Finding into death of Leon Edward Balshaw

IN THE CORONERS COURT Court Reference: COR 2018 521

OF VICTORIA AT MELBOURNE

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 and section 52(3A) of the Coroners Act 2008

I, AUDREY JAMIESON, Coroner, having investigated the death of LEON EDWARD

BALSHAW without holding an inquest:

find that the identity of the deceased was LEON EDWARD BALSHAW

born on 26 October 1962

and that the death occurred on 31 January 2018

at St Vincent’s Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065

from: 1 (a) BRONCHOPNEUMONIA IN A MAN WITH A HEALING MYOCARDIAL

INFARCTION

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

following circumstances: Background

1. Leon Edward Balshaw, aged 55 at the time of his death, lived at 118 Dalmahoy Street, Bairnsdale, Victoria with his partner, Mellisa Mobourne. He had three daughters from

former relationships with whom he had sporadic contact.

2. Mr Balshaw’s medical history included asthma, depression, alcohol dependence, cervical spondylosis, airway disease, gout and evidence of peripheral vascular disease

causing intermittent claudication. He smoked 25 cigarettes per day.

The coronial investigation

3. Mr Balshaw’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (Vic) (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury or, of

a person who, immediately before death was a person placed in custody or care.

4. 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.

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

criminal or civil liability.

6. 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.

Ws Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation into Mr Balshaw’s death. The Coroner’s Investigator investigated the

matter on my behalf and submitted a coronial brief of evidence.

! 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.

For the sake of completeness, the matter was reviewed by the Health and Medical

Team (HMIT) of the Coroners Prevention Unit (CPU).?

After considering all the material obtained during the coronial investigation, I 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.

Identity of the deceased

On 12 February 2018, Mr Balshaw was visually identified by his brother, Garry Balshaw.

Identity is not in dispute and requires no further investigation.

Medical cause of death

On 2 February 2018, Dr Gregory Young, Forensic Pathologist at the Victorian Institute of Forensic Medicine (the VIFM) conducted an autopsy upon the body of

Mr Balshaw and reviewed a post mortem computed tomography (CT) scan.

Toxicological analysis of post mortem specimens taken from Mr Balshaw was non-

contributory for any alcohol or any other common drugs or poisons.

The autopsy revealed:

“Well established bilateral bronchopneumonia with positive microbiology for Escherichia coli and Klebsiella oxytoca. Healing myocardial infarction and foci of acute infarction with associated severe triple vessel stenosis (75-95%) ischaemic colitis; liver

contusion with moderate steatosis; mild nephrosclerosis of the kidneys; reactive changes

2 The role of the CPU is to assist coroners investigating deaths, particularly deaths that occur in healthcare

settings.

Sepecrtiong My in the hilar lymph node with a single non-caseating granuloma, abrasions with bruising and intramuscular haemorrhage involving the right chest wall, acute fractures in the

right 5" and 6" ribs.

Pneumonia is infection of the lung parenchyma with microorganisms causing inflammation and difficulty breathing. The deceased did have a history of asthma, some degree of heart failure due to the myocardial infarction, alcoholism and was a smoker, which are risk factors for the development of pneumonia. Coronary artery disease is caused by narrowing of the blood vessels that supply the heart with blood and oxygen.

This usually occurs by accumulation of cholesterol within the walls of these vessels. As a result, the heart does not receive the required oxygen and nutrients which can lead to myocardial infarction and/or a fatal arrhythmia. The risk factors for developing coronary artery disease include, age above 50, hypertension, diabetes, high blood cholesterol, smoking, obesity and a family history. The deceased had several risk factors including

hypertension and smoking.

The histological changes seen in the heart are several weeks old with focal areas of acute infarction with minimal acute inflammation. These acute changes may have occurred around the time of his death. Patients with difficulty breathing (due to underlying lung disease) are at increased risk of developing pneumonia that increases the risk of developing a cardiac arrhythmia which in the presence of pre-existing cardiac disease

and lung disease will cause sudden death”.

Dr Young commented further that there was no post-mortem evidence of any injuries which may have caused of contributed to death and the injuries to the right chest are in keeping with resuscitation and unlikely to have contributed to the development of pneumonia. He concluded that “ am of the opinion that this death was due to natural

causes’.

After reviewing the CT scan and toxicology results, Dr Young completed a report,

dated 13 August 2018, in which he formulated the cause of death as

“1 (a) Bronchopneumonia in a man with healing myocardial infarction”.

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

y CE Fic SE BOR Tages

Circumstances in which the death occurred

On 25 January 2018, at approximately 7:00am Mr Balshaw was arrested by police following a siege type situation at his home in Bairnsdale. He had been drinking alcohol with his domestic partner, Mellisa Mobourne and her niece, Stephanie Duggan when a dispute arose, and Mr Balshaw grabbed Ms Mobourne around the throat. Police were called and when they arrived, Mr Balshaw barricaded himself in the house but eventually surrendered to the Critical Incident Response Team. He was noted to have a self-inflicted injury on his left forearm and to be intoxicated (BAC 0.19%). He was taken to the Emergency Department of Bairnsdale Regional Heath

Service (BRHS) for assessment.

According to the records from BRHS for that attendance, at the conclusion of the assessment Mr Balshaw was assessed as medically stable, and suitable for discharge into police custody (“bloods unremarkable, baseline obs unremarkable”). | note that an electrocardiogram (ECG) was performed and the results were abnormal, showing

an “anteroseptal infarct, old. Nonspecific T abnormalities, inferior leads”.

Mr Balshaw was taken to Bairnsdale Police Station arriving at 2:54pm and was

observed in his cell at regular recorded intervals.

On 27 January 2018 at 1:30am, Mr Balshaw requested medication from his property.

He was known to suffer from asthma, depression, alcohol dependence, cervical spondylosis, airways disease, gout and evidence of peripheral vascular disease causing intermittent claudication. He was also a smoker. His medications included Symbicort, Pantoprazole, MS Contin (for back pain related to multi-level nerve root

and disc disease), Avanza, Lyrica and Endep.

At 5:40pm, Mr Balshaw was seen at Bairnsdale Police Station by Dr Mina Tadrous, a general practitioner. Dr Tadrous noted that Mr Balshaw appeared to be alert and not in any distress. His main concern was access to his medications. He gave a history of

having had diarrhoea for one or two days. On examination, he was afebrile, blood

pressure 150/90 and pulse rate 80. He had dual heart sounds with no added sounds.

On chest examination, there was good air entry, very faint expiratory wheezes on both

sides. There was good chest expansion and no evidence of acute asthma.

On abdominal examination, the abdomen was soft with no organomegaly and intact intestinal sounds. Dr Tadrous changed the dressing on Mr Balshaw’s forearm, noting no signs of infection. She accessed and reviewed a CT cervical spine performed in

2013 which confirmed his multi-level nerve root and disc disease.

Dr Tadrous prepared an interim Webster pack with sufficient medications to last until Sunday night, noting that she substituted Pandeine Forte for MS Contin which was unavailable at the police station, with a view to police attending the pharmacy on Monday. Dr Tadrous considered that the diarrhoea was viral in origin and she

recommended that Mr Balshaw avoid dairy products and drink plenty of fluid.

On the morning of 29 January 2018, Mr Balshaw was conveyed to Bairnsdale Magistrates Court and was remanded in custody to 31 January 2018. He was returned to the Bairnsdale Police Station at approximately 10:30am. At approximately 11:00am he complained to custody staff that he had coughed up yellow mucous which was blood stained. He was advised to report if this occurred again. It was noted that he

normally smoked 25 cigarettes/day and had not smoked since 25 January 2018.

At approximately 1:27pm Mr Balshaw was seen on CCTV footage to be sitting at a table in the common area of the cells. He appeared to be short of breath and started coughing before falling onto the floor. Police attended to investigate and found Mr Balshaw unconscious, breathing irregularly and making a gurgling sound.

Resuscitation was commenced. An ambulance was called and Mr Balshaw was intubated and transferred to BRHS arriving at 2:52pm. An ECG revealed a left bundle

branch block and possible acute myocardial infarction.

Mr Balshaw was transferred to St Vincent’s Hospital by air ambulance, arriving at

approximately 5:35pm. A coronary angiogram performed on 29 January 2018

29,

revealed chronic artery disease without clearly occluded arteries with the conclusion that arrythmia was due to previous scarring of cardiac muscle rather than an acute

ischaemic event.

Mr Balshaw, who was nursed in the Intensive Care Unit, subsequently developed cardiogenic shock. His condition continued to deteriorate, leading to cessation of active management in the setting of irreversible organ failure. Mr Balshaw died on

31 January 2018.

The HMIT identified no areas of concern and concluded that the medical treatment

provide to Mr Balshaw was at all stages appropriate and timely.

Findings

Section 52 of the Act mandates the holding of an inquest if the deceased was, immediately before death, a person paced in custody. However, an inquest is not mandatory where the

person is deemed to have died from natural causes, pursuant to section 52(3A).

Having investigated the death, I accept and adopt the medical cause of death as identified by Dr Gregory Young and find that Mr Balshaw died on 31 January 2018 at St Vincent’s Hospital, Fitzroy from natural causes, being bronchopneumonia in the setting of a healing

myocardial infarction.

On the evidence available to me, I find that the provision of care to Mr Balshaw while he was in custody was appropriate. I further find that there was no causal connection between the

fact that Mr Balshaw was a person placed in custody and his death

Pursuant to section 73(1) of the Coroners Act 2008, I direct that this finding be published on

the internet.

I direct that a copy of the finding be provided to the following: Ms Crystal Balshaw, Senior Next of Kin

Ms Leah Balshaw, Senior Next of Kin

Ms Melanie Kyezor, St Vincent’s Hospital

Ms Juliette Wenn, Bairnsdale Regional Health Service; and

Detective Sergeant Ian Marr, Coroner’s Investigator, Victoria Police

Signature:

AUDREY JAMIESON

Coro: _ Date: T AUBEST2O19 :