Finding into death of Colin Cannon

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2017 001774

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2)

Section 67 of the Coroners Act 2008

As amended on 13 November 2017 pursuant to section 76 of the Coroners Act 2008!

I, AUDREY JAMIESON, Coroner having investigated the death of COLIN VIVIAN

CANNON

without holding an inquest pursuant to section 52(3A) of the Coroners Act 2008: find that the identity of the deceased was COLIN VIVIAN CANNON born 7 May 1971 and the death occurred on 16 April 2017 at 14-16 Eisenhower Street, Warragul, Victoria 3820 from: 1(a) COMPLICATIONS OF LENNOX-GASTAUT SYNDROME

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

1. Colin Vivian Cannon was a 45 year-old man residing in a Department of Health and Human Services care facility in Eisenhower Street, Warragul. Mr Cannon is survived by his parents, Jennifer Cannon and Dennis Cannon, and his two siblings, Cheryl Otten and

Jeffery Cannon.

2. Mr Cannon suffered German measles as a 20 month-old and subsequently experienced

ongoing health problems. Mr Cannon’s medical history included childhood meningitis,

' Colin Cannon’s date of birth and date of death were corrected.

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Lennox-Gastaut syndrome,’ epilepsy, schizophrenia, behavioural difficulty and

agitation.

3. In 1975, Mr Cannon began attending Mawarra Centre, a disability support centre in Warragul. For the past 10 years, Mr Cannon was put under general anaesthesia once per year to undergo routine blood tests and an examination by his general practitioner, Dr Thiru Ketheeswaran. At the time of his death, Mr Cannon was prescribed doxycycline,

sodium valproate, carbamazepine, diazepam, and olanzapine.

4. Mr Cannon moved into permanent, residential care at Eisenhower Street in Warragul at age 21. Mr Cannon received 24-hour care at the residential facility and continued to

attend the Mawarra Centre during the day.

5. On 16 April 2017, an Eisenhower staff member located Mr Cannon unresponsive in his unit. Cardio Pulmonary Resuscitation (CPR) was initiated and emergency services contacted. However, attending paramedics were unable to revive Mr Cannon and he was

declared deceased.

6. Mr Cannon’s death was considered reportable pursuant to section 4 of the Coroners Act 2008 (Vic) (‘the Act’) because he was a person placed in care. Pursuant to section 3 of the Act, a person placed in care includes a person who is under the control, care or

custody of the Department of Health and Human Services.

INVESTIGATIONS Forensic pathology investigation

7. Dr Gregory Young, a Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an external examination upon the body of Mr Cannon, reviewed a post mortem computed tomography (CT) scan and referred to the Victoria Police Report of Death, Form 83. Anatomical findings showed some bruising on the knees but no unexpected signs of trauma. CT scanning revealed no obvious airway obstruction. There was coronary artery calcification seen in the heart. No significant pathology was

identified. Toxicological analysis of Mr Cannon’s post mortem blood identified:

? Lennox-Gastaut Syndrome is a category of severe, disabling epilepsy. It is characterised by frequent, treatment-resistant seizures, and cognitive impairment. See: JS Archer et al, ‘Conceptualising Lennox-Gastaut syndrome as a secondary network to epilepsy’ [2014] Frontiers in neurology

<http://journal. frontiersin.org/article/10.3389/fneur.2014.00225/full>

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carbamazepine (~7 mg/L); valproic acid (~27 mg/L), olanzapine (~0.1 mg/L), paracetamol (~7 mg/L), diazepam (~0.05 mg/L) and its metabolite nordiazepam (~0.1 mg/L).

Dr Young noted Mr Cannon’s Lennox-Gastaut diagnosis and reported that the condition is associated with an increased risk of aspiration. He opined that Mr Cannon’s cause of death was likely to be the result of a seizure or cardiac arrhythmia. Dr Young ascribed

Mr Cannon’s cause of death to complications of Lennox-Gastaut syndrome.

Police investigation

Victoria Police Officers attended Mr Cannon’s residence and were met by attending ambulance paramedics who briefed them on their resuscitative efforts. Police found no evidence of suspicious circumstances nor third party involvement. Police contacted Mr

Cannon’s parents.

Senior Constable James Carter, the nominated coroner’s investigator,’ conducted an investigation of the circumstances surrounding Mr Cannon’s death at my direction. This included the preparation of the coronial brief which contained, inter alia, statements

made by Dennis Cannon, Dr Ketheeswaran, and Mr Cannon’s carers on the day he died.

During the course of the investigation, police learned that Mr Cannon’s health began to deteriorate in February 2017. His epileptic seizures were increasing in frequency and severity. Staff at the DHHS care facility arranged for a video of one of Mr Cannon’s seizures to be viewed by Neurologist and Epileptologist Professor Graeme Jackson. On 5 April 2017, Professor Jackson viewed the video and prescribed Mr Cannon lamotrigine

(25mg) once per day to work in conjunction with sodium valproate.

On 12 April 2017, a staff member at the Eisenhower facility, Rebecca Garlick, noticed that Mr Cannon had developed a strange gait; he shuffled, leaned forward, and seemed to be restricted in this movement. On 14 April 2017, Dr Ketheeswaran visited Mr Cannon and decided to withhold the sodium valproate. On 15 April 2017, staff at the

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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Eisenhower facility noted that Mr Cannon’s walk had improved and it appeared that his spirits had lifted.

On 16 April 2017, staff members Amanda Willshire and Julie Walker attended Mr Cannon’s unit. They noted that his mobility had again improved. Mr Cannon had his morning medication and a glass of fruit juice before being showered. Mr Cannon was then given further medication before having breakfast. Staff check on Mr Cannon every

10 or 15 minutes during the day.

At 10.30am, a staff member, Clare Benfell fed Mr Cannon an Easter egg. At approximately 11.00am, Ms Benfell fed Mr Cannon a hot-cross bun that was cut up into small pieces. Ms Benfell returned to the main building of the facility and informed other

staff members that Mr Cannon had enjoyed the hot-cross bun.

At approximately 12.0S5pm, Ms Willshire returned to Mr Cannon’s residence to provide him with his lunchtime medications and a drink. Ms Willshire found Mr Cannon on his couch. He was unresponsive and Ms Willshire believed that he was deceased. She called

out for assistance from other staff members.

Staff members commenced cardio pulmonary resuscitation (CPR) and contacted emergency services. Paramedics attended at approximately 12.15pm and took over the resuscitative efforts. Dr Ketheeswaran attended and would not declare Mr Cannon deceased so paramedics continued CPR for approximately 30 minutes before declaring

Mr Cannon deceased at 12.47pm.

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FINDINGS

Section 52 of the Coroners Act 2008 mandates the holding of an Inquest if the deceased was, immediately before death, a person placed in care, save for circumstances where the person is deemed to have died from natural causes, pursuant to section 52(3A). Dr Young has ascribed Mr Cannon’s death to natural causes: complications of Lennox-Gastaut syndrome. Therefore, I have determined it is appropriate to conclude this investigation by way of an in-chambers

Finding.

The investigation has identified that Mr Cannon had a long and complex medical history that included epilepsy and epileptic seizures. Mr Cannon’s seizures had recently increased in frequency and severity. Professor Jackson prescribed sodium valproate in an attempt to increase Mr Cannon’s seizure control. However, Dr Ketheeswaran subsequently withheld the

medication due to apparent adverse effects on Mr Cannon’s mobility and mood.

On 16 April 2016, Mr Cannon’s meals were supervised with no ill effects. His mobility had

improved and his mood was lifted. No seizure activity was witnessed.

I accept and adopt the cause of death prescribed by Dr Young and I find that Colin Vivian

Cannon died of complications of Lennox-Gastaut syndrome.

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:

Jennifer and Dennis Cannon, Senior Next of Kin

Senior Constable James Carter, Coroners’ Investigator

Signature:

AUDREYSAMIESON __ CORONER Date: 13 November 2017

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