Finding into death of Sandra Mary Carroll

IN THE CORONERS COURT Court Reference: COR 2016 5310

OF VICTORIA AT MELBOURNE

Findings of:

Deceased:

Date of birth:

Date of death:

Cause of death:

Place of death:

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

Caitlin English, Coroner

Sandra Mary Carroll

28 August 1947

8 November 2016

I(a) Findings consistent with pneumonia/sepsis

Northeast Health Wangaratta 35-47 Green Street, Wangaratta, Victoria

BACKGROUND

1. Sandra Mary Carroll was a 69-year-old woman who lived in disability accommodation in

Benalla at the time of her death.

2. Ms Carroll became ill with a urinary tract infection in October 2016. Her condition deteriorated and she was brought to Northeast Health Wangaratta on 31 October 2016. She

did not recover and died in hospital on 8 November 2016.

THE PURPOSE OF A CORONIAL INVESTIGATION

3. Ms Carroll’s death was reported to the Coroner as Ms Carroll was a ‘person placed in custody or care’ immediately before her death for the purposes of the Coroners Act 2008 (the Act) and therefore her death fell within the definition of a reportable death.

4. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine

criminal or civil liability.

5. The Coroner’s Investigator prepared a coronial brief in this matter. The brief includes statements from witnesses, including Ms Carroll’s sister, Mary Carroll, the forensic

pathologist who examined Ms Carroll, treating clinicians and investigating officers.

6. I have based this finding on the evidence contained in the coronial brief. In the coronial

jurisdiction facts must be established to the standard of proof of the balance of probabilities.!

IDENTIFICATION OF THE DECEASED

7. On 8 November 2016, Mary Anne Carroll visually identified Ms Carroll’s body as being that of her sister Sandra Mary Carroll, born 28 August 1947.

8. Identity is not in dispute and requires no further investigation.

' This is 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.

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CIRCUMSTANCES IN WHICH THE DEATH OCCURRED

Lt;

Ms Carroll contracted encephalitis at the age of 8 months which caused major brain and spinal

damage.”

At seven years old Ms Carroll went into care at Kew Cottages and was in care for the remainder of her life.? In July 2016 she moved to a disability accommodation facility in Benalla operated by the Department of Health and Human Services.* Ms Carroll received 24-

hour carer high level support.

According to Ms Carroll’s general practitioner Dr David Rodgers:

‘[Ms Carroll] had minimal language to communicate her needs, and significant muscle problems with muscle spasm and weakness. Complicating these issues she had suffered ministrokes as an adult, had epilepsy and inflammatory bowel disease [and] she had

previously had fractures after falls’.

Ms Carroll was visited every six to eight weeks by her sister, Mary Carroll.”

' Events proximate to death

On 20 October 2016 Ms Carroll was suffering from a urinary tract infection and was placed on antibiotics by a General Practitioner. She saw another General Practitioner on 31 October 2016 and presented with a cough and temperature of 38 degrees. She was prescribed further

antibiotics.®

On the night of 31 October 2016 Ms Carroll’s health deteriorated, she was usually mobile but was unable to bear her own weight and an Ambulance was called. Ms Carroll was transported

to Northeast Health Wangaratta and arrived at 11.35pm.?

Upon her admission, Ms Carroll was examined by Dr Adithya Balasubramanian, who found left-sided transmitted upper airway sounds. A chest X-ray showed left lower zone

opacification. According to Dr Mark Dowling:

Statement of Mary Carroll dated 27 October 2017, Coronial Brief.

Ibid.

Statement of Andrea Skelton dated 1 March 2017, Coronial Brief.

Statement of Dr David Rodgers dated 20 February 2017, Coronial Brief.

Ibid.

Statement of Mary Carroll dated 27 October 2017, Coronial Brief.

Statement of Andrea Skelton dated 1 March 2017, Coronial Brief.

Statement of Andrea Skelton dated 1 March 2017, Coronial Brief; Statement of Tim Nolet dated 9 May 2017, Coronial Brief.

Li.

‘Based on [his] findings and the fact that the patient lived in supported accommodation with other sick residents, Dr Balasubramanian made the diagnosis of health-care associated

pneumonia.’'®

Dr Balasubramanian discussed Ms Carroll’s condition with her sister Mary Carroll and they

agreed to a course of management with intravenous antibiotics.!!

Ms Carroll’s condition worsened over the next several days. On 7 November 2016 Ms Carroll’s medical team consulted with Mary Carroll and a decision was made to continue with palliative care. Ms Carroll deteriorated further overnight and died at 9.03am on 8

November 2016.!*

CAUSE OF DEATH

2A.

On 10 November 2016, Dr Malcolm Dodd, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an inspection and provided a written report, dated 13 November 2016. In that report, Dr Dodd concluded that a reasonable cause of death was

‘I(a) Findings consistent with pneumonia/sepsis’ .

Toxicological analysis of the post mortem samples identified the presence of morphine, carbamazepine, midazolam and paracetamol, consistent with Ms Carroll’s treatment in

hospital.

Dr Dodd stated that ‘/T/here is no evidence to suggest that this death was due to anything

other than natural causes’.

I accept Dr Dodd’s opinion as to cause of death.

FINDINGS AND CONCLUSION

22s

Ms Carroll was ‘a person placed in custody or care’ for the purposes of the Act. Section 52(2)(b) of the Act requires that I hold an inquest into her death, however section 52(3A)

states that no inquest is required if I consider that her death was due to natural.causes.

Dr Dodd’s report includes an opinion that Ms Carroll’s death was due to natural causes

pursuant to section 52(3B) and I accept his opinion.

10 Statement of Dr Mark Dowling dated 3 April 2017, Coronial Brief.

" Ibid.

? Thid.

24. Having investigated the death, without holding an inquest, I find pursuant to section 67(1) of the Act that Sandra Mary Carroll, born 28 August 1947, died on 8 November 2016 at Wangaratta, Victoria, from I(a) Findings consistent with pneumonia/sepsis in the *

circumstances described above.

25. Pursuant to section 73(1B) of the Coroners Act 2008, | order that this Finding be published

on the internet.

26. Idirect that a copy of this finding be provided to the following: Ms Mary Carroll, senior next of kin.

Northeast Health.

Senior Constable Akif Kurtoglu, Victoria Police, Coroner’s Investigator.

Signature:

CAITLIN ENGLISH

CORONER Date: 12 February 2018