Finding into death of Alan William Worrall

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE

Court Reference: COR 2015 4598

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2)

Section 67 of the Coroners Act 2008 |

J, AUDREY JAMIESON, Coroner having investigated the death of ALAN WILLIAM WORRALL

without holding an inquest:

find that the identity of the deceased was ALAN WILLIAM WORRALL born 13 June 1968

and the death occurred on 9 September 2015

at St Vincent’s Hospital Melbourne, 41 Victoria Street, Fitzroy Victoria 3065

from:

1(a) PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY

2 HUMAN IMMUNODEFICIENCY VIRUS INFECTION AND JC VIRUS INFECTION |

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

1. Alan William Worrall was 47 years of age at the time of his death. Mr Worrall was diagnosed

with human immunodeficiency virus (HIV) in 1992 and was previously taking anti-retroviral

medication, but with poor adherence to treatment. His medical history also included hepatitis C, epilepsy, depression and a pulmonary embolism that was not anti-coagulated. Mr Worrall was a

former intravenous drug user and had a history of alcohol and substance abuse. Mr Worrall had

/ |

very few social supports and did not have known contact with any family members.

2. At approximately 10.00pm on 6 May 2015, police arrested Mr Worrall at the Bendigo Hospital, for offences including assaulting an emergency worker while on duty, and committing an

indictable offence while on bail. Over the next week, Mr Worrall was convicted and sentenced

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to a three month term of imprisonment and taken to the Melbourne Custody Centre, followed by the Melbourne Assessment Prison, and then transferred to the Port Phillip Prison on 12 May

2016. While in custody, Mr Worrall was also remanded until 23 September 2015, on further

charges.

On 11 August 2015, Mr Worrall was admitted to the St Augustine’s secure ward at St Vincent’s Hospital Melbourne, with a febrile illness and neurological symptoms including impaired balance, dysdiadokokinesia (difficulty in executing quick, alternating movements), left hand tremor and diplopia. On admission, Mr Worrall’s CD4 count was measured as 30.' A medical resonance imaging (MRI) scan of Mr Worrall’s brain and a lumbar puncture were positive for John Cunningham (JC) virus, causing progressive multifocal leukoencephalopathy. Mr Worrall was treated with anti-retroviral medications to no effect. Mr Worrall’s neurological condition deteriorated and in late August he developed difficulty in swallowing. Mr Worrall’s health continued to deteriorate despite active treatment. On 5 September 2015, following discussion between general medical, infectious disease and palliative care teams, a decision was madc to withdraw active treatment. Mr Worrall was made comfortable and was declared deceased at

3.40pm on 9 September 2015.

Mr Worrall’s death was reportable pursuant to section 4 of the Coroners Act 2008 (Vic) (‘the Act’) because he was immediately before death a person placed in custody, as defined by

section 3 of the Act.

INVESTIGATIONS

Forensic pathology investigation

Dr Jacqueline Lee, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an external examination upon the body of Mr Worrall, reviewed a post mortem computed tomography (CT) scan and e-medical deposition form from St Vincent’s Hospital, and referred to the Victoria Police Report of Death, Form 83. Dr Lee reported that the post mortem CT scan showed cerebral atrophy, radiopaque material in the intestines, splenomegaly and patchy pulmonary infiltrates. Dr Lec noted that Mr Worrall appeared chronically ill, and had a body mass index of 17.7

} The CD4 count of an uninfected adult who is in good health ranges from 500 cells/mm? to 1600 cells/mm}. A very low CD4 count (less than 200 cells/mm? is one of the ways to determine whether a person living with HIV has progressed to stage 3 infection (AIDS). See: https://www.aids. gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/understand-your-testresults/cd4-count/, accessed 12 August 2016.

2Body Mass Index (BMI) is one of the anthropometric measures of body mass; it has the highest correlation with skinfold thickness or body density. BMI is determined by an individual’s weight in kilograms, divided by their height in

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On the basis of the information available to her, Dr Lee ascribed the cause of Mr Worrall’s death to progressive multifocal leukoencephalopathy with the contributing factors of human immunodeficiency virus infection and JC virus infection. Dr Lee was of the opinion that Mr

Worrall’s death was due to natural causes.

Police investigation

Senior Constable Jacinta Clark, the nominated coroner’s investigator,’ conducted an investigation of the circumstances surrounding Mr Worrall’s death, at my direction, including the preparation of the coronial brief. The coronial brief contained a statement made by Medical Director of St Vincent’s Correctional Health Service at Port Phillip Prison Dr Charles Roth and Head of General Medicine at St Vincent’s Hospital Melbourne Associate Professor Wilma

Beswick.

Dr Charles Roth stated that in the days following Mr Worrall’s transfer to the Port Phillip Prison from the Melbourne Assessment Prison on 12 May 2015, he concluded that he was immunecomprised as a result of untreated HIV infection. Dr Roth also noted his itinerant lifestyle, dressings on both forearms from récent self-harm incidents, and his general lack of concern for his health. Dr Roth said that at a review on 15 May 2015, he explained to Mr Worrall that he was immuno-compromised as a result of his untreated HTV infection and eventually managed to

persuade him to have further investigations and a review by an HIV specialist.

Dr Roth stated Mr Worrall suffered from two possible seizures while at Port Phillip Prison.

After the first possible seizure on 5 July 2015, there were no beds available at the St John’s inpatient unit, so he was placed in an observation cell overnight. On the second occasion on 12 July 2015, Mr Worrall was admitted to the St Jobn’s unit for a night and discharged back to his unit the next day. Upon medical review on 29 July 2015, Mr Worrall was inter alia noticed to

be vaguer than on previous occasions and with definite weight loss.

On 10 August 2015, Mr Worrall was admitted to St John’s inpatient unit with generalised abdominal pain and fever. Dr Roth noted that on review the next morning, Mr Worrall’s vital signs were normal but due to concerns about his abdominal pain, fever, disorientation on a background of untreated HIV infection, he was transferred to St Vincent’s Hospital for further

assessment.

metres. It is designed for men and women over the age of 18. A healthy BMI is generally considered to be between 20 and 25. A result below 20 indicates that an individual may be underweight.

3 A coroner’s investigator is a police officer nominated by the Chief Commissioner of Police or any other person nominated by the coroner to assist the coroner with his/her investigation into a reportable death. The coroncr’s investigator takes instructions direction from a coroner and carrics out the role subject to the direction of a comcr.

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Dr Wilma Beswick noted that upon admission to St Vincent’s Hospital on 11 August 2015, Mr Worrall said he had previously been treated for HIV infection at the Royal Melbourne Hospital, but had not been taking any treatment for some years. Dr Beswick reported that on the evening of 30 August 2015, Mr Worrall was found to have fallen out of his bed onto the floor. He was assessed by medical staff, but there were no apparent injuries and Dr Beswick stated that his condition was unchanged, Dr Beswick reported that Mr Worrall became agitated as his condition deteriorated, and he expressed a desire to die. She stated that the Consultant Liaison Psychiatry Service reviewed Mr Worrall and felt his agitation and distress should be managed as

a priority.

Department of Justice and Regulation - Office of Correctional Services Review

By way of letter dated 30 December 2015, Emma Catford, Director at the Office of Correctional Services Review (OCSR) provided the court with a report providing an overview of Mr Worral’s management in custody and the circumstances of his death. The report also included a

review conducted by Justice Health of Mr Worrall’s health management.

. The report noted that file records provided conflicting information regarding whether or not Mr

Worrall was an indigenous Australian. However, immediately following Mr Worrall’s death, enquiries by Corrections Victoria confirmed that while he had contacts within the aboriginal

community, he did not identify as indigenous.

. It was noted that while Mr Worrall’s incarceration from 7 May 2015 was his ninth term of

imprisonment, he had not been in prison since 1997. The review identified that Mr Worrall actively participated in garden work while at Port Phillip Prison, and participated in two drug

and alcohol programs, as well as the Quit program to address his smoking habit.

. The report found that Mr Worrall’s custodial management by Corrections Victoria was

appropriate and there were no recommendations for systemic changes. It was noted that Mr

Worrall’s death was not unexpected given the gravity of his health condition.

COMMENTS

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

the death:

Section 52 of the Act mandates the holding of an Inquest if the deceased was, immediately

before death, a person placed in custody, save for circumstances where the person is deemed to

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have died from natural causes, pursuant to section 52(3A). In Mr Worrall’s circumstances, it is

therefore appropriate to conclude the investigation by an in-chambers Finding.

FINDINGS

Mr Worrall was suffering from a number of co-morbidities, on a background of poor compliance with anti-retroviral medications for his HIV infection. On the evidence available to me, I find that the provision of care to Mr Worrall while he was imprisoned at Port Phillip Prison and the St Augustine’s ward at St Vincent’s Hospital appears to have been appropriate, I further find that there was no causal connection between the fact that Mr Worrall was a person placed in custody and the

cause of his death,

laccept and adopt the medical cause of death as identified by Dr Jacqueline Lee and find that Alan William Worrall died from natural causes in the form of progressive multifocal leukoencephalopathy, with the contributing factors of human immunodeficiency virus infection and

JC virus infection.

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:

Ms Melanie Kyezor, Clinical Risk Manager, St Vincent’s Health Ms Emina Catford, Office of Correctional Services Review, Department of Justice and Regulation

Senior Constable Jacinta Clark

Signature:

AUDREY-IAMIESON ~~ AUDREY JAMIESON

Date: 26 August 2016

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