Finding into death of Martin Robert Beaty

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2014/3640

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2)

Section 67 of the Coroners Act 2008

I, AUDREY JAMIESON, Coroner having investigated the death of MARTIN ROBERT BEATY

without holding an inquest:

find that the identity of the deceased was MARTIN ROBERT BEATY born 27 June 1962

and the death occurred on 18 July 2014

at the Monash Medical Centre, 246 Clayton Road, Monash, 3168 from:

1(a) COMMUNITY ACQUIRED PNEUMONIA IN A MAN WITH MYOTONIC

DYSTROPHY

Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Mr Martin Robert Beaty was 52 years of age at the time of his death. He lived in Yooralla House supported accommodation, located at 184 Grange Road, Glen Huntly. He had been a resident at that location for approximately four years. His medical history included Myotonic

Dystrophy, and lifelong anticoagulation therapy secondary to pulmonary embolism.

2. On 13 July 2014, Mr Beaty was taken to the Emergency Department (ED) at Monash Medical Centre (MMC). A chest X-ray demonstrated bibasal atelectasis. Mr Beaty was transferred into the care of the General Medical Unit in the Acute Assessment Unit. He was discharged on 14 July 2014 with a diagnosis of mild community acquired pneumonia. He was provided with oral

antibiotics and a diuretic.

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3. Mr Beaty was again taken to the MMC ED via ambulance on 17 July 2014 at 10.5lam with shortness of breath. Upon admission, a venous blood gas suggested the presence of a respiratory acidosis with type 2 respiratory failure, with an elevated carbon dioxide level. He was commenced on non-invasive ventilation in the ED. He was also noted to be in atrial fibrillation and was commenced on digoxin. He was then reviewed by the General Medical Registrar Dr Birrell at 1.07pm, who concurred with the diagnosis of Respiratory Failure secondary to pneumonia, complicated by the underlying Myotonic Dystrophy. The General Medical Registrar contacted the Respiratory Registrar, Dr Phillip George, and requested a Respiratory High Dependency Unit (HDU) bed for Mr Beaty and ongoing management of ventilatory support.

4. Mr Beaty was admitted to the Respiratory HDU at 3.25am on 18 July 2014. He was reviewed by the overnight junior doctor at 5.40am, who noted that Mr Beaty had a tachycardia (heat rate of 130 beats per minute) and was in atrial fibrillation, for which Mr Beaty was given metoprolol. Mr Beaty was reviewed by the Respiratory medical team at 9.15am. At this time, it was noted that the respiratory acidosis and Mr Beaty’s oxygen saturations had not improved.

His conscious stated measured by the Glascow Coma Score (GCS)! was impaired at 12.

5. The Respiratory Unit implemented an ongoing management plan, which included BiPAP noninvasive ventilation, follow up venous blood gas samples, and a review by the General Medical

Unit in order to clarify treatment goals.

6. At 10.20am, General Medical Unit Registrar Dr Khai Khong was contacted by the Respiratory Registrar to request a review of Mr Beaty, who had increasing oxygen demands and evidence of increased work of breathing. The Respiratory Registrar expressed a view that Mr Beaty was

failing to respond to non-invasive ventilation.

7. Mr Beaty was reviewed by Dr Khong and MMC Staff Specialist Dr Sara Barnes at 10.30am.

Dr Barnes considered that in the context of Mr Beaty’s profound impairments arising from Myotonic Dystrophy, combined with the severe, acute pneumonia with worsening respiratory

failure resistant to active management (up to and including non-invasive ventilatory support

} Glasgow Coma Scale is a standardised system for assessing response to stimuli in a neurologically impaired patient; reactions are given a numerical value in three categories (eye opening, verbal responsiveness, and motor responsiveness), and the three scores are then added together. The lowest values are the worst clinical scores. (Source: Dorland’s Illustrated Medical Dictionary, 30" Edition).

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and antimicrobial treatment), that Mr Beaty was in the terminal phase of his illness and no further escalation of treatment was possible. Dr Barnes explained the process of withdrawal of active treatment to Mr Beaty’s carer Ms Donisa Scalzo, and Mr Beaty was provided with

palliative care. He died at 11.02pm on 18 July 2014.

INVESTIGATIONS

Dr Linda Iles, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an external examination on the body of Mr Beaty, reviewed a post mortem CT scan and reviewed the Victorian Police Report of Death, Form 83 and the e-Medical Deposition.

Anatomical findings included a calcified falx/hyperostosis frontalis interna, consolidation of the right middle and lower lobes, and left lowers lobe of the lung as well as patchy opacification of the right upper lobe, and extensive atrophy/fatty replacement of skeletal muscle. Dr Iles ascribed the cause of Mr Beaty’s death to natural causes, being community

acquired pneumonia in a man with Myotonic Dystrophy.

The circumstances of Mr Beaty’s death have been the subject of investigation by Victoria Police on my behalf. Police obtained statements from MMC Staff Specialist Dr Sara Barnes

and General Practitioner Dr Tony Hammond.

Mr Beaty’s death was reported to the Coroners Court of Victoria as it was considered a “reportable death”, as defined in section 4 the Coroners Act 2008 (the Act), as his death was “unexpected” and because he was “person placed...in care” as it is defined in the Act.

Although Mr Beaty was a “person placed...in care”, because his death was attributed by Dr Iles in her report to natural causes, an inquest was not held into Mr Beaty’s death pursuant to

section 52(3A) of the Act.

Dr Hammond had treated Mr Beaty since April 2013. Dr Hammond noted Mr Beaty’s episodes of chest infection in June and July 2014, which he stated were entirely expected to be due to

Myotonic Dystrophy.

FINDING

L accept and adopt the medical cause of death as identified by Dr Linda Iles and find that Mr Martin

Robert Beaty died from natural causes, being community acquired pneumonia in a man with

Myotonic Dystrophy.

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AND I further find that the were no relationship between the cause of Mr Beaty’s death and the fact

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

As Mr Beaty 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.

I direct-that a copy of this finding be provided to the following:

Ms Donisa Scalzo

Department of Health and Human Services

Ms Susan Van Dyk on behalf of Monash Health

Senior Constable S Yakopo

Signature: = =

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AUDREY JAMIESON CORONER- == Date: 30 July 2015

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