitis and leg ulcers.”

' Statement of Dr Peter Wexler dated 5 August 2014, page 1.

Qa Tbid.

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On 31 December 2012, Ms O’Donnell suffered a fall which resulted in a piece of skin peeling back on her leg, creating a wound. She saw her doctor initially and then every

second day to have the wound cleaned, but despite this it became worse.

On 25 February 2013, Ms O’Donnell complained of chest pains and was transported to Box Hill Hospital where she remained until 15 March 2013. Whilst there she received a skin

graft to her wound.

On 16 March 2013, Ms O’Donnell complained again of chest pain and was admitted to the Austin Hospital to investigate the cause of the pain. She undertook physiotherapy while at

hospital to assess her mobility.

On 19 March 2013, Ms O’Donnell was assessed by clinicians and it appeared that her cardiac status had deteriorated significantly over the previous six months. Initially it was believed her chest pain was due to gastroesophageal reflux disease and treatment was commenced. Her symptoms improved somewhat but her pain continued. Tests were not

indicative of a cardiac cause for her pain.

On 21 March 2013, the Psychogeriatric team were of the opinion that Ms O’Donnell was having an ongoing issue with depression as well as acute delirium. She was given a change in medication to assist in the management of her illness. A review of her leg wound revealed that the skin graft had failed and as a result a different type of wound management

was initiated.

On 26 March 2013, Ms O’Donnell was being assisted to the toilet by nursing staff when she _ became weak in the legs and again complained of chest pain. Her blood pressure was found to be 105/60 and she had a blood sugar level of 12. Her blood pressure fell further to 95/60 and she becamie hypoxic. Intravenous resuscitation was commenced, but Ms O’Donnell

continued to deteriorate and suffered acute renal failure.

On 27 March 2013, following consultation with her family and treating clinicians, palliative care was commenced. Ms O’Donnell died the following morning on 28 March 2013 at

approximately 9.19 a.m.

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Signature:

Dr Robert Lefkovits, Consultant Physician at the Austin Hospital, concluded that Ms O’Donnell appeared to have suffered septic complications producing a pre-renal acute kidney injury and oliguric renal failure in the context of her recent surgery, cardiac deterioration and generalised poor state.? Following ongoing review and management involving multiple clinical specialties, there seemed to be no alternative to palliation, which

is what occurred after discussion with Ms O’Donnell’s family.’

An inspection of Ms O”Donnell’s body was undertaken by Dr Noel Woodford, Senior Forensic Pathologist with the Victorian Institute of Forensic Medicine. The post mortem CT scan revealed the presence of an enlarged heart with mitral valve and coronary artery calcification and extensive subcutaneous oedema and fluid (ascites) within the peritoneal

cavity. Dr Woodford reported the cause of death as 1(a) Congestive Cardiac Failure.

. lam satisfied the clinical care and management of Ms O’Donnell by staff at Kew Cottages

and the Austin Hospital was appropriate and satisfactory.

I find that Margaret O’Donnell died on 28 March 2013 of natural causes, being congestive

cardiac failure.

As Ms O’Donnell was in care within the meaning of the Coroners Act 2008, this Finding

will be published on the Internet in accordance with section 73(1B) of the Act.

Jalso direct that a copy of this Finding be provided to the family of Margaret O’Donnell, the

Interested Parties and to the Investigating Police Officer.

ROSEMARY CARLIN CORONER 17 February 2015

Statement of Dr Robert Lefkovits dated 7 July 2014, page 3.

4: Ibid.

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