Finding into death of Carey Livingstone James

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2015 2478

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 CAREY LIVINGSTONE

JAMES without holding an inquest: find that the identity of the deceased was CAREY LIVINGSTONE JAMES born on 3 January 1942 and the death occurred on 21 May 2015 at Goulburn Valley Health, Graham Street, Shepparton Victoria 3630

from:

1(a) MULTISYSTEM ORGAN FAILURE IN THE CONTEXT OF TRAUMA AND

LIMB FRACTURE

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

1. Carey Livingstone James was 73 years of age at the time of his death. He was an indigenous Australian and lived in Shepparton with his wife, Dianne. Mr James’ medical history included type 2 diabetes mellitus, hypertension, obesity, obstructive sleep apnoea and ischaemic heart disease. He suffered from early onset peripheral neuropathy, which prevented him from walking

long distances. Mr James often used a mobility scooter.

2. At approximately 11.30am on Friday 24 April 2015, Mr James was riding his mobility scooter on the footpath along the western side of Maude Street in Shepparton. The footpath adjoins the

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car park on the corner of Maude Street and Vaughan Street, and the car park has an exit on Maude Street. A red Hyundai Elantra, driven by John Johnson, was leaving the car park. Mr Johnson was unable to see the footpath on Maude Street because parked cars were blocking his view. As the car pulled out of the car park, Mr James collided with the front left fender of the Hyundai vehicle. Mr James’ scooter tipped on its side, and ejected him onto the ground. Mr James was conscious and seemed coherent, but his right ankle appeared injured. Witnesses stopped to render assistance and contacted emergency services. Ambulance paramedics and police arrived shortly afterwards. Mr Johnson underwent a preliminary breath test for alcohol,

which returned a negative result.

Mr James was transported by ambulance to Goulburn Valley Health in Shepparton. He was diagnosed with a distal comminuted tibula-fibula fracture, with a fracture through the medial malleolus. The right leg was set that afternoon, and Mr James was to be kept in hospital over the weekend for observation. Mr James subsequently became less responsive, and developed a fever, rapid heart rate and breathing difficulties. It was suggested that Mr James may have developed the fever in response to taking tazocin' medication. Mr James later developed acute on chronic renal impairment and a bowel obstruction. His clinical condition continued to deteriorate, with significant oxygen desaturations and increased respiratory effort; imaging suggested aspiration pneumonia. Mr James was treated with intravenous broad spectrum antibiotics and BiPAP, but continued to deteriorate. After discussions with his family, he was palliated on the morning of 21 May 2015, and made comfortable. Mr James was declared

deceased at 3.05pm on 21 May 2015.

INVESTIGATIONS

Forensic pathology investigation

Dr Malcolm Dodd, Senior Forensic Pathologist at the Victorian Institute of Forensic Medicine performed a full post mortem examination upon the body of Mr James, reviewed a post mortem computed tomography (CT) scan and e-Medical Deposition Form from Goulburn Valley Health, and referred to the Victoria Police Report of Death, Form 83.

At autopsy, Dr Dodd observed cardiac enlargement, and the heart muscle showed minimal

patchy fibrosis. Mr James’ lungs were firm to palpation and there was a marked focal fibrin

' Tazocin is a combination antibiotic used to treat serious bacterial infections. It contains two active ingredients; piperacillian and tazobactum. Piperacillin is a penicillin-type antibiotic and tazobactam prevents bacteria from inactivating pipericilin.

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layering on a background of organising pneumonia. His liver showed a pattern of emerging .

cirrhosis and the renal tissue showed a pattern of diabetic glomerulonephropathy” in tandem with inflammatory cell infiltrates. Biochemical analysis disclosed an elevated glucose level at 6.3 mmol/L. Toxicological analysis of bodily fluids was non-contributory. Dr Dodd noted that the injury to the right lower leg in isolation would not be deemed to be life threatening however, coupled with significant pre-existing comorbidities, it would appear that Mr James had decompensated during his period of convalescence. Dr Dodd ascribed the cause of Mr James’ death to multisystem organ failure in the context of trauma resulting in limb fracture,

subsequent to being struck by a motor vehicle while riding a mobility scooter.

Police investigation

6. First Constable (F/C) Jaiden Schaeche, the nominated coroner’s investigator,’ conducted an investigation of the circumstances surrounding Mr James’s death, at my direction, including the preparation of the coronial brief. The coronial brief contained, inter alia, statements made by Mr James’ wife (and nurse at Goulburn Valley Health) Dianne James, driver of the red Hyundai

John Johnson, and witness to the collision Jacqui Evans.

7. Mr Johnson stated that as he drove through the car park, towards the driveway onto Maude Street on 24 April 2015, he was driving slowly because he could not properly see the footpath. ‘There was a big 4WD parked there blocking my view.’ Mr Johnson said he could see clearly to the right but not to the left. Following the collision, Mr Johnson said he spoke to Mr James, who said his knee was hurting and made reference to a potato cake which was in the scooter. Mr Johnson said a bystander had told him that Mr James had been eating prior to the incident and not holding the

scooter properly. Police advised that no further action was taken against Mr Johnson.

8. Witness Ms Evans reported that there were many cars in the car park on 24 April 2015, and it would have been hard for Mr Johnson to have seen Mr James until he got close enough to the footpath, due to where the cars were parked. Ms Evans did note that Mr Johnson appeared to

have been ‘travelling a little too quickly for the area’ but was not ‘revving loudly or screeching’.

? Glomerulonephropathy is an inflammation of glomerulus of the kidney.

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 coroner’s investigator takes instructions direction from a coroner and carries out the role subject to the direction of a corner.

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Mrs James stated that her husband was prescribed the antibiotic tazocin, while at Goulburn Valley Health. On the evening of 25 April 2015, she noticed that Mr James was struggling to breathe and a Medical Emergency Team (MET) call was made. Mrs James said that each time Mr James was administered the antibiotic over the next few days, within one hour he needed another MET call. She stated there were a total of six MET calls. Mrs James said that on the evening of Tuesday 28 April 2015, she refused for her husband to be given anymore antibiotics.

On 29 April 2015, Mr James was transferred from the surgical ward to the medical ward, where

he developed the bowel obstruction, and his health continued to decline.

By way of email dated 20 April 2016, F/C Schaeche advised the Court that he believed the design of the driveway was the reason Mr Johnson was unable to see Mr James prior to the collision. F/C Schaeche noted that when the car park is full, parked vehicles block vision of the footpath to any vehicles exiting. He described the full car park as unsafe, due to this reduced visibility. F/C Scaeche had not identified any other incidents at this location since 1 January

. F/C Schaeche suggested that possible solutions would be to install a mirror to help pedestrians

and exiting vehicles see each other. In addition, warning signs could be used to warn pedestrians to stop and exiting vehicles to proceed with caution. Alternatively, F/C Schaeche suggested that the parking spaces directly parallel to the footpath could be ‘no standing’ zones, thus increasing visibility around parked vehicles. F/C Schaeche added that the carpark is owned by Shepparton City Council.

Coroners Prevention Unit review

Following the receipt of the coronial brief, I asked the Coroners Prevention Unit (CPU) to review the circumstances surrounding Mr James’ death, including his care at Goulburn Valley Health and the administration of the antibiotic tazocin. The review encompassed information including Mr James’ medical records from Goulburn Valley Health, the coronial brief and a statement obtained from Dr Emanoil Geaboc, Director of Acute Care at Goulburn Valley

Health.

4 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 to the formulation of prevention recommendations, as well as assisting in monitoring and evaluating the effectiveness of the recommendations. The CPU comprises a team with training in medicine, nursing, law, public health and the social sciences.

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The review identified that Mr James developed fever, shortness of breath, hypoxia and delirium on Sunday 26 April 2015, and a MET call was made at 5.10pm. Mr James was commenced on tazocin antibiotics, three times per day, with the first dose given at 6.50pm on 26 April 2015.

The review also noted that after Mrs James requested that the tazocin be ceased, Consultant Dr Tunde Ibrihim agreed on 29 April 2015 that as the source of the fever was unclear, and blood cultures were negative, it was reasonable to cease these antibiotics. When Mr James’ condition later further deteriorated, the intravenous antibiotic ceftriaxone was commenced, as medical

staff had now documented a tazocin allergy.

The review noted that Mr James died from complications of his significant comorbid medical illnesses, including respiratory and cardiac conditions. It was likely that the injury sustained in the collision on 24 April 2015 and subsequent hospitalisation and immobilisation contributed to

the decompensation in his respiratory status and death.

It was also noted that while a drug fever with tazocin can be seen, such a drug reaction would not usually be accompanied by hypoxia and respiratory failure. It was identified that the last dose of tazocin was administered two weeks prior to Mr James’ death, and there was unlikely to have been a causal relationship. Review of the medication chart also evinced that the fever and hypoxia related MET call on 26 April 2015 was prior to the first dose of tazocin that was administered. Mr James was not known to have a penicillin allergy, which is the usual allergen

for tazocin reactions.

The review identified that Mr James’ care was subject to an in-depth case review at Goulburn Valley Health. This in-depth review made several recommendations or improvement, including a review of plans after MET calls and handover, review of the admission criteria for higher dependency areas, and morbidity triggers for patients with a length of stay with more than 10

days and multidisciplinary team meetings with family present.

In addition, it was noted that the Australian Competition and Consumer Commission has commissioned a study and public awareness campaign relating to the safety of motorised mobility scooters.° Key findings of this report included that support for the ongoing use of motorised mobility scooters by older people and people with disabilities was strong; and training and education of users emerged as a primary factor contributing to the safety of

mobility scooters. Notably, the physical environment was identified as a powerful factor

Gibson K, Ozanne-Smith J, Clapperton A, Kitching F, and Cassell E, ‘Targeted Study of Injury Data Involving Motorised Mobility Scooters’, Clayton: Monash University, 2011.

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influencing safe motorised mobility scooter use. Specifically, design and maintenance to footpaths and road safety was raised, including high fencing restricting visibility of parked or reversing cars, for example, from driveways. Moreover, access in and around shopping centres

and on public transport was identified as challenging, due to conflicts with pedestrians.

FINDINGS |

The weight of the evidence leads me to find that the collision on 24 April 2015, which caused Mr James’ limb fracture, and led to his decline in health and ultimately his death, occurred as a result of the poor visibility of the footpath, at the car park on the corner of Maude and Vaughan Streets in Shepparton. There is no evidence that Mr James’ treatment with tazocin at Goulburn Valley Health

was causal or contributory to his death.

I find that Carey Livingstone James, who had suffered from trauma and a limb fracture, died from

multisystem organ failure.

I direct that pursuant to Section 49(2) Coroners Act 2008 (Vic), the Principal Registrar notify the Registrar of Births, Deaths and Marriages of the prescribed particulars of my Findings following my investigation and accordingly that the Registrar amend the currently registered cause of death to

reflect my Findings in the cause of death of Carey Livingstone James.

RECOMMENDATION Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation:

1. With the aim of preventing like deaths and protecting pedestrians and drivers, I recommend that the Greater Shepparton City Council implement safety measures at its car parks — including the car park on the corner of Maude and Vaughan Streets — with such measures as, but not

necessarily limited to, mirrors, signage and/or ‘no standing’ parking spaces.

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

internet.

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

Goulburn Valley Health

Transport Accident Commission

Greater Shepparton City Council

First Constable Jaiden Schaeche

Signature:

ea

AUDREY JAMIESON a

CORONER

Date: 23 February 2017

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