Finding into death of Linda Tucker

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2014 6201

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 LINDA TUCKER

without holding an inquest:

find that the identity of the deceased was LINDA TUCKER

born 24 March 1952

and the death occurred on 6 December 2014

at Western Health — Footscray Hospital, 160 Gordon Street, Footscray Victoria 3011 from:

1(a) STOMACH PERFORATION COMPLICATING RECURRENT PSEUDOOBSTRUCTION OF THE BOWEL

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

1. Linda Tucker was 62 years of age at the time of her death. She lived in Department of Health and Human Services (DHHS) accommodation in Werribee and had resided in government supported residential care since the age of 21 years. Ms Tucker was non-verbal; she had an intellectual disability which arose as a consequence of infantile meningitis, and had also suffered from recurrent pseudo bowel obstructions and secondary aspiration pneumonia. She required assistance with all activities of daily living. Ms Tucker was prescribed a range of

medications including inter alia clonazepam, quetiapine and metoclopramide.

2. On 5 December 2014, Ms Tucker ate dinner at 6.00pm. At approximately 7.45pm, Disability Support Officer Elizabeth Shannon noticed that Ms Tucker was coughing. At 8.00pm, Ms

Shannon found Ms Tucker standing in the lounge room, hunched over, with her hands resting

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on her thighs. She was distressed and drowsy. Emergency services were called; ambulance paramedics attended and transported Ms Tucker to Western Health — Footscray Hospital,

arriving at 9.51pm.

3. On admission, Ms Tucker was noted to have a markedly distended abdomen, fast heart and breathing rates, and low oxygen saturation levels in her blood. Initial medical investigations indicated free intra-abdominal gas, highly suspicious of perforation. Ms Tucker was given intravenous antibiotics and was initially referred to a surgical registrar but her condition deteriorated rapidly before she was seen. Following discussion with her family, she was transferred to palliative care. At 12.05am on 6 December 2014, Ms Tucker was declared deceased. At the hospital it was suggested that a possible cause of Ms Tucker’s death was

perforated viscus, possibly secondary to gastric distension.

INVESTIGATIONS Forensic pathology investigation

4. Dr Heinrich Bouwer, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed a full post mortem examination upon the body of Ms Tucker, reviewed a post mortem computed tomography (CT) scan, Western Health Medical records and e-medical deposition form, and referred to the Victoria Police Report of Death, Form 83. At autopsy, Dr Bouwer observed marked abdominal distension and perforation of Ms Tucker’s stomach with copious amounts of stomach contents leaking into the abdominal cavity. The bowel loops were markedly distended although it appeared viable. There were no fibrous bands, volvulus, intussusception or tumours, which was in keeping with the clinical diagnosis of pseudo bowel obstruction. Dr Bouwer also found bilateral pleural effusions; right lung adhesion; dilated

cerebral ventricles and evidence of chronic aspiration in Ms Tucker’s lungs.

5. Post mortem toxicological analysis of blood detected an elevated blood alcohol concentration at

0.07g/100mL.' Quetiapine,’ carbamazepine,* 7-aminoclonazepam* and metoclopramide* were

' This compares with the 0.05g per 100ml being the legal limit for blood alcohol concentration for fully licensed car drivers.

? Quetiapine is an antipsychotic drug used in the treatment of schizophrenia.

Carbamazepine is an anti-convulsant used in the treatment of epilepsy, some types of neuralgia and schizophrenia.

*7-aminoclonazepam is a metabolite of clonazepam, which is a benzodiazepine related to diazepam possessing sedative and anticonvulsant properties.

Metoclopramide is an anti-emetic drug used for the treatment of nausea and vomiting.

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also identified. Dr Bouwer noted that Ms Tucker’s C-Reactive Protein® levels were not elevated

and therefore it was unlikely that her stomach perforation was complicated by sepsis.

Dr Bouwer opined that Ms Tucker’s death was due to natural causes, and ascribed her death to stomach perforation complicating recurrent pseudo-obstruction of the bowel, and listed Ms

Tucker’s acquired brain injury as a contributing factor.

Police investigation

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The circumstances of Ms Tucker’s death have been the subject of investigation by Victoria Police on my behalf. Police obtained statements from Ms Tucker’s sister Glenda Blair, DHHS House Supervisor Valerie McPherson, DHHS Disability Support Officer Elizabeth Shannon and Western Health — Footscray Hospital Emergency Department Physician and Director Dr Michael Bryant. Police also obtained Ms Tucker’s medical records from Western Health,

Werribee Mercy Hospital, Tarneit Road Health Clinic and St Vincent’s Hospital.

DHHS House Supervisor Ms McPherson reported that Ms Tucker lived at a group home in Werribee that provides accommodation and support to five women with moderate to high support needs. Ms Tucker had lived at the home since 1990. Ms McPherson stated that Ms Tucker had limited expressive and receptive communication skills and required full support

with all activities of daily living, including full assistance with eating and drinking.

Ms McPherson stated that prior to April 2013, Ms Tucker had been energetic and apparently healthy. However, she had subsequently endured multiple admissions to St Vincent’s Hospital

and Werribee Mercy Hospital due to bowel obstructions.

COMMENTS

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

the death:

Ms Tucker’s death was reportable pursuant to section 4 of the Coroners Act 2008 (Vic) (‘the Act’) because she was immediately before death a person placed in care, as defined by section 3 of the Act. Section 52 of the Act mandates the holding of an Inquest, save for circumstances where the person is deemed to have died from natural causes, pursuant to section 52(3A). In Ms Tucker’s circumstances, it is therefore appropriate to conclude the investigation by an in-

chambers Finding.

§ C-Reactive Protein is a marker of inflammation and infection.

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FINDINGS

Ms Tucker had a significant history of health problems, including an almost lifelong intellectual disability and multiple hospital admissions for pseudo bowel obstructions. On the evidence available to me, I am unable to find issues with the care provided to Ms Tucker by Western Health

or the Department of Health and Human Services.

I accept and adopt the medical cause of death as identified by Dr Heinrich Bouwer and find that Linda Tucker died from a stomach perforation complicating recurrent pseudo-obstruction of the

bowel, and that her acquired brain injury was a factor contributing to her death.

AND I find that there is no causal connection between the cause of Ms Tucker’s death and the fact

that she was a person placed in care.

Pursuant to section 73(1B) of the Coroners Act 2008, | order that this Finding be published on the internet.

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

Ms Glenda Blair

Dr Kent Hoi, Western Health - Footscray Hospital

Dr Guiseppe Garra, Tarneit Road Health Clinic

Ms Kym Peake, Secretary of the Department of Health and Human Services

Senior Constable Christine Wallace

Signature: a Se, ) AUDREY JAMIESON . ai

CORONER — Date: 7 June 2016 —

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