Finding into death of PH

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2017 0425

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: MICHELLE HODGSON, CORONER Deceased: *PH Date of birth: 8 September 1965 Date of death: 26 January 2017 Cause of death: l(a) COMPLICATIONS OF ASPIRATION

PNEUMONIA IN A MAN WITH’ STATUS EPILEPTICUS Place of death: St Vincent’s Hospital, 41 Victoria Parade, Fitzroy, Victoria

• This is a redacted version of the original signed finding. Names have been replaced with initials to preserve the privacy of PH’s family.

HER HONOUR: Background

1. PH was born on 8 September 1965. He was 51 years old when he died on 26 January 2017

from complications of aspiration pneumonia and status epilepticus.

2. PH was the youngest son of DH and GH. He was born with an intellectual disability and required ongoing specialised care. He was subsequently cared for at Kew Cottages and spent

weekends with his parents and two older brothers.

3. When Kew Cottages closed, he moved to a residential home with carers and four other residents. According to his mother, it was at this time that PH flourished. He loved nature and enjoyed being outdoors. PH was stimulated by colour and music — he enjoyed watching television, listening to music, and outings with his family to museums and live performances,

which fixated him for hours.

4. Despite being unable to communicate verbally, PH was able to show his love in other ways, especially for his brother, MH. He was very attentive and deeply expressive in his eye contact, which clearly conveyed his love for his family. He visibly enjoyed family outings,

laughing and clapping when he was having fun.

5. According to his mother, it was only in the year before his death that PH spoke for the first time since his infancy. After his carer had questioned him after a day out, he answered “yep”

three times.

6. PH was also a faithful member of Holy Trinity Kew, where he accompanied his mother to Sunday services. Before his death, PH attended a Christmas service, which he clearly enjoyed

as he was transfixed by the choir and organ.

7. Inrecent years, PH had been admitted to the Austin Hospital on a number of occasions due to seizures. His medical history included Lennox-Gastaut syndrome,! gastro-oesophageal reflux disease, osteoporosis, osteoarthritis, hepatomegaly, and recurrent aspiration pneumonia. PH

had an epilepsy management plan, which was endorsed by his treating general practitioner

1In 2012, PH was diagnosed with Lennox-Gastaut syndrome, a form of childhood-onset epilepsy, which is characterised by frequent and different seizure types. Treating doctors advised staff at the care facility that PH was likely to experience regular seizures despite treatment with prescription medications. At baseline, PH experienced one seizure per day.

and neurologist. The staff at the care facility supported PH in accordance with the plan, which

was reviewed regularly.

The coronial investigation

PH’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). PH’s death was reportable because he was in the care of the State immediately before the time of his death.” Deaths of persons in the care of the State are reportable to ensure independent scrutiny of the circumstances surrounding their deaths. If such deaths occur as a result of natural causes, a coronial investigation must take place but the

holding of an inquest is not mandatory.

Coroners independently investigate reportable deaths to find, if possible, identity, 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. Coroners make findings on the balance of probabilities, not proof beyond

reasonable doubt.

The law is clear that coroners establish facts; they do not cast blame, or determine crimirial or

civil liability.

Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death

under investigation.

Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation into PH’s death, The Coroner’s Investigator conducted inquiries on my behalf, including taking

statements from witnesses, and submitted a coronial brief of evidence.

After considering all the material obtained during the coronial investigation, I determined that Thad sufficient information to complete my task as coroner and that further investigation was

not required.

2 See section 4{2)(c) of the Coroners Act 2008 (Vic).

3 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.

Whilst I have reviewed all the material, I will only refer to that which is directly relevant to

my findings or necessary for narrative clarity.

Identity of the deceased

PH was visually identified by his mother, DH, on 27 January 2017. Identity was not in issue

and required no further investigation.

Medical cause of death

On 29 January 2017, Dr Gregory Young, Forensic Pathologist at the Victorian Institute of Forensic Medicine, conducted an external examination of the body of PH and reviewed a post mortem computed tomography (CT) scan. The examination revealed cerebral oedema,

increased lung markings, and pleural effusions.

Dr Young noted that aspiration pneumonia occurs when there is aspiration of food, stomach contents or vomitus into the lungs, leading to pneumonia (chest infection). He explained that Lennox-Gastaut syndrome is a form of childhood-onset epilepsy that results in multiple seizures, and is associated with intellectual disability and increased risk of aspiration pneumonia. Status epilepticus is an epileptic seizure that lasts five minutes or more, and often

requires management in hospital.

After reviewing toxicology results, Dr Young completed a report, dated 1 February 2017, in which he formulated the cause of death as “J(a) Complications of aspiration pneumonia in a man with status epilepticus”. He was also of the opinion that the death was due to natural

causes. I accept Dr Young’s opinion as to the medical cause of death.

Circumstances in which the death occurred

On 13 December 2016, PH was admitted to the Austin Hospital with a cluster of seizures that was thought to be secondary to faecal loading. His anticonvulsant medications were increased

during the admission and he was subsequently discharged to his care facility.

On 28 December 2016, PH was assessed by his general practitioner due to a cough. He was diagnosed with a chest infection and prescribed antibiotics. That night, PH experienced

approximately 15 seizures and had no improvement in conscious state following the seizures.

On 29 December 2016, PH presented to St Vincent’s Hospital with status epilepticus and

aspiration pneumonia. He required intubation and sedation.

Initially, it was thought that an underlying infection in the chest or central nervous system was the cause of PH’s epilepticus. Tests ruled out an infection of the central nervous system, but a chest x-ray showed a right mid to low zone of opacity, which suggested a respiratory focus for infection. He was commenced on intravenous antibiotics and transferred to the intensive care

unit, where anticonvulsant medications were recommenced.

On 30 December 2016, an electroencephalography (EEG) was performed, which excluded ongoing seizures. The next day, PH was extubated and discharged from the intensive care unit. However, he continued to experience ongoing frequent seizures and an antiepileptic medication was commenced. Despite this, seizures continued and were later complicated by

aspiration pneumonia. Intravenous antibiotics were recommenced.

On 13 January 2017, PH continued to be administered antibiotics. He had a nasogastric tube re-inserted after he had vomited it out earlier. He was continued on antiepileptic medications.

PH removed the nasogastric tube and nursing staff were unable to re-insert it despite multiple

attempts.

A speech therapist reviewed PH and recommended nil by mouth due to his decreased alertness and aspiration risk. His antiepileptic medications. were subsequently changed to intravenous formulations. Later that evening, PH went into status epilepticus and remained refractory to escalating anti-epileptic agents. The antibiotic regimen was broadened due to

ongoing fevers and multiple seizures.

Despite optimal treatment, PH remained unwell. On 16 January 2017, medical staff discussed his poor prognosis with his mother. Over the next few days, it was decided that PH be

provided with palliative care.

On 20 January 2017, a chest x-ray was performed, which demonstrated extensive left lung

consolidation. However, it seemed that PH was clinically improving.

On 22 January 2017, PH became febrile and later experienced 14 seizures. He continued to

deteriorate and was found to be anaemic, which required a blood transfusion. Bacterial

infection (clostridium difficile) was isolated on a stool sample and an intravenous antibiotic

was commenced.

29. On 25 January 2017, active treatment was withdrawn after further family discussions. He passed away the next day.

30. PH will be remembered for his radiating love, and his gentle and peaceful nature.

Findings Pursuant to section 67(1) of the Coroners Act 2008 I find as follows:

(a) the identity of the deceased was PH, born 8 September 1965;

(b) PH died on 26 January 2017 at St Vincent’s Hospital, 41 Victoria Parade, Fitzroy, Victoria, from complications of aspiration pneumonia in a man with status epilepticus;

and

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

I convey my sincere condolences to PH’s family.

I direct that a copy of this finding be provided to the following: DH, Senior Next of Kin GH, Senior Next of Kin St Vincent’s Health

First Constable Craig Duncan, Coroner’s Investigator, Victoria Police

Pursuant to section 73(1B) of the Act, I order that this finding be published on the internet in

accordance with the rules.

Signature:

MICHELLE HODGSON | CORONER Date: 27/08/2018