Finding into death of Garry Serve

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2015 5924

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: Paresa Antoniadis Spanos, Coroner Deceased: Garry Serve Date of birth: 28 August 1933 Date of death: 20 November 2015 Cause of death: Trauma related intracerebral hemorrhage Place of death: Frankston

I, PARESA ANTONIADIS SPANOS, Coroner, having investigated the death of GARRY SERVE without holding an inquest: find that the identity of the deceased was GARRY SERVE born on 28 August 1933 and that the death occurred on 20 November 2015 at Frankston Hospital, 2 Hastings Road, Victoria 3199 from: I (a) TRAUMA RELATED INTRACEREBRAL HEMORRHAGE Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Mr Serve was an 82-year-old man who was living in a Bupa high level residential care facility in Edithvale [Bupa Edithvale] at the time of his death. He had lived there for about eight years and, according to his family, was well cared for by staff and very happy at the facility.

Mr Serve had a medical history that included obstructive sleep apnoea, ischaemic heart disease, type two diabetes mellitus, dementia and cerebellar ataxia. He was unable to mobilise without a wheelchair and could only transfer from his bed to the chair using standing machine.

2. In the months prior to Mr Serve’s death, his daughter, Deborah Whittington, had noticed that her father was not answering phone calls and was responding with one word answers when spoken to. She suspected that he might be having hearing difficulties and raised this with Hanna Soria, the care manager of the Bupa Edithvale Bayside Unit where Mr Serve was residing. Ms Soria commenced arrangements to have Mr Serve’s hearing checked and his cognitive ability assessed. After being advised that the Australian Hearing Clinic [Australian Hearing] would not be able to provide an on-site visit for some months, Ms Soria obtained permission from Ms Whittington for Mr Serve to be taken off-site to Australian Hearing’s Chelsea rooms. An initial assessment there in September 2015 determined that Mr Serve required a hearing aid and so a follow-up appointment was made for November 2015.

3. On 16 November 2015, April Plant, a Bupa personal care attendant [PCA], was finishing her shift when she overheard Ms Soria saying that she needed an escort on 20 November 2015 to take a client to an appointment to have a hearing aid fitted. Ms Plant offered to do the escort as she had worked with Mr Serve in the past and had no other commitments that day.

4. On 20 November 2015 at about 12:30pm, Ms Plant arrived at Bupa Edithvale for her shift and attended reception to collect an escort form. According to Ms Plant, she then spoke to Ms Soria to determine whether she needed to take any documentation with Mr Serve to the appointment but was told that nothing was required. She thought that this was unusual for an off-site attendance, but did not pursue the issue. When Ms Plant asked about the return taxi

arrangements, she was told she would have to arrange one herself when at Australian Hearing as it was unclear how long Mr Serve’s appointment would take.

5. At about 12:50pm, Ms Plant collected a manual wheelchair, fitted with footplates, from Mr Serve’s room and took it to the dining room. With the assistance of another staff member, she used a standing machine to transfer Mr Serve to the wheelchair and then took him to reception to await the pre-arranged maxi taxi. When the maxi taxi arrived, Ms Plant wheeled Mr Serve outside and the taxi driver transferred Mr Serve and his wheelchair into the rear of the taxi.

6. At about 1:15pm, Mr Serve and Ms Plant arrived at Australian Hearing, which that day was operating out of a room at the Chelsea Community Support Service [CCSS]. At the entrance there were three concrete steps with a landing leading to the front door and a wheelchair access ramp to the side. Ms Plant wheeled Mr Serve up the ramp and they waited in the reception area for the appointment to commence.

7. At about 2:30pm, when the appointment concluded, Ms Plant asked a staff member of CCSS to call a taxi for herself and Mr Serve for the return trip to Bupa Edithvale. The staff member reached an automated message service and left details requesting a maxi taxi. Shortly afterwards, Ms Plant saw a taxi sedan pull up outside the clinic. According to Ms Plant, she wheeled Mr Serve to the concrete landing outside the front doorway, set back from the concrete stairs, and left him there while she went to speak to the taxi driver.

8. While Ms Plant was speaking to the taxi driver to organise for a maxi taxi to be sent out, she heard a loud ‘thump’. When she turned around, she saw that Mr Serve was lying face down at the bottom of the concrete stairs with his wheelchair on top of him. Ms Plant ran over, removed the wheelchair and rolled Mr Serve onto his back. He was breathing and responding to her questions, but was bleeding from a number of cuts to his face. Ms Plant asked CCSS staff to contact emergency services.

9. Meanwhile, Senior Constable James Hutton and another member of Victoria Police were departing the nearby Chelsea Police Complex when they saw Mr Serve lying on the asphalt at the bottom of the CCSS steps with a pool of blood near his head and shoulder area. They stopped to render assistance. According to SC Hutton, Mr Serve was conscious and breathing while he assisted him, but was at times unresponsive to questions, appeared to be in a confused state and was bleeding heavily at this point. SC Hutton placed Mr Serve in the recovery position and provided first aid with the help of CCSS staff.

10. Ambulance paramedics arrived a short time later and assessed Mr Serve as having a Glasgow Coma Scale [GCS] 1 of 15, indicating he was alert and able to follow instructions well. They placed him in a Philadelphia collar2 and conveyed him to Frankston Hospital in a stable condition. SC Hutton took Mr Serve’s wheelchair to the Chelsea Police Complex, while Ms Plant returned to Bupa Edithvale to make an incident report.

11. On arrival at the Frankston Hospital emergency department, Mr Serve was assessed as having a GCS of 13. His pupils were equal and reactive to light. He was able to follow instructions and give one word responses, and raise all limbs, although there was difficulty eliciting reflexes. However, due to ongoing bleeding from his face, Mr Serve developed breathing difficulties. Nursing staff attempted airway adjuncts but he was unable to tolerate them and he subsequently developed sinus tachycardia.

12. CT scans revealed extensive facial fractures, a left sided subdural haematoma, a traumatic subarachnoid haemorrhage and a large prevertebral soft tissue haematoma suggestive of occult fracture. The injuries were deemed non-survivable and following consultation with Mr Serve’s family, the decision was made to adopt a palliative approach to further treatment. Mr Serve was kept comfortable until he passed away at 8:20pm that night.

13. Forensic pathologist, Dr Paul Bedford of the Victorian Institute of Forensic Medicine, reviewed the circumstances of the death as reported by police to the coroner, post-mortem computer assisted tomography [PMCT] scans of the whole body and performed an external examination. Among Dr Bedford’s anatomical findings were facial fractures and multiple intracerebral lesions with haemorrhages and contusions.

14. Routine toxicological analysis detected fluoxetine3 and metoclopramide4 at levels consistent with therapeutic use but no alcohol or other commonly encountered drugs or poisons.

15. Dr Bedford concluded that it was reasonable to attribute Mr Serve’s death to trauma related intracerebral haemorrhage, without the need for autopsy.

16. SC Hutton commenced a coronial investigation, later preparing the brief of evidence upon which this finding is largely based.5 The brief establishes that: 1 The Glasgow Coma Scale is a neurological scoring system which is used to assess conscious level after a head injury.

It categorises severity of a brain injury into mild (13-15), moderate (9-12) and severe (8 or less).

2 This is a two piece collar used to support the neck bones and ligaments and reduce movement which may further damage the neck.

3 Normally marketed as Lovan or Prozac, this is a substitute propylamine indicated for the treatment of major depressive disorders and obsessive compulsive disorders.

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

5 This was supplemented by materials obtained by WorkSafe during the course of their separate investigation.

a. Ms Plant did not perform any checks on the wheelchair prior to taking it for use offsite but said that it was rolling properly and did not appear heavy.6 She had never been provided with training on the use of wheelchairs or selection of wheelchairs.

b. Ms Plant had escorted clients off-site on multiple occasions, but had never been provided with any training on what needs to be done when taking clients off-site.

c. According to Ms Soria, while Bupa Edithvale did not provide specific training on wheelchair management, all staff undergo manual handling training where they are reminded to always assess their surroundings to ensure it is safe to perform a task.7 d. Ms Plant was unable to recall whether she engaged the brakes on Mr Serve’s wheelchair before leaving him on the landing to speak to the taxi driver.

e. According to Mr Serve’s general practitioner, Dr William Varney, Mr Serve was unable to mobilise himself in the wheelchair and needed to be pushed. He had no reckless or risk-taking behaviours that might have contributed to the incident. Due to cerebellar ataxia, he would not have had the reflex speed needed to put his hands out to break a fall.

f. The three concrete steps were each 160cm high with a tread that was 30cm deep.

g. A forensic survey of the scene undertaken by Anna Magennis showed the angle of inclination between the doorway of the CCSS building (the higher point) and the top of the concrete steps (the lower point) to be about one degree i.e. there was no significant gradient or abnormality in the surface of the landing.

h. Julian Skipper, a service technician, performed an inspection of the wheelchair used by Mr Serve and concluded that it was in a satisfactory functional condition with all its features operating in the desired manner. The brakes were in good condition, easy to apply and provided sufficient force to stop the wheelchair from moving while on a medium gradient.

17. I find that Mr Serve, late of Station Street in Edithvale, died on 20 November 2015 at Frankston Hospital and that the cause of his death was trauma related intracerebral haemorrhage in circumstances of an accidental fall from his wheelchair down the three concrete steps to the footpath below, a drop of 480cms.

18. Despite the investigations undertaken, it remains unclear how Mr Serve came to be so close to the top of the steps and travel over the edge. While the injuries to Mr Serve’s face and knees 6 Coronial Brief of Evidence, Statement of April Plant.

7 Coronial Brief of Evidence, Statement of Hanna Soria.

indicate some degree of forward momentum, I am unable to determine the mechanism by which this occurred.

COMMENTS Pursuant to section 67(3) of the Coroners Act 2008 I make the following comments in connection with the death.

1. At my request, Bupa provided some additional materials about its work practices for the safe use of wheelchairs. These materials indicate that Bupa has responded appropriately to Mr Serve’s death by revising its policies to enhance training to staff who escort residents on outings, changing the resident suitability for outings checklist, ensuring mobility aids are in good repair by monthly audit and mandating the use of seatbelts in wheelchairs.

2. This should improve the safety of its residents in the future and Bupa are commended for responding to the tragic circumstances in which Mr Serve died in a constructive fashion.

I direct that a copy of this finding be provided to the following: Deborah Whittington Bupa Care Services Frankston Hospital WorkSafe Victoria SC James Hutton, Chelsea Police Signature: ______________________________________

PARESA ANTONIADIS SPANOS CORONER Date: 15 November 2017