Finding into death of Gultekin Yuksel

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2018 000196

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: Peter Charles White, Coroner Deceased: Gultekin Yuksel Date of birth: 5 March 1939 Date of death: 12 January 2018 Cause of death: Ruptured abdominal aortic aneurysm

Place of death: Shepparton

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2018 000196

FINDING INTO DEATH WITHOUT INQUEST

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

I, PETER CHARLES WHITE, Coroner,

having investigated the death of GULTEKIN YUKSEL

without holding an inquest:

find that the identity of the deceased was GULTEKIN YUKSEL

born on 5 March 1939

and that the death occurred on 12 January 2018

at Goulburn Valley Health, 40 Monash Street, Shepparton, Victoria 3630

from: I(a) RUPTURED ABDOMINAL AORTIC ANEURYSM

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

circumstances:

1. Mr Yuksel was a 78-year old man of Turkish descent who lived in Shepparton. He had a medical history of coronary artery disease including bypass grafting in 2003, hypertension, high cholesterol,

benzodiazepine addiction and generalized anxiety disorder.

2. On 30 November 2017, Mr Yuksel presented to Goulburn Valley Health with psychotic symptoms including delusional thinking for the previous several months, and a history of self-neglect, and denied any suicidal thoughts or plans. He was admitted to the psychiatric inpatient unit, Wanyarra,

for treatment of very-late-onset schizophrenia-like psychosis [VLSLP].

3. Mr Yuksel was commenced on an increasing dose of antipsychotic medication olanzapine, which he tolerated well and produced mild improvement in his psychotic symptoms. As he had no previous history of psychosis or neurological illness, the cause of his VLSLP was investigated, with computerized tomography [CT] scanning of his brain revealing only moderate brain atrophy and

blood tests eliminating metabolic and infectious dysfunction.

4. In light of his benzodiazepine dependence and history of significant daily use of oxazepam and diazepam, MrYuksel input was sought from the Drug and Alcohol Clinical Advisory Service

consultant, who advised that he be weaned from these drugs sequentially. Mr Yuksel tolerated

weaning of oxazepam well, experiencing no withdrawal symptoms or seizures but initially craved benzodiazepines and surreptitiously brought some into Wanyarra and unsuccessfully endeavoured to

persuade nursing staff on the unit to provide him with benzodiazepines without informing doctors.

On 21 December 2017, nursing staff found Mr Yuksel drowsy and ataxic.' During a search, a number of benzodiazepine tablets were located in Mr Yuksel’s clothing. Thereafter, nursing staff performed regular checks of Mr Yuksel and search for any sign that he was hoarding medication, but

found none.

On 22 December 2017, Mr Yuksel was made a compulsory (involuntary) psychiatric patient subject to a temporary treatment order under the Mental Health Act 2014. The same day, Mr Yuksel experienced mild chest pain and episodes of hypotension, which upon electrocardiogram [ECG] investigation revealed no acute ischaemic changes. His condition was discussed with the medical registrar who advised that his hypertensive medication be withheld and, upon doing so, Mr Yuksel’s

blood pressure stabilized. He did not report any further chest pain.

Throughout the following fortnight, Mr Yuksel became more cooperative with treatment and his psychotic symptoms demonstrated further improvement such that he was able to participate in

accompanied leave from Wanyarra without incident.

On 4 January 2018, Mr Yuksel underwent echocardiography which showed normal left ventricle size with posterolateral hypokinesis suggestive of previous left circumflex territory infarction, increased apical wall thickness indicating of cardiomyopathy, a mildly dilated aortic root and normal right

ventricle and valvular function.

On 11 January 2018, Mr Yuksel had a period of accompanied leave from Wanyara and when searched on return no tablets were found in his possession. He interacted well with staff that

evening and ate dinner before retiring for the night.

At about 7.50am on 12 January 2018, Mr Yuksel was found by nursing staff performing a medication round lying on his bed, pale and unresponsive. A Code Blue was initiated, with cardiopulmonary resuscitation commenced immediately, but he was not able to be revived. Mr Yuksel was

declared dead at 8.16am.

Senior Constable Kirby Bissett of Shepparton Police commenced a coronial investigation and, at my

request, later compiled the brief of evidence on which this finding is largely based.

Forensic pathologist, Dr Gregory Young of the Victorian Institute of Forensic Medicine [VIFM] conducted an external examination of the body, considered the circumstances of the death as reported by police to the coroner and reviewed available medical records and post-mortem CT scans when preparing a report of his findings. Among Dr Young’s anatomical findings were the absence

of any unexpected signs of trauma, on post-mortem CT scans, ruptured abdominal aortic aneurysm

' Without full control of bodily movements.

14,

measuring nine centimetres in diameter, coronary artery calcification and right peritoneal

haemorrhage.

Routine post-mortem toxicology detected naloxone,” codeine, diazepam and olanzapine at levels

consistent with their therapeutic use and a trace amount of paracetamol.

Dr Young attributed Mr Yuksel’s death to natural causes, namely, ruptured abdominal aortic aneurysm. The pathologist commented that an aneurysm is an abnormal outpouching of a blood vessel, which in this case, was the aorta. The mechanism of Mr Yuksel’s death was bleeding due to rupture of the aneurysm. Hypertension, smoking and atherosclerosis are major risk factors for the

development of aneurysms.

At the time of his death, Mr Yuksel was a “person placed in custody or care” as defined in section 3°

of the Coroners Act 2008 [the Act] because he was a compulsory psychiatric inpatient pursuant to the Mental Health Act 2014.

Mr Yuksel’s designation as a “person placed in custody or care” is significant. This is because the Act recognizes that people in the control, care or custody of the State are vulnerable and therefore, irrespective of the nature of the death, requires it to be reported to the Coroner and so subject to the

independent scrutiny and accountability of a coronial investigation.

As an additional protection, until the insertion of section 52(3A) into the Act in November 2014, all deaths of people placed in custody or care required a mandatory inquest. Now, the Coroner is no longer required to hold an inquest if satisfied that the death was due to natural causes but must publish Findings made concerning natural causes deaths of people in custody or care.* Of course, the Act preserves a discretionary power to hold an inquest in relation to any death a coroner is

investigating.°

I find that Mr Yuksel, late of Packham Street in Shepparton, died at the Wanyarra unit of Goulburn

Valley Health in Shepparton on 12 January 2018 of a ruptured abdominal aortic aneurysm. In

accordance with the advice provided by Dr Young, I am satisfied that Mr Whelan’s death was due to

natural causes.

I direct, pursuant to section 73(1B) of the Coroners Act 2008, that this Finding be published on the Internet

in accordance with the rules.

I direct that a copy of this finding be provided to:

2 A synthetic opioid antagonist.

3 See section 3 for the definition of a “person placed in custody or care” and section 4(2)(c) of the definition of “reportable death”.

4 Section 73(1B).

5 Section 52(1) provides that a coroner may hold an inquest into any death that the coroner is investigating.

Taner Yavuzcehre, Turkish Cultural Centre (Shepparton) Dr Ravi Bhat, Goulburn Valley Area Hental Health Senior Constable K. Bissett, Shepparton Police

PETER cats W HITE

CORONER

Date: 22 _\ mens