Finding into death of Robert James Wright

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2017 3270

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

Findings of: MICHELLE HODGSON, CORONER

Deceased: ROBERT JAMES WRIGHT

Date of birth: 7 December 1953

Date of death: 8 July 2017

Cause of death: l(a) BRONCHOPNEUMONIA IN A MAN WITH

CHOLANGITIS DUE TO CHOLEDOCHOLITHIASIS

Place of death: Box Hill Hospital, 8 Arnold Street, Box Hill, Victoria

HER HONOUR:

Background

lL.

Robert James Wright was born on 7 December 1953. He was 63 years old when he died on 8 July 2017 from an infection in his lungs on the background of bile duct infection due to obstruction by gallstones.

Mr Wright lived in Burwood in a group home managed by the Department of Health and

Human Services.

Mr Wright was born with an intellectual disability, which prevented him from speaking. He initially lived at Kew Cottages before moving to the group home in Burwood in 2005. His sister, Maryanne Young, regularly visited him and they often enjoyed going to a Chinese restaurant for lunch. In 2009, Mr Young moved to Kerang and distance prohibited regular

visits.

Ms Young noted that her brother began to deteriorate approximately four years before his death. He became unsteady on his feet and his involuntary hand and head movements made it difficult for him to eat and drink independently. In the months before his death, Mr Wright

began to lose weight.

Wayne Hargreaves, Operational Manager in Disability Accommodation Services for the East Division, confirmed there had been a decline in Mr Wright’s overall health and wellbeing in the 12 months before his death. He lost some weight and lost his ability to eat

and perform certain daily tasks independently.

Mr Wright’s medical history included organic mental disorder, epilepsy, pulmonary embolism, pneumothorax, portal venous thrombosis, and chronic constipation. He was prescribed a number of medications to treat his various conditions. Mr Wright also had a

history of fatty liver, gallstones, renal scarring, and splenic haematoma.

The coronial investigation

Mr Wright’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Mr Wright’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 rcsult 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. Swrounding cixcumstances 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 criminal

or civil lability.

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 Mr Wright’s death. The Coroner’s Investigator investigated the matter on my behalf and

submitted a coronial brief of evidence.

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

investigation was not required.

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.

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

? 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.

Identity of the deceased

14. Mr Wright was visually identified by his sister, Maryanne Young, on 8 July 2017. Identity

was not in issue and required no further investigation.

Medical cause of death

15. On 12 July 2017, Dr Gregory Young, Forensic Pathologist at the Victorian Institute of Forensic Medicine, conducted an autopsy upon the body of Mr Wright and reviewed a post

mortem computed tomography (CT) scan.

16. The autopsy revealed bronchopneumonia throughout both lungs. Obstructing

choledocholithiasis was also seen, as well as cholelithiasis (gallstones).

17. | Dr Young also explained that bronchopneumonia is an infection of the lungs, which is often seen in hospitalised patients. In some cases, it may be due to aspiration, which occurs after

inhaling (aspirating) foreign material, such as food of vomitus.

18. Cholangitis is an infection of the bile duct, usually caused by bacteria ascending from its junction with the duodenum. Dr Young explained that it tends to occur if the bile duct is

already partially obstructed by gallstones (choledocholithiasis).

19. A post mortem blood culture isolated klebsiella pneumoniae? and staphylococcus aureus.‘

20. After reviewing toxicology results, Dr Young completed a report, dated 7 August 2017, in which he formulated the cause of death as “/(a) Bronchopneumonia in a man with cholangitis due to choledocholithiasis”. Dr Young opined that the cause of 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

21. On 17 June 2017, Ms Young was notified that her brother did not seem his usual self. A

doctor’s appointment was scheduled for 21 June.

22. On 18 June 2017, Ms Young visited her brother and observed his dramatic weight loss.

3 Klebsiella pneumoniae is a bacterium that is often implicated in cholangitis, and is also seen in cases of aspiration pneumonia. The most common bacteria linked to cholangitis include Klebsiella pneumoniae, escherichia coli,

Enterobacter.

4 Staphylococcus aureus is a bacterium that is often found on the skin.

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25,

29,

On 21 June 2017, Mr Wright underwent a CT scan of his brain and abdomen, which showed he had gallstones. He was subsequently admitted to the Austin Hospital for immediate treatment. He was discharged the next day with a plan to remove the gallstones in the next

few days.

On 26 June 2017, Mr Wright underwent an ERCP procedure® to remove the gallstones. The cholangiogram was clear at the end of the procedure. He was discharged later that day.

On 29 June 201, Mr Wright was reviewed by his general practitioner and appeared to be

recovering well.

On 30 June 2017, Mr Wright appeared weak and pale. He refused to eat or drink and vomited. His temperature was slightly raised at 38.6 degrees. He was subsequently admitted to the Box Hill Hospital.

Upon admission, Mr Wright was found to have sepsis and deranged liver function tests. The treating team consulted Ms Young about whether to perform a repeat ERCP but it was

decided to treat Mr Wright conservatively with intravenous antibiotics and fluid.

On 1 July 2017, Mr Wright began suffering low blood pressure caused by multiple organ failure. Mr Wright’s sister was notified of her brother’s deteriorating condition. After discussion with the treating team, it was decided to provide Mr Wright with palliative

treatment. He was kept comfortable with morphine.

Ms Young visited her brother daily until he passed away at 2.41am on 8 July 2017.

Findings

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

(a) the identity of the deceased was Robert James Wright, born 7 December 1953;

(b) Mr Wright died on 8 July 2017 at Box Hill Hospital, 8 Arnold Street, Box Hill, Victoria, from bronchopneumonia in a man with cholangitis due to

choledocholithiasis; and

5 An ERCP (short for endoscopic retrograde cholangiopancreatography) is a procedure used to diagnose diseases of the gallbladder, biliary system, pancreas, and liver.

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

Publication

I direct that this finding be published on the internet pursuant to section 73(1A) of the Coroners Act 2008.

I convey my sincere condolences to Mr Wright’s family.

I direct that a copy of this finding be provided to the following: Maryanne Young, Senior Next of Kin Austin Health Eastern Health First Constable Anna Johnston, Coroner’s Investigator, Victoria Police

Signature:

MICHELLE HODGSON CORONER

Date: 3 September 2018.