Finding into death of Mernita Nancy Crooks

IN THE CORONERS COURT OF VICTORIA AT MELBOURNI

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Court Reference: COR 2014 003486

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 MERNITA NANCY CROOKS without holding an inquest: ‘

find that the identity of the deceased was MERNITA NANCY CROOKS born on 8 May 1926 and the death occurred on 9 July 2014 at Stud Road, Rowville, Victoria from: l(a) UPPER CERVICAL SPINE INJURY IN A MOTOR VEHICLE INCIDENT

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. Ms Mernita Crooks was born on 8 May 1926 and she was 88 years old at the time of her

death. Ms Crooks resided alone in Dandenong North, Victoria. She is survived by her family.

2. Victoria Police provided a bricf to the Coroner which included statements from Ms Crooks’ daughter, neighbour, treating clinician, witnesses and investigating officers. I have drawn on

all this material as to the factual matters in this finding

Background and Medical History

3. Ms Crooks had a number of health issucs in recent years including ostcoarthritis, a minor stroke and brain haemorrhage and cataracts requizing non-urgent attention. She had recovered

from a broken foot, wrist and arm and walked with the aid of a walking stick.

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According to a neighbour, Ms Crooks’ driving skills had deteriorated over the last 3-4 years and she collided into neighbours’ cars on numerous occasions when exiting her driveway.

She had also twice knocked down a brick fence. On 20 March 2014, this neighbour wrote to

VicRoads outlining concerns about Ms Crooks’ driving ability.

On 2 April 2014, VicRoads wrote to Ms Crooks requesting that she provide them with a medical report. As Ms Crooks did not comply with the request on 2 May 2014, VicRoads

issued a Notice of Suspension of her driver licence commencing 16 May 2014.

On 12 May 2014 Ms Crooks presented to her General Practitioner, Dr Ronald Ling for a medical assessment for the purposes of complying with VicRoads’ request. Dr Ling was unaware that Ms Crooks had been involved in any driving incidents. He was satisfied that she met the national medical standards, including as to vision, to hold a driver licence. VicRoads received Dr Ling’s favourable report on 16 May 2014 and cancelled the planned suspension of

Ms Crooks licence. However, VicRoads requested that she submit an eyesight report.

On 22 May 2014, Victoria Police submitted a licence review request to VicRoads based on observations they had made of Ms Crooks erratic driving and parking and slowness of movement and speech, VicRoads wrote to Ms Crooks on 29 May 2014 requesting she submit

another medical report together with the previously requested eyesight report.

On 23 June 2014, Dr Ling again assessed Ms Crooks and arrived at the samc conclusion as to her driving ability. VicRoads received Dr Ling’s second report on 1 July 2014, however due to Ms Crooks not submitting an eyesight report; it issued another Notice of Suspension of her

licence. The suspension was due to commence on 16 July 2014.

Ms Crooks appeared to be in good spirits in the weeks preceding her death. Her daughter, Deborah Prpich saw her on 27 June 2014 and spoke to her on 7 July 2014. She described her mother as being happy.

Circumstances

10. On 9 July 2014, at approximately 7 p.m., Ms Crooks was driving her car in a southerly

direction along Stud Road in Rowville. She was travelling in the right hand lane. At the time,

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traffic was light but it was raining and the road was very wet. It is reported that visibility was greatly reduced and there was evidence that Ms Crooks may not have been using her

headlights.

For reasons unknown, Ms Crooks veered into the right U-turn lane and drove over the centre median road divider colliding with a road sign and then a large tree. Upon impact, the car flipped upside down on its roof and continued to slide across the southbound lancs of Stud Road, before lightly colliding into the rear of a stationary vehicle. There was no evidence of

braking or evasive action taken by Ms Crooks prior to the collision.

Emergency services werc notified and Ms Crooks was removed from her vehicle, however she

was already deceased.

Post-mortem Examination

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Dr Michael Burke, Senior Forensic Pathologist with the Victorian Institute of Forensic Medicine, performed an autopsy on Ms Crooks’ body. The post mortem examination revealed an upper cervical spine injury associated with a fracture of the second cervical vertebrac.

There was also significant underlying natural disease in the form of myocardial fibrosis with relatively mild coronary artery discasc and evidence of an old cerebrovascular accident.

Toxicological analysis of post mortem blood samples detected venlafaxine!, diltiazem? and

oxycodone? in Ms Crooks’ system.

Dr Burke opined that the old cerebrovascular accident and myocardial fibrosis were consistent with causing sudden loss of control of a motor vehicle, as a consequence of a seizure or sudden cardiac arrhythmia and ‘may well have contributed to the collision’. He reported the

cause of death as 1(a) Upper Cervical Spine Injury in a Motor Vehicle Incident.

' Venlafaxine is used for the treatment of depression.

2 Medication used in the treatment of angina pectoris, hypertension and supraventricular arrhythmias,

3 An opiate narcotic used lo treat moderate to severe pain.

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Finding

15. Iam satisfied having considered all of the evidence before me that no further investigation is required. It is not possible to determine whether the collision occurred due to driver error or a medical event causing loss of control of the vehicle.

16. | find that Ms Mernita Crooks died on 9 July 2014 from an upper cervical spine injury sustained in a motor vehicle incident in which she was the driver.

COMMENTS

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

1. Following receipt of the coronial brief including Dr Ling’s statement | made further enquiries’

of Dr Ling and VicRoads.

Dr Ling indicated that he not aware that Ms Crooks had any previous accidents prior to his medical assessments and she informed him that she was a careful and meticulous driver. He was not aware of the reasons VicRoads were requesting the medical reports and Ms Crooks claimed not to know either. He did not know if the requests were routine or arose because of an acute event. He stated that he would have referred Ms Crooks for a VicRoads driving

assessment had he known of her driving history.

Dr Ling stated that General Practitioners often receive requests for VicRoads medical reports.

He suggested it would be helpful if VicRoads indicated the reason the reports were required as

medical practitioners could then concentrate on the areas of concern and act accordingly.

In response VicRoads submitted that they ‘should not interfere with or influence an independent medical assessment’ and that medical assessments should be made in a ‘holistic and thorough manner’ in accordance with national guidelines, rather than focussing on any particular aspect that may have been reported by someone without medical expertise, as is

usually the case.

In addition, VicRoads submitted that ‘medical practitioners are already able to approach VicRoads to obtain further information about the nature of concerns raised in relation to a

patient’s driving should they wish to obtain it.’ —_— In this regard VicRoads pointed to the fact

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the medical report form states ‘[i]f you have any doubts about the information required, or

wish to discuss the case personally, please contact VicRoads Medial Review (vehicles) on ...’.

6. 1 am satisfied that there is ample material available to medical practitioners conducting independent medical assessments at VicRoads’ request. These include the national guidelines regarding fitness to drive and other literature available on the VicRoads website and easily

accessible through a search of relevant terminology.

7. | am satisfied that VicRoads is working to improve its communications with health professionals to assist them with effectively assessing a patient’s fitness to drive. In its submission to the Court VicRoads indicated it would look at ways to improve its processes and to make health professionals more aware that they can approach VicRoads for more

information.

8. Lconsider there is value in a medical practitioner knowing in broad terms the reason VicRoads has requested a.medical report. Patients may not know the reason, or alternatively choose not to inform their doctor, In my view the present statement in the medical report form indicating that medical practitioners can contact VicRoads does not make it clear that this includes ascertaining the nature of any concerns. Further, the statement appears on a page of small

typeface and is easy to miss.

RECOMMENDATIONS Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s) connected with the death:

1. That VicRoads consider amending its medical report forms to highlight the ability of

medical practitioners to contact VicRoads as to the reasons the assessment is required.

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] direct this Finding be published on the internet.

I also direct that a copy of this Finding be provided to the following: The family of Ms Mernita Nancy Crooks; Dr Ronald Ling; VicRoads; Royal Australian College of General Practitioners; Investigating Member, Victoria Police; and

The Interested parties

Signature:

ROSEMARY CARLIN CORONER 9 October 2015

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