Finding into death of Ian Kenneth Pye

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 1501

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: Ian Kenneth PYE

Delivered On: 23 April 2015 Delivered At: Coroners Court of Victoria

65 Kavanagh Street Southbank 3006 Victoria Hearing Date: 23 April 2015 !

Findings of: - JAIN WEST, DEPUTY STATE CORONER | Representation: 2 Coroncr’s Assistant Sonja Mileska .

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I, IAIN TRELOAR WEST, Deputy State Coroner having investigated the death of Ian Kenneth

PYE

AND having held an inquest in relation to this death on 23 April 2015

at MELBOURNE

find that the identity of the deceased was Jan Kenneth PYE

born on 13 October 1956

and the death occurred on 8 April 2013

at Austin Health-Austin Hospital, 145 Studley Road Heidelberg, 3084 Victoria

from:

1 (a) CEREBRAL HYPOXIA IN A MAN WITH RESPIRATORY INSUFFICIENCY AND

DOWN’S SYNDROME

in the following circumstances:

Ian Pye was a 56 year old man who resided in supported care at the Department of Human

Services group home in Reservoir. This group home is a purpose built home for people with physical and intellectual disabilities and Mr Pye had been a resident of the facility since mid 2009.

Mr Pye’s medical history included Down’s Syndrome, Alzheimer’s dementia, schizophrenia, osteoporosis, bilateral hip dysplasia, severe cervical canal stenosis and seizures. Mr Pye was unable to care for himself and required assistance for basic living. He also required a wheelchair for mobility, and rarely talked.

In the months preceding his death, Mr Pye became increasingly lethargic and drowsy, waking only for meals and medication. On 7 April 2013, Mr Pye was unable to be roused by staff and was taken to the Austin Hospital where he presented with type II respiratory failure, likely due to aspiration. He had a decreased conscious state with a Glasgow Coma Score (GCS) of 10. A CT brain scan was undertaken which indicated ‘no focal abnormality.’

On admission, his conscious state further deteriorated to a GCS of 7. A venous blood gas revealed a picture consistent with respiratory acidosis and type II respiratory failure.

Examination by Associate Professor Richard O’Brien revealed reduced respiratory function and low blood oxygen levels. Although a chest x-ray was relatively clear, it was felt most likely that Mr Pye had aspirated food, fluid or secretions and this had led to the impaired respiration.

Mr Pye was admitted and given IV fluids and oxygen but remained in a very reduced conscious state. On arrival in the ward, Mr Pye had a convulsion and was given intravenous medication to prevent further convulsions. Unfortunately, there was no improvement in his conscious level and he was subsequently palliated. Mr Pye died at 2.45pm on 8 April 2013.

Senior Forensic Pathologist Dr Malcolm Dodd performed an autopsy on Mr Pye on 12 April

2013. The myocardium was clear of naturally occurring disease and the coronary artery tree was patent throughout. The lungs showed congestion and there was evidence of pulmonary artery thickening and changes consistent with chronic obstructive airways disease. There was no immediate evidence of aspiration or active pneumonitis.

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7. The examination of brain tissue showed hippocampal changes that may have been due to repeated episodes of seizures or may. be secondary to hypoxia. The loss of the granular layer in the cerebellum is an indicator of hypoxia. Toxicological analysis of body fluids was unremarkable with Olanzapine present in the blood at therapeutic levels. Dr Dodd stated that there was no evidence to suggest that Mr Pye’s death was due to anything other than natural causes.

8. I find that the cause of death of lan Pye was cerebral hypoxia in a man with respiratory insufficiency and Down’s Syndrome. ‘

I direct that a copy of this finding be provided to the following: Ms Beverley Pye ‘

Ms Debra Harris

Constable Matthew Cook, Heidelberg Police Station

Mrs Pauline Chapman, Austin Health

Signature:

IAIN WEST DEPUTY STATE CORONER Date: 23 April 2015

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