Finding into death of James Donohoe

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 5015

FINDING INTO DEATH WITH IN QUEST

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

Inquest into the Death of: JAMES DONOHOE

Delivered On: 3 September 2015 Delivered At: Coroners Court of Victoria

65 Kavanagh Street, Southbank

Melbourne 3006 Hearing Date: 3 September 2015 Finding Of: AUDREY JAMIESON, CORONER Counsel Assisting Leading Senior Constable Joanne Allen

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I, AUDREY JAMIESON, Coroner having investigated the death of JAMES DONOHOE

AND having held an inquest in relation to this death on 3 September 2015

at MELBOURNE

find that the identity of the deceased was JAMES DONOHOE

born on 15 November 1953

and the death occurred on 1 November 2013

at the Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050

from:

1 (a) COMBINED EFFECTS OF ACUTE ON CHRONIC PNEUMONIA AND

PULMONARY THROMBOEMBOLISM

in the following circumstances:

On 3 September 2015, a mandatory inquest under section 52(2)(b) of the Coroners Act 2008 (Vic) (the Act) was held into the death of Mr James Donohoe, because immediately before his death, Mr Donohoe was “a person placed in....care” as it is defined in the Act. Mr Donohoe had an intellectual disability and had been a client of the Department of Human

Services (DHS)! Disability Services for most of his life.

BACKGROUND AND CIRCUMSTANCES

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Mr James Donohoe was 59 years of age at the time of his death. He had two older half siblings and a younger sister, Ms Anne Jones, who visited him on a regular basis. He had been placed in care at the age of 14 years. His father, Mr James Donohoe, died in 1985, and

his mother, Mrs Violet Donohoe, died in 1995.

Sine 2005, Mr Donohoe had lived at a DHS managed group home at 5 Baltusrol Close, Sunbury, with four other residents. He attended the day service run by Distinctive Options

five days per week.

Mr Donohoe’s medical history included recurrent urinary tract infections (UTIs) and chest

infections, an intellectual disability with minimal verbal communication, and a physical

'T note that the DHS is now known as the Department of Health and Human Services (DHHS).

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disability rendering him confined to a wheelchair for mobility purposes and dependant on

others for assistance with his activities of daily living.

On 11 October 2013, Mr Donohoe was conveyed to the Royal Melbourne Hospital (RMH) via ambulance with significant weight loss of 6kg over two weeks. Upon arrival to the RMH, Mr Donohoe was conscious, responsive and found to be severely dehydrated and hypernatremic. Mr Donohoe’s Admission/Assessment/Planning Form prepared on 11 October 2013 indicated he had a special slip-on suit jacket with a zip fastener at the back, which was used to stop him from getting his hand in his pants, as he had a history of pulling the stuffing out of the pads he wore and eating it.

On the second day of Mr Donohoe’s admission, it was noted that he was coughing up food and his oxygen saturation levels were considered low. He was provided with antibiotics and reviewed by a Speech Pathologist, who confirmed that he had minimal swallowing function.

He was subsequently fed via a naso-gastric tube (NGT), which was not well tolerated by Mr Donohoe, who repeatedly pulled it out. Mr Donohoe was provided with Specialist one on one nursing care. Chest X-rays depicted shadows on the chest and aspiration pneumonia was suspected. Four separate attempts were made at a CT scan, however Mr Donohoe became agitated during the process, and the scans were unable to be completed. His medical issues during his inpatient stay included hypernatremia, recurrent aspirations, cachexia and left

lower lobe lung nodules.

On 20 October 2013, the treated medical staff spoke with Ms Jones about her brother’s poor prognosis, and a decision was made to provide Mr Donohoe with palliative care. Mr

Donohoe died on 1 November 2013.

FORENSIC PATHOLOGIST EXAMINATION AND EVIDENCE

Dr Victoria Francis, Forensic Pathology Registrar at the Victorian Institute of Forensic Medicine (VIFM), under the supervision of Dr Sarah Parsons, Forensic Pathologist at the VIFM, performed a post mortem examination upon the body of Mr Donohoe, reviewed a post mortem CT scan and reviewed the Victorian Police Report of Death, Form 83. Dr Francis also had available to her the RMH medical record, the eMedical Deposition, Ambulance Victoria records and the medical record of Mr Donohoe’s General Practitioner

(GP) at the Sunbury Medical Centre.

Post mortem anatomical findings included bronchitis, pneumonia, bronchiectasis,

pulmonary thromboemboli within the right lower lobe of the lung with associated infarction,

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heart weight of 200g (25"" percentile for height 212g, sot percentile for weight 227) with patchy myocardial fibrosis, chronic outflow obstruction-type changes in the kidneys, markedly trabeculated and thickened bladder wall, a body mass index of 12.6 and a blue plastic foreign object within the distal third of the oesophagus with associated mucosal ulceration. Dr Francis commented that the mucosal ulceration indicated that the blue plastic

foreign object had been present for more than several hours.

Dr Francis stated that toxicological analysis of blood showed no alcohol, common drugs or poisons, No glucose was detected. Post mortem biochemistry showed increased sodium (hypematremia) and chloride as well as significantly increased creatinine and urea. Creactive protein (CRP), a molecule that increases with inflammation, particularly infections,

was significantly elevated,

Post mortem microbiology showed Pseudomonas aeruginosa and Staphylococcus aureus in a left lung abscess. Dr Francis noted that Mr Donohoe had been suffering episodes of aspiration for a prolonged period of time. His lungs showed generalised pneumonia as well

as multiple abscesses.

Dr Francis commented that Pseudomonas aeruginosa often affects the pulmonary tract in hospitalised, immunocompromised individuals and while it is known to occasionally cause community acquired pneumonia, it most commonly affects ventilated patients, cystic fibrosis patients, or catheterised individuals. Dr Francis further commented that Staphylococcus aureus is a bacterium that normally lives on the skin but may cause significant infections. Some strains release toxins that can cause rapid onset of septic shock

and death. It commonly causes infections around prostheses as well as pneumonia.

Dr Francis referred to a blood test performed by Mr Donohoe’s GP on 30 September 2013, which showed a blood urea of 15.7mmol/L and a creatinine of 127mmol/L, both of which are considered mildly elevated and similar to Mr Donohoe’s previous test results. Dr Francis compared this to Mr Donohoe’s post mortem urea and creatinine levels, which were 106mmol/L and 826mmol/L respectively, which Dr Francis considered indicates that Mr

Donohoe was suffering from acute on chronic renal failure.

Dr Francis commented that it is likely that chronic respiratory infections and UTIs were responsible for Mr Donohoe’s weight loss. Dr Francis observed that medical practitioners apparently had trouble in maintaining oral intake, and that his treating medical team thought

that his chronic hypernatremia was caused by chronic dehydration. Dr Francis noted that his

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medical record indicates that these issues were difficult to treat, as Mr Donohoe did not

tolerate his feeding tube and frequently pulled it out.

Dr Francis opined that the significance of the blue plastic object lodged in Mr Donohoe’s distal oesophagus is uncertain. While Dr Francis concedes that is appears to have been in situ for over a matter of several hours, Dr Francis considered it was unlikely to have

contributed to his death.

Dr Francis ascribed the cause of Mr Donohoe’s death to the combined effects of acute on

chronic pneumonia and pulmonary thromboembolism.

POLICE INVESTIGATION

The circumstances of Mr Donohoe’s death have been the subject of investigation by Victoria Police on my behalf. Police obtained statements from Ms Jones, DHS Disability Accommodation Services Manager Mr Pravin Ram, DHS Disability Development Services Officer (DDSO) Ms Tracey Rodger, GP Dr Rowshanul Alam, and the RMH and Sunshine Hospital.

Mr Donohoe’s medical needs were attended to by GP Dr Alam and Dr Kumar, who practiced at the Sunbury Medical Centre (the Clinic). Mr Donohoe’s last annual health assessment was completed on 23 November 2012, and a review was scheduled for

November 2013.

The Clinic medical records indicate that Mt Donohoe had a Speech Pathology assessment conducted in July 2013, which showed an impaired swallowing reflex. Mr Donohoe was

subsequently placed on a thickened fluids diet.

Dr Alam stated that Mr Donohoe was reviewed by numerous GPs in the months prior to his death. Mr Donohoe had a long history of recurrent UTIs and was seen by the Urology Unit at the Western General Hospital in 2008. His UTIs persisted.

Mr Donohoe attended the Clinic in February, March and June 2013 with UTIs and was referred to Urologist Mr Andrew Troy for management of recurrent UTIs, mild renal

impairment and abnormal urinary bladder ultrasound findings.

Mr Donohoe was seen by Mr Troy in July 2013. Mr Donohoe again attended the Clinic on 23 September 2013 with urinary symptoms and weight loss. He was referred to the Sunshine

Hospital for further management of his UTIs and weight loss, however attended the RMH

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ED on this day. The RMH discharge documentation details that Mr Donohoe was waiting

for outpatients investigations for weight loss and further management of recurrent UTIs.

Mr Donohoe presented to the Sunshine Hospital on 26 September 2013 with a UTL Mr Donohoe presented to the Clinic on 30 September 2013 with urinary symptoms and an urgent referral was made to the RMH Urology Clinic.

Mr Donohoe next presented to the Clinic on 2 October 2013 with an injury to his right leg, which required dressings. Dr Alam reviewed Mr Donohoe’s right leg on 7 October 2013, and prescribed him with prophylactic antibiotics for his recurrent UTIs, in accordance with

Mr Troy’s management plan.

Ms Jones had been appointed as Mr Donohoe’s medical power of attorney. Ms Jones received a telephone call on 10 October 2013 from one of her brother’s carers to inform her that he was unwell. Ms Jones received another telephone call on 11 October 2013, informing her that her brother had been transported to the RMH via ambulance. It appears that Ms Jones found out about her brother being unwell for a number of weeks and his attendance at Emergency Departments upon her arrival at the RMH. Ms Jones stated that she had requested an explanation from the DHS House Supervisor Ms Alison Ames regarding why

no one had contacted her earlier.

Mr Ram stated that on 26 September 2013, an attempt was made to contact Ms Jones to

advise of her brother’s attendance at the Sunshine Hospital, and a message was left.

I note that a lack of communication, if occurred, is capable of causing distress to family members in an already distressing situation, however I do not consider that these issues were

causal to Mr Donohoe’s death, or relevant to the coronial jurisdiction.

FACTORS CAUSING OR CONTRIBUTING TO DEATH

The evidence supports a conclusion that Mr Donohoe died on 1 November 2013 and that the cause of his death was the combined effects of acute on chronic pneumonia and pulmonary thromboembolism. The circumstances under which Mr Donohoe died were, according to the pathologist, consistent with Mr Donohoe’s relevant medical history. There was no evidence to suggest any other cause or contribution to his death. Mr Donohoe’s cause of death

appears to be related to his underlying medical conditions.

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COMMENTS Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the death:

In all the circumstances, I am satisfied that there would be no benefit from conducting a full inquest into Mr Donohoe’s death or obtaining any further medical or other evidence, as neither would assist me to further understand the medical issues before me or the cause of Mr Donohoe’s death which resulted from the combined effects of acute on chronic pneumonia and pulmonary thromboembolism in the context of his underlying medical conditions. I am also satisfied that the care received by Mr Donohoe from the DHS, his General Practitioners and other treating practitioners, and the frequent medical reviews and investigations undertaken in the months prior to his death were reasonable and appropriate in the circumstances. I accept Dr Francis’ opinion that the blue plastic foreign object identified at autopsy did not contribute to Mr Donohoe’s death, although its presence is somewhat perplexing. Its presence is however possibly explained by Mr Donohoe’s known

past behaviour of placing objects within his reach into his mouth.

FINDING I accept and adopt the medical cause of death as ascribed by Dr Victoria Francis and I find that James Donohoe died from the combined effects of acute on chronic pneumonia and pulmonary

thromboembolism.

AND I further find that there is no relationship between the cause of Mr Donohoe’s death and the

fact that he was “a person placed in care”.

Pursuant to section 73(1) of the Coroners Act 2008, I order that the following be published on the

internet.

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

Dr Rowshanul Alam, Sunbury Medical Centre

The Royal Melbourne Hospital, Melbourne Health

Mr Shane Beaumont, Manager Complex Support and Systemic Improvement, Residential Services & Complex Support, Service Implementation & Support, Department of Health and Human

Services

Senior Constable Helen Farmer

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Signature:

AUDREYJAMIESON CORONER —__— Date: 3 September 2015

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