Finding into death of Sabri Saljiu

IN THE CORONERS COURT Court Reference: COR 2016 4994

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: JUDGE SARA HINCHEY, STATE CORONER Deceased: SABRI SALJIU Date of birth: 8 January 1949 Date of death: 15 October 2016 Cause of death: Complications of non small cell lung carcinoma in a man with ischaemic cardiomyopathy, chronic obstructive pulmonary disease and other medical comorbidities Place of death: Broadmeadows Health Service, 35 Johnstone Street, Broadmeadows, Victoria Catchwords: Deceased person in custody or care; natural causes.

TABLE OF CONTENTS Background 1 The purpose of a coronial investigation 3 Matters in relation to which the Coroner must, if possible, make a finding

• Identity of the deceased, pursuant to section 67(1)(a) of the Act 4

• Medical cause of death, pursuant to section 67(1)(b) of the Act 4

• Circumstances in which the death occurred, pursuant to section 67(1)(c) of 4 the Act Comments pursuant to section 67(3) of the Act 5 Findings and conclusion 6

HER HONOUR: BACKGROUND

1. Sabri Saljiu (Mr Saljiu) was a 67-year-old man who was subject to a Non-Custodial Supervision Order under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 at the time of his death.

2. Mr Saljiu had a psychiatric history of schizophrenia, with the diagnosis formally made in October 1988 during an admission to a psychiatric hospital. Mr Saljiu had a medical history of arthritis, chronic obstructive pulmonary disease, hyperlipidaemia, non-insulin dependent Diabetes Mellitus, ischaemic cardiomyopathy, atrial fibrillation and heart failure. Mr Saljiu was a lifelong smoker, smoking approximately 75 packets of cigarettes a year.

3. At the time of his death, Mr Saljiu’s mental health care was managed by consultant psychiatrist Dr Sanjeewanie Karunaratne and case manager Mr David Chisholm of the Northern Mental Health Service.1

4. On 7 October 1989 Mr Saljiu attacked his wife Mrs Marcia Saljiu with an iron bar while she slept in their Northcote home, subsequently leading to Mrs Saljiu’s death. In December 1990 Mr Saljiu was found not guilty of murder by reason of mental impairment.2

5. On 23 April 1991, pursuant to section 420 of the Crimes Act 1958 the Supreme Court of Victoria declared that Mr Saljiu be held in custody at Her Majesty’s Prison Pentridge until His Excellency the Governor’s pleasure be known.3

6. On 21 May 1991, His Excellency ordered that Mr Saljiu be kept in the custody of the DirectorGeneral of the Office of Corrections. As a result of this, Mr Saljiu was admitted to the Rosanna Forensic Psychiatry Centre from 1991 to 1996. 4

7. In 1996 Mr Saljiu was transferred to Main Drive House, a supported accommodation service in the grounds of Mont Park Hospital.5 1 Coronial brief, statement of Dr Grant Lester, dated 20 February 2017, 15.

2 Ibid, 14.

3 Above n 1, 14.

4 Above n 1, 14.

5 Above n 1, 14.

8. In 1998, Mr Saljiu was granted extended leave by the Supreme Court of Victoria under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997. 6

9. In 2000, Mr Saljiu was moved from Main Drive House to his own accommodation in Reservoir. On 13 December 2000, a Non-Custodial Supervision Order was granted. The last major review of Mr Saljiu’s Non-Custodial Supervision Order took place in December 2015.

The Supreme Court of Victoria confirmed the Order and ordered a further major review take place in three years’ time.7

10. In March 2007 and December 2015, Mr Saljiu applied for revocation of the Non-Custodial Supervision Order. Both applications were dismissed by the Supreme Court of Victoria on the basis of concerns regarding possible non-compliance with psychiatric treatment should the Order be revoked.8

11. In February 2016, Mr Saljiu was diagnosed with locally advanced right upper lobe lung adenosquamous carcinoma. Following diagnosis, Mr Saljiu commenced radiotherapy and concurrent chemotherapy at Northern Health. Mr Saljiu’s condition was deemed unsuitable for surgery. 9

12. On 31 July 2016, Mr Saljiu was admitted to the Northern Hospital. He was treated with intravenous antibiotics, diuresis, anti-arrhythmics and management of his dyspnoea with morphine. While Mr Saljiu made some improvement, his functional level remained poor and he was considered not appropriate for discharge home due to living alone. Mr Saljiu’s condition was reviewed by an oncology and palliative care team, and in consideration of the high possibility of rapid clinical deterioration it was suggested that Mr Saljiu be assessed in the Broadmeadows Health Service Palliative Care Unit (BHS PCU).10

13. On 8 August 2016, Mr Saljiu was transferred to the BHS PCU for assessment. Mr Saljiu’s condition was discussed with his son and daughter, and a treatment plan of palliative and 6 Above n 1, 14.

7 Above n 1, 14.

8 Above n 1, 14.

9 Coronial brief, statement of Dr Georgina Whittaker, dated 19 February 2017, 8.

10 Ibid, 9.

symptom based care was planned, with a view to finding an appropriate aged care facility for Mr Saljiu in the event of stabilisation of his condition.11

14. After a period of assessment, Mr Saljiu’s condition appeared to stabilise, and discharge planning to an appropriate aged care facility commenced. The discharge planning was complicated and delayed by the need to find an aged care facility within the catchment area of Mr Saljiu’s long-term case manager, as continuity of treatment was felt to be in Mr Saljiu’s best interest and was also in accord with his wishes.12

THE PURPOSE OF A CORONIAL INVESTIGATION

15. The role of a coroner is to investigate reportable deaths to establish, if possible, the identity, of the deceased, the medical cause of death and, with some exceptions, surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The law is clear that coroners establish facts; they do not lay blame, or determine criminal or civil liability.13

16. The jurisdiction of the Coroners Court of Victoria is inquisitorial.14 The Coroners Act 2008 (Vic) (the Act) provides for a system whereby reportable deaths are independently investigated to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which death occurred.15

17. Mr Saljiu’s death constituted a ‘reportable death’ under the Act, as the death occurred in Victoria and, at the time of his death, he was a person considered to be “a person placed in custody or care.”16

18. The Act provides that a coroner must hold an inquest into all deaths which occurred while a person is “in custody or care”,17 except in those circumstances where the death is considered to be due to natural causes.18 11 Above n 9, 9.

12 Above n 9, 11.

13 In the coronial jurisdiction facts must be established on the balance of probabilities subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

14 Section 89(4) Coroners Act 2008.

15 See Preamble and s 67, Coroners Act 2008.

16 Section 3 and 4 Coroners Act 2008.

17 Section 52(2)(b) of the Coroners Act 2008.

18 Section 52(3A) of the Coroners Act 2008.

19. In accordance with section 52(3B) of the Act, a death may be considered to be due to natural causes if the coroner has received a report from a medical investigator, in accordance with the Coroners Court Rules 2009, that includes an opinion that the death was due to natural causes.

I have received such a report in this case. Therefore, I limit my findings with respect to the circumstances in which the death occurred and exercise my discretion not to hold an inquest.

MATTERS IN RELATION TO WHICH THE CORONER MUST, IF POSSIBLE, MAKE A FINDING Identity of the Deceased, pursuant to section 67(1)(a) of the Act

20. On 24 October 2016, Ms Zudija Potoi identified the body of the deceased to be her father, Mr Sabri Saljiu, born 8 January 1949.

21. Identity was not in issue and requires no further investigation.

Medical cause of death, pursuant to section 67(1)(b) of the Act

22. On 21 October 2016, Dr Victoria Francis, Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an examination upon Mr Saljiu’s body and provided a written report, dated 2 November 2016. In that report, Dr Francis concluded that a reasonable cause of death was complications of non small cell lung carcinoma in a man with ischaemic cardiomyopathy, chronic obstructive pulmonary disease and other medical comorbidities.

23. Dr Francis reported that the post-mortem Computed Tomography (CT) scan showed peripheral oedema, pericardial effusion, calcified coronary arteries, and increased bilateral lung markings with a possible left hilar lung mass. On external examination, Dr Francis noted a linear red fascicular type rash over the left chest suggestive of shingles.

24. On the basis of the information available at the time of completing her report, Dr Francis provided an opinion that Mr Saljiu’s death was due to natural causes.19 Circumstances in which the death occurred, pursuant to section 67(1)(c) of the Act

25. At approximately 1.10pm on 14 October 2016, Palliative Care Registrar Dr Georgina Whittaker reviewed Mr Saljiu’s condition. Mr Saljiu reported concern regarding constipation, 19 Medical Examiner’s Report, page 4.

ongoing insomnia, night restlessness and worsening of breathing. Treating clinicians arranged for an increase in Mr Saljiu’s prednisolone and frusemide doses.20

26. On 15 October 2016 at 5.50am, covering Hospital Medical Officer (HMO) Dr Engel was asked to review Mr Saljiu in relation to anxiety symptoms. Mr Saljiu reported waking the past 3 nights with angina and dyspnoea. Mr Saljiu was administered oxycodone at 5.10am, olanzapine at 5.15am, and glyceryl trinitrate spray at 5.45am.21

27. At 3.10pm, Mr Saljiu was administered oral morphine. Covering HMO Dr Rowan conducted a further review of Mr Saljiu’s condition following reports that he was increasingly chesty.

Mr Saljiu was reported to have increased work of breathing, audible upper airway secretions, oxygen saturations of 90% on 3 litres of oxygen, a heart rate of 73 beats per minute, and a respiratory rate of 30 breaths per minute. Dr Rowan’s findings on examination were coarse crepitations in the left chest and transmitted upper airway sounds.22

28. Dr Rowan’s documented impression was that Mr Saljiu’s condition had progressed to terminal stage, and in consultation with Palliative Care Consultant Dr Charmaine Foo subcutaneous medication comfort measures were agreed upon. At 5.25pm, doses of subcutaneous morphine and midazolam were signed for by nursing staff. The medical records indicate that before the comfort measures could be implemented Mr Saljiu passed away at 5.30pm.23

COMMENTS PURSUANT TO SECTION 67(3) OF THE ACT

29. I am satisfied that Mr Saljiu’s death was due to natural causes.

30. Following a thorough review of the coronial brief of evidence and Mr Saljiu’s medical records, I am satisfied that the management of Mr Saljiu’s medical care while in custody was reasonable and appropriate in the circumstances.

31. Having considered the evidence, I am satisfied that no prevention issues arise from this matter and no further investigation is required.

20 Above n 9, 11.

21 Above n 9, 11.

22 Above n 9, 12.

23 Above n 9, 12.

FINDINGS AND CONCLUSION

32. Having investigated the death, without holding an inquest, I make the following findings pursuant to section 67(1) of the Coroners Act 2008:

(a) the identity of the deceased was Sabri Saljiu, born 8 January 1949;

(b) the death occurred on 15 October 2016 at Broadmeadows Health Service, 35 Johnstone Street, Broadmeadows, Victoria, from complications of non small cell lung carcinoma in a man with ischaemic cardiomyopathy, chronic obstructive pulmonary disease and other medical comorbidities; and

(c) the death occurred in the circumstances described above.

33. I convey my sincerest sympathy to Mr Saljiu’s family.

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

(a) Ms Zudija Potoi, Senior Next of Kin;

(b) Ms Melissa Iskov, Forensicare;

(c) Ms Jackie Petrov, the Northern Hospital; and

(d) First Constable Julie Cutrone, Coroner’s Investigator, Victoria Police.

35. Pursuant to section 73(1B) of the Act, I order that this finding be published on the internet in accordance with the Coroners Court Rules 2009.

Signature: ______________________________________

JUDGE SARA HINCHEY STATE CORONER Date: 21 November 2017