Finding into death of Dianne Kaye Quinlan

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2014 4212

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: CAITLIN ENGLISH, CORONER Deceased: Dianne Kaye Quinlan Date of birth: 20 October 1962 Date of death: 18 August 2014 Cause of death: l(a) Pulmonary Thromboembolism in the setting of morbid obesity Place of death: Maroondah Hospital

1 Davey Drive, Ringwood East, Victoria

Background

Dianne Kaye Quinlan was born on 20 October 1962. She was 51 years old at the time of her death. Ms Quinlan lived alone in an apartment in Larissa Avenue Ringwood, Victoria. Ms Quinlan was divorced and is survived by her son, Josh. She was supported on a disability

pension at the time of her death.

According to family members Ms Quinlan was a kind hearted, spiritual person who believed in trying to make the world a better place. She raised Josh after her divorce and had maintained a good relationship with her ex-husband, Peter Baker. Ms Quinlan had previously worked in women’s retail and manchester and more recently was engaged as a volunteer for the Ringwood branch of the Red Cross. Ms Quinlan enjoyed reading and painting and had

attended locally run art classes prior to her death.

The coronial investigation

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Ms Quinlan’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act (2008).

Ms Quinlan was ‘in care’ as an involuntary patient at Maroondah Hospital at the time of her death, in accordance with section 3(d) of the Coroners Act 2008 (Vic) (the Act). This provision covers the death of a person in the care of the Secretary to the Department of

Human Services.

Due to Ms Quinlan’s ‘in care’ status, her death is a reportable death to the coroner.! Further, her ‘in care’ status mandates that a coroner must hold an inquest into her death.2 However, a coroner is not required to hold an inquest in relation to a death occurring in care if the coroner considers that the death was due to natural causes.’ A death may be considered to be due to natural causes if the coroner has received a report from a medical investigator that includes an

opinion that the death was due to natural causes.*

The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death and surrounding circumstances. Surrounding circumstances

are limited to events which are sufficiently proximate and causally related to the death. The

1 Coroners Act 2008 (Vic) s 11(1)

? Coroners Act 2008 (Vic) s 52(2)(b)

3 Coroners Act 2008 (Vic) s 52(3A)

4 Coroners Act 2008 (Vic) s 52(3B) I have received a report from Forensic Pathologist Dr Jacqueline Lee dated 18 September 2015.

law is clear that coroners establish facts; they do not cast blame, or determine criminal or civil liability °.

A coronial brief has been prepared by the Coroner’s Investigator who is a member of Victoria Police. The brief includes statements from witnesses, including family members, as well as the forensic pathologist who examined Ms Quinlan. The brief also includes statements from

Ms Quinlan’s treating clinicians and medical records from Maroondah Hospital.

I have based this finding on the evidence contained in the coronial brief. In the coronial jurisdiction facts must be established to the standard of proof which is the balance of

probabilities. °

Circumstances in which the death occurred

Ms Quinlan had a complex medical history including depression, hypothyroidism, hypercholesterolemia and morbid obesity, at one time weighing in excess of two hundred and twenty kilograms (220kg). She had unsuccessfully tried gastric banding surgery in 1999.

Ms Quinlan had recently been diagnosed with non-insulin dependent diabetes.’

Ms Quinlan was treated by her general practitioner Dr Helen Hayes at the Warrandyte Road Clinic in Ringwood who prescribed medications included Celestone, Efexor, Oroxine,

Otocomb, Parie, Symbacort and more recently Metformin for diabetes.

Ms Quinlan also had a long standing history of Bipolar Affective/ Schizoaffective disorder since 1997. Since 2012 she had been treated under a shared care arrangement between her

private psychiatrist Dr Tom Eimany and the Eastern Health Continuing Care Team (CCT).

Consultant Psychiatrist Dr Tom Eimany had treated Ms Quinlan for the past six years. He advised she had developed a psychotic illness subsequent to depression in relation to work

place conflict in 2013.8

On 11 April 2014, Ms Quinlan advised Dr Eimany she had decided to cease taking her medication. She refused to recommence any other anti-psychotics. Dr Eimany reported he

subsequently observed Ms Quinlan’s mental health deteriorate over the ensuing months.

’ In the coronial jurisdiction facts must be established on the balance of probabilities subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

7 Letter from general practitioner Dr Helen Hayes dated31 December 2014.

8 Letter from consultant psychiatrist Dr Tom Eimany dated 11 May 2016.

On 29 May 2014, Ms Quinlan was investigated at Maroondah hospital for a suspected left

leg deep vein thrombosis, possible cellulitis and/or peripheral vascular disease.’

An ultrasound was performed the following day and no thrombosis was found at that time, although the examination was noted to be difficult due to ‘patient body habitus’.!° Ms

Quinlan was then treated for cellulitis of her left leg.

Dr Hayes saw Ms Quinlan on 30 May 2014. She noted the discharge instructions from Maroondah being that Ms Quinlan had poor peripheral circulation and was advised to have further follow up examinations to test the arterial circulation in her legs.'' Dr Hayes organised a referral for an arterial Doppler follow up. It appears that for some reason Ms

Quinlan did not pursue the follow up appointment.

On 12 August 2014, Ms Quinlan presented to Dr Eimany’s rooms ‘in a disorganised

manner, vague, evasive and suspicious...”

Dr Eimany recommended involuntary admission and Ms Quinlan was admitted later that day to the Maroondah Hospital Inpatient Unit two (IPU2), a high dependency psychiatric

unit.

Consultant psychiatrist Dr Shameera Rehman noted Ms Quinlan’s condition on admission as ‘severely agitated, distressed, disorganised and at times aggressive’. She was prescribed

Risperidone, Valproate and Lorazepam and Halloperidol if needed for extreme agitation.

Dr Rehman indicated an organic screening was undertaken on admission including a thyroid function test and electrocardiogram, which were found to be within normal limits. She was reviewed daily by her medical team, was placed on twice daily physical observations and

regular blood sugar monitoring.

On 14 August 2014, Josh Baker visited his mother and took her some clothes. He noted she appeared ‘lethargic’ and ‘very drugged up’.

On 15 August 2014, Ms Quinlan had complained of leg pain. She was examined the psychiatric registrar in relation to both the leg pain and further psychotic symptoms. Her

° Eastern Health medical records dated 29 May 2014.

10 Eastern Health US Doppler Leg DVT report of Dianne Kaye Quinlan dated 30 May 2014.

11 Letter from Dr Helen Hayes dated 31 December 2013.

Cellulitis is a skin infection which can be treated with antibiotics.

12 Statement of Josh Baker dated 11 January 2015, coronial brief p8.

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Risperidone dosage was titrated at that time.’ It appears the leg pain did not give rise to any

further treatment.

On 17 August 2014, Dr Rehman reported Ms Quinlan’s mental state was gradually

improving.

On 18 August 2014, staff informed consultant psychiatrist Dr Shameera Rehman that over the weekend Ms Quinlan had been experiencing difficulty in sleeping and had also

experienced intermittent difficulty in breathing. !*

Enrolled Nurse, Clare Fredericks stated Ms Quinlan was on fifteen minute observations on the morning of her death. Nurse Fredericks stated Ms Quinlan appeared settled and chatty but reported having slept poorly. She noted Ms Quinlan presented as ‘tired and sedated”. !°

Nurse Fredericks recorded Ms Quinlan’s vital signs at 8.00 am which were within normal limits !° and in consultation with the Nurse Unit Manager withheld Ms Quinlan’s morning

sedative, pending peer review.

Registered nurse Raelene Poon reported she assessed Ms Quinlan at 8.00 am wherein she appeared sedated. She reported she observed that Ms Quinlan ‘became short of breath after light physical exertion’ and that her respiration was ‘shallow’!’ She stated Ms Quinlan declined a shower advising she would shower in the afternoon. Ms Quinlan was made comfortable in bed, sitting in an upright position to aid respiratory effort, encouraged to do

deep breathing exercises

Nurse Fredericks repeated Ms Quinlan’s vital signs at 11.30 am and again reported they

were within normal limits.'*

At approximately 1.45 pm Nurse Poon woke Ms Quinlan to attend her medical review. Ms Quinlan waited in the common room of IPU2. When called to the doctor’s room Ms Quinlan

walked approximately fifteen metres before collapsing and hitting her head on the ground.

IPU2 staff responded and noted Ms Quinlan had a pulse and her eyes were open but she was unconscious and not responding. Medical staff attended and assessed the situation. Ms

Quinlan’s pulse shortly became unpalpable. Hospital staff performed CPR for approximately

13 Eastern Health Discharge Summary, final report generated 1 December 2014.

14 Statement of Consultant Psychiatrist Dr Shameera Rehman p3, coronial brief p16.

15 Statement of Enrolled Nurse Clare Fredericks dated 12 December 2014, coronial brief p 20.

16 Blood pressure 133/80, oxygen saturation 92%, pulse 92, respiratory rate 16.

17 Statement of Registered Nurse Raelene Poon, coronial brief p22.

18 Blood pressure 145/89, oxygen saturation 92%.

thirty minutes. Resuscitation attempts were unsuccessful and Ms Quinlan was pronounced

deceased at 2.19 pm.

Victoria Police members attended the scene. Investigators found no evidence to suggest that

there were any suspicious circumstances surrounding Ms Quinlan’s death.

Post mortem examination

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39).

On 21 August 2014, Forensic Pathologist Dr Jacqueline Lee at the Victorian Institute of Forensic Medicine, conducted a post mortem examination. Dr Lee completed a report, dated 18 September 2014, in which she formulated the cause of death. I accept Dr Lee’s opinion

as to the medical cause of death.

Toxicological analysis of post mortem specimens taken from Ms Quinlan identified Risperidone at a concentration of ~ 11ng/ml and its metabolite Hydroxyrisperidone at ~ 20

ng/ml. It also detected Desmethylvenlafaxine (the metabolite of Venlafaxine) at ~ 0.01mg/I.

Dr Lee commented the autopsy showed bilateral pulmonary thromboemboli in the setting of

deep venous thrombosis of each leg.

Hisologic sections of the veins sampled from the legs and the pulmonary vasculature

showed no evidence of organizing thrombi or thromboemboli.

Dr Lee advised pulmonary thromboemboli are the result of venous thrombi (blood clots), which travel through larger veins to lodge within the large arteries of the lungs. Often the thrombi are first formed within the deep veins of the legs. When the thrombi are lodged in the larger arteries of the lungs the blood supply to the lungs is obstructed. This can result in failure of the right ventricle of the heart to work properly.

Dr Lee advised the risk factors for forming thrombi include an inherited blood abnormality (thrombophilia), obesity, smoking, cancer, heart failure, medications such as birth control

pills and previous deep vein thrombosis or pulmonary thromboembolism.

Dr Lee also noted and enlarged heart of 672 grams and a fatty liver.

Dr Lee noted Ms Quinlan’s body mass index to be seventy four point two zero (74.20).

Morbid obesity is defined as a body mass index greater than forty (40). Dr Lee reported a body mass index above twenty nine (29) is an additional risk for pulmonary

thromboembolism.

40. Dr Lee reported death was the result of pulmonary thromboembolism in the setting of morbid obesity. Dr Lee reported there was no evidence of infection associated with Ms Quinlan’s death. Lastly there was no evidence in the tissues examined that the thrombus was

associated with the left ankle pain in May.

Finding

41. I find that Dianne Kaye Quinlan died on 18 August 2014 from a pulmonary thromboembolism in the setting of morbid obesity at Maroondah Hospital, Ringwood East

in Victoria.

I direct that a copy of this finding be provided to the following: Mr Joshua Baker, Senior Next of Kin

Constable Dean Harris, Coroner’s Investigator, Victoria Police

Signature:

Gf

CAITLIN ENGLISH CORONER

Date: 28 July 2016