Finding into death of Patricia Mary Russell

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2015 4249

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 PATRICIA MARY RUSSELL without holding an inquest:

find that the identity of the deceased was PATRICIA MARY RUSSELL

born on 17 December 1938

and the death occurred on 21 August 2015

at St Vincent’s Hospital Fitzroy Victoria 3065

from:

l(a) ASPIRATION PNEUMONIA COMPLICATING CATATONIA AND

DEPRESSION IN THE SETTING OF METASTATIC BLADDER CANCER

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

1. Mrs Patricia Russell was 76 years of age at the time of her death, she was married and had three

children. She lived at 547 Stephensons Road Mount Waverley.

2. Mrs Russell had a history of bladder cancer, a non-functioning left kidney, hypothyroidism, hypertension, deep vein thrombosis, anxiety disorder, bipolar effective disorder and severe

depression complicated with episodes of catatonia.

3. In March 2015, Mrs Russell had elective spinal surgery at Epworth Hospital. During this procedure, it was discovered that she had bladder cancer and a non-functioning left kidney, however Mrs Russell was not given treatment due to her poor physical and mental health. Her mental health continued to deteriorate from this period and she was diagnosed with severe

depression complicated with episodes of catatonia and agitation. On 22 July 2015, Mrs Russell

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was made a compulsory patient under the Mental Health Act 2014 (Vic). She was in a catatonic state and was refusing all oral nutrition and hydration. She was given electro-convulsive treatment, which provided some improvement in her mental health, however her physical health

continued to decline.

At approximately 10.00am on 20 August 2015, Mrs Russell had an episode of pulmonary aspiration’ whilst vomiting. At 10.45pm a Medical Emergency Team (MET) was called as it

was suspected that Mrs Russell had aspirated again.

At approximately 7.50am on 21 August 2015, a second MET was called when Mrs Russell was found to be tachypnoeic, tachycardiac and unresponsive. At 11.30am, Mrs Russell died in the

presence of her husband in Palliative Care Unit of St Vincent’s Hospital.

INVESTIGATIONS

Forensic pathology investigation

Dr Jacqueline Lee, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an external examination on the body of Ms Russell, referred to medical records and

the Victoria Police Report of Death, Form 83.

Dr Lee stated that the CT examination showed that Ms Russell there was no intracranial haemorrhage, consolidation of the right lung, focal consolidation of the left lung, slight coronary

artery calcification, and absent left kidney, dilated right renal pelvis and cholelithiasis’.

On the evidence available to her, Dr Lee reported to the Coroner that the causes of Mrs Russell’s death was aspiration pneumonia complicating catatonia and depression in the setting

of metastatic bladder cancer. She was of the opinion that the death was due to natural causes.

COMMENTS

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

the death:

Mrs Russell’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

' Pulmonary aspiration is the entry of material (such as pharyngeal secretions, food or drink, or stomach contents) from the oropharynx or gastrointestinal tract into the larynx and lower respiratory tract.

? Cholelithiasis are gall stones in the gallbladder.

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where the person is deemed to have died from natural causes, pursuant to section 52(3A). In these circumstances, ] have exercised my discretion pursuant to section 52(3A) not to hold an

inquest into Ms Russell’s death.

FINDINGS

On the evidence available to me, I find that Patricia Mary Russell died of natural causes.

I accept and adopt the medical cause of death as identified by Dr Jacqueline Lee and find that Patricia Mary Russell, who had metastatic bladder cancer, catatonia and depression died of

aspiration pneumonia.

And I further find that there is no relationship between the cause of Ms Russell’s death and the fact

she was a person placed in care.

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

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

Mr Andrew Russell

Dr Stephen Tam

Ms Melanie Kyesor, St Vincent’s Hospital

Ms Kym Peake, Department of Health and Human Services

Dr Neil Coventry Chief Psychiatrist

Senior Constable Laurence Shanahan

Signature: \ }

AUDREY JAMIESON ; CORONER ~— = |

Date: 15 June 2016

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