Finding into death of Attilio Crozzoli

IN THE CORONERS COURT OF VICTORIA

AT MELBOURNE Court Reference: COR 2014 4211

FINDING INTO DEATH WITHOUT INQUEST

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

I, CAITLIN ENGLISH, Coroner having investigated the death of Attilio Crozzoli

without holding an inquest:

find that the identity of the deceased was Attilio Crozzoli

born on 21 July 1920

and the death occurred on 15 August 2014

at 1 Glendale Court, Werribee, Victoria

from: 1 (a) MULTI-SYSTEM ORGAN FAILURE AND SEPSIS 1(b) PERITONITIS

l(c) ACUTE GANGRENOUS CHOLECYSTITIS AND GALLBLADDER EMPYEMA

WITH CHOLELITHIASIS

CONTRIBUTING FACTORS ISCHAEMIC HEART DISEASE, DIABETES MELLITUS

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. Attilio Crozzoli was 94 years of age at the time of his death. Mr Crozzoli lived in the Glendale nursing home and was receiving high-level nursing care at the time of his death.

Health History

2. Mr Crozzoli had an extensive past medical history including cholelithiasis, ischacmic heart | disease, diabetes mellitus type 2 and dementia. Mr Crozzoli had coronary bypass grafts in

2003 and a transurethral resection in 2006: In 2010, Mr Crozzoli suffered episodes of

hypoxia, hospital-acquired pncumonia and acute pulmonary oedema following surgery. Mr Crozzoli’s son, John Grom, and daughter, Tiziana Scott, signed an advanced care plan on 17 January 2010, which stated that Mr Crozzoli did not want any treatment administered to sustain life, wishing only for treatments providing comfort and dignity. A ‘not for

resuscitation’ order was signed and dated 12 August 2010.

Events Proximate to Death

In August 2014, Mr Crozzoli became unwell and was treated with oral antibiotics for an infection. Dr Al-Jabbari, a GP, attended Mr Crozzoli on 3 and 10 August 2014, On 10 August 2014, Mr Crozzoli was noted to have increasing confusion and reduced cognitive responsiveness. During the period 3-10 August, Mr Crozzoli was bedridden and

expericncing bladder and bowel incontinence and difficulties with hearing and vision.

On 10 August 2014, Dr Al-Jabbari found Mr Crozzoli to be afebrile, tachycardic and with a blood pressure of 112/64, Dr Al-Jabbari considered diagnoses of aspiration pneumonia, severe iron deficiency anaemia and a urinary tract infection. The treatment plan included obtaining a urine sample to exclude a urinary tract infection, supplemental iron and

commencement of oral antibiotics.

Following a clinical review, Ms Scott and her husband agreed that Mr Crozzoli should not

be resuscitated, should it be required.

On 12 August 2014, Glendale nursing home discussed with Ms Scott the reasons for not transferring Mr Crozzoli to hospital. According to Glendale nursing home’s medical records, Ms Scott was ‘very happy’ with Mr Crozzoli’s care. On 14 August 2014, Dr Al-

Jabbari reviewed Mr Crozzoli and provided a clinical update to Mr Grom.

On 13 August 2014, Glendale nursing home requested Dr Al-Jabbari refer Mr Crozzoli for palliative care, as his condition had deteriorated further. Antibiotics could no longer be given orally as Mr Crozzoli was experiencing great difficulty swallowing. Mr Crozzoli was lethargic, had a temperature of 37.8 degrees, an elevated heart rate and further symptoms of aspiration pneumonia.

From 13 August 2014, despite intravenous administration of antibiotics (cephazolin) twice daily, Mr Crozzoli’s health deteriorated further and he diced at approximately 10.00am on 15 August 2014.

Ll.

Dr Al-Jabbari omitted to sign the death certificate on 15 August 2014 and was then unable to do so due to being on leave overseas. Although it was open to them to do so, other medical practitioners at the Westgate Medical Centre declined to sign a death certificate on the basis of Mr Crozzoli’s medical records. Mr Crozzoli’s death was reported to the Coroner pursuant to section 4(2)(h) of the Coroners Act 2008, because a death certificate had not

been signed and was not likely to be signed.

Following the report of Mr Crozzoli’s death to the Coroners Court of Victoria,

Mr Grom and Ms Scott expressed concems regarding: a. the care provided by Dr Al-Jabbari and Glendale nursing home; and

b. the failure of the Glendale nursing home to transfer Mr Crozzoli to hospital for the administration of antibiotics.

Mr Grom and Ms Scott expressed that their dissatisfaction in Mr Crozzoli’s end of life care

was compounded by Dr Al-Jabbari’s failure to sign the death certificate and subsequent

report to the Coroners Court, which resulted in delays to funeral arrangements.

Post Mortem Examination

Dr Victoria Francis, Forensic Pathologist at the Victorian Institute of Forensic Medicine, conducted a post mortem examination. Dr Francis completed a report, dated 21 October

2014. Dr Francis formulated the cause of death as ‘Multi-system organ failure, peritonitis, acute gangrenous cholecystitis with cholelithiasis in a background of ischaemic heart disease and diabetes mellitus’. Dr Francis opined that Mr Crozzoli’s death was due to

natural causes. I accept Dr Francis’ opinion as to the medical cause of death.

Coroners Prevention Unit investigation

Despite a report of a medical investigator that contained an opinion that this death was due to natural causes and in light of the family’s concerns, I asked the Coroncrs Prevention Unit’s (CPU)! Health and Medical Investigation Tcam (HMIT) to review Mr Crozzoli’s

case, including his treatment and medical records.

' The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner. The unit assists the Coroner with research in matters related to public health and safety and in relation (o the formulation of prevention recommendations, as well as assisting in monitoring und evaluating the effectiveness of the recommendations. The CPU comprises a team with training in medicine, nursing, law, public health and the social sciences.

14. Following their review, the HMIT confirmed that Mr Crozzoli’s treatment and management was reasonable in the circumstances. I accept the HMIT’s opinion as to Mr Crozzoli’s medical treatment and management.

Finding

15.‘ find that:

a. ‘The identity of the deceased was Attilio Crozzoli; and

b. Mr Crozzoli died on 15 August 2014 from Multi-system organ failure, peritonitis, acute gangrenous cholecystitis with cholelithiasis in a background of ischacmic heart disease and diabetes mellitus, at Glendale nursing home in Werribce, Victoria.

COMMENTS

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

with the death:

Mr Crozzoli was a very elderly and frail man with significant health problems who resided in high-level care at a nursing home. According to the Glendale nursing home, hospital and GP medical records, there were clearly documented discussions that in the event of

deterioration, Mr Crozzoli was not to be actively treated.

As he deteriorated, Mr Crozzoli was able to remain in his familiar home environment at Glendale nursing home and this would likely have been of some comfort to him in his increasing state of cognitive deterioration.

Although a focus of the infection was undetermined, and despite a plan not to actively treat, Mr Crozzoli was treated by the administration of intravcnous antibiotics. It has not been

suggested to me that hospital treatment would have gone beyond such measures.

It is unfortunate that Dr Al-Jabbari or another medical practitioner from his practice were

unable to complete the death certificate. This failure to sign a death certificate caused:

a. Mr Crozzoli’s death to be reported to the Coroners Court and Mr Crozzoli to

undergo an autopsy; and b. subsequent delays in Mr Crozzoli’s funeral arrangements.

Mr Crozzoli’s death would otherwise not have been reportable under section 4 of the

Coroners Act 2008.

23,

24,

It was (and remains) open to Mr Grom and Ms Scott to have referred their concerns

regarding Mr Crozzoli’s end of life care to:

a. the Health Services Commissioner, whose role includes receiving and resolving

complaints about health services providers;

b. the Australian Health Practitioner Regulation Agency, whose role includes recciving and investigating complaints and concerns about the behaviour and conduct of

registered health practitioners; and/or

c, the Aged Care Complaints Commissioner, whose role includes investigating and

resolving complaints and concerns about aged care service providers.

The negative consequences of deaths bemg unnecessarily reported can include creating unnecessary intrusion into bereavement and pressure on public resources.” Fellow medical practitioners from Dr Al-Jabbari’s practice may not have realised that they could issue a death certificate for Mr Crozzoli based on information obtained from their practice’s

medical records.

Laccept that another medical practitioner from the practice may not be comfortable issuing a death certificate for a colleague’s patient because they are unfamiliar with the coronial system and/or unsure of their ability to sign a death certificate for a patient of their medical practice for whom they were not the treating doctor. However, if a medical practitioner from the same practice/hospital is satisfied on the medical records that the death is from natural causes and not otherwise reportable pursuant to section 4 of the Coroners Act 2008, they are

able to sign the death certificate in the treating medical practitioner’s place.

I consider this case a valuable opportunity to educate medical practitioners about their reporting obligations and to encourage them_to contact Coronial Admissions & Enquiries to seek advice if there is apparently sufficient information available to support another medical practitioner (from the same practice/hospital) issuing a death certificate where the treating

medical practitioner is unavailable.

In light of the above comments and pursuant to section 73(1A) of the Coroners Act 2008, I order

that a copy of this finding be published on the internet.

? Barnes, M., Kirkegaard, A, Carpenter, B. (2014), ‘Jntake rigour : ensuring only “reportable deaths” become coroners’ cases’, Journal of Law and Medicine, 21, pp. 572-583.

I convey my sincere condolences to Mr Crozzoli’s family.

I direct that a copy of this finding be provided to the following: John Grom, Senior Next of Kin Glendale nursing home

Westgate Medical Centre

Signature:

is.

CATTLIN ENGLISH

CORONER Date: 14 April 2016