Finding into death of Robert Conkie Gray

IN THE CORONERS COURT Court Reference: COR 2018 2596

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

Simon McGregor, Coroner

Robert Conkie Gray

22 September 1942

2 June 2018

Ischaemic Heart Disease and Cardiomegaly

Latrobe Regional Hospital 10 Village Avenue, Traralgon West, Victoria

TABLE OF CONTENTS

Purpose of a coronial investigation..

INTRODUCTION

1. Robert Conkie Gray was a 75-year-old man who lived in Paynesville at the time of his death.

2. Mr Gray had mounting psychiatric disabilities, and on 25 May 2018, he had been transferred, after a series of physical assaults on residents and staff, from his usual residence at Opal Paynesville to the Emergency Department of the Latrobe Regional Hospital on an inpatient assessment order. Mr Gray was subsequently placed on an Inpatient Temporary Treatment Order and admitted to the Macalister Ward, an acute psychiatric ward for older patients, on

26 May 2018.

3. On 2 June 2018, as part of the regular rounds, Mr Gray’s nurse found him not breathing and

unresponsive. Resuscitation was not successful.

PURPOSE OF A CORONIAL INVESTIGATION

4. Mr Gray was ‘a person placed in custody or care’ for the purposes of the Coroners Act 2008 as his Inpatient Temporary Treatment Order made him a person under the control, care or custody of the Secretary to the Department of Health and Human Services. His death was

therefore a ‘reportable death’ under the Act and was reported to the coroner.

5. | Therole ofa 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 purposc of a coronial investigation is to establish the facts, not to 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.”

7. The Coroner’s Investigator, Senior Constable Bradley Gallagher of Victoria Police, prepared a coronial brief in this matter. The brief includes statements from witnesses including Opal and Latrobe staff, the forensic pathologist who examined Mr Gray, treating clinicians and the

investigating officers.

8. 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. 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.

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

jurisdiction facts must be established on the balance of probabilities.!

BACKGROUND CIRCUMSTANCES

Mr Gray had a medical history of a surgically treated brain aneurysm in 2015, vascular dementia, an acute brain injury, ventricular tachycardia cardiac arrest in 2017, chronic obstructive pulmonary disease, ischaemic heart disease, type two diabetes. mellitus,

dyslipidaemia, hypertension, asthma, left total hip replacement and delirium?

Mr Gray was admitted to residential aged care facility Opal Paynesville in April 2017. During his admission his mental health deteriorated, and he exhibited aggressive behaviours. In the months before his death, Mr Gray became unmanageably aggressive and assaulted eight residents and two staff. In response to Mr Gray’s physical and verbal behaviours, Opal Paynesville arranged for Mr Gray to be referred to and assessed by the Aged Persons Community Mental Health Services (APCMHS) on 9 April 2018. Mr Gray was the focus of the Opal Paynesville Peer Enablement Program in which his specific behaviours were discussed along with his past life and medical history and strategies were developed to

complement the Lifestyle Teams initiatives.? Circumstances in which the death occurred

On 25 May 2018, Mr Gray was observed to assault another resident and subsequently threaten and assault staff who attempted to intervene. Due to Mr Gray’s escalating behaviours, Opal Paynesville contacted Bairnsdale Police and emergency services to arrange for Mr Gray be transferred to Latrobe Regional Hospital’s Emergency Department by ambulance on an Inpatient Assessment Order. Opal Paynesville provided paramedics and hospital staff with

comprehensive background information on Mr Gray prior to the transfer.*

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 cvidence provides a comfortable level of satisfaction as to those matters taking into account the conscquences of such findings or comments.

ba

Statements of Janice Ford dated 4 December 2018, Dr Yan Huang dated 28 November 2018 and Dr Brij Kishore

dated 31 October 2018, Coronial Brief.

3 Statement of Janice Ford dated 4 December 2018, Coronial Brief.

4 Statement of Janice Ford dated 4 December 2018, Coronial Brief.

On 26 May 2018, Mr Gray was reviewed by duty psychiatrist Dr Vijay Pajapati in the Emergency Department at Latrobe Regional Hospital. Mr Gray was placed on an Inpatient Temporary Treatment Order (ITTO) and admitted to the Macalister Ward for further management. Dr Pajapati advised nursing staff to monitor Mr Gray’s mental state’ and behaviours and minimise the use of PRN (as needed) medications to reduce the risk of over-

sedation.*

At approximately 2.30pm on 2 June 2018, nursing staff conducted a bedside handover with the afternoon shift. According to nurse Nirmala Ronnie, Mr Gray ‘responded and did not express any concerns’. Ms Ronnie checked on Mr Gray again at approximately 3.20pm. He was in bed in a supine position and told Ms Ronnie that he was ok. Ms Ronnie reported that

Mr Gray ‘appeared settled, comfortable and I did not observe any clinical changes with him’ §

At approximately 3.34pm, Associate Nurse Unit Manager Anthony Wenzel checked on Mr Gray. Mr Wenzel found that Mr Gray was not breathing and was unresponsive.

Cardiopulmonary resuscitation was commenced but Mr Gray was unable to be revived. Mr

Gray was pronounced deceased at 4.00pm.”

IDENTITY AND CAUSE OF DEATH

On 3 June 2018, Mr Gray’s daughter, Andrea Ray-Barker, visually identified the body of Robert Conkie Gray, born 22 September 1942. Identity is not in dispute and requires no further

investigation.

Dr Heinrich Bouwer, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an autopsy examination of Mr Gray’ body and reviewed a post mortem computed tomography (CT) scan, E-medical deposition form and clinical records from Paynesville Medical Centre and Latrobe Regional Hospital. Dr Bouwer completed a report, dated 14 August 2018, in which he formulated the cause of death as ‘I(a) Ischaemic Heart

Disease and Cardiomegaly’.

Toxicological analysis identified the presence of olanzapine, haloperidol and mirtazapine at

therapeutic levels,

Statement of Dr Brij Kishore dated 31 October 2018, Coronial Brief.

§ Statement of Nirmala Ronnie dated 25 October 2018, Coronial Brief.

7 Statement of Anthony Wenzel dated 5 December 2018, Coronial Brief.

Dr Bouwer noted that autopsy revealed significant natural disease affecting the cardiovascular system. He noted there was significant cardiac enlargement with triple vessel coronary artery atherosclerosis and thrombosis of the right coronary artery. There was also evidence of remote

myocardial infarct in the posterior wall of the left ventricle.

Dr Bouwer concluded:

‘On the basis of the information available to me at this time, I am of the opinion that this death

is due to natural causes’.

T accept Dr Bouwer’s opinion as to the medical cause of death.

FINDINGS AND CONCLUSION

24,

As Mr Gray was ‘a person placed in custody or care’, section 52 of the Act requires that I hold an inquest into Mr Gray’s death unless I consider his death was due to natural causes. Based on Dr Bouwer’s opinion expressed in his report, I consider that Mr Gray’s death was due to

natural causes. This means that an inquest is not mandatory.*

Having investigated the death, without holding an inquest, I make the following findings pursuant to section 67(1) of the Act:

(a) The identity of the deceased was Robert Conkie Gray, born 12 September 1942;

(b) The death occurred on 2 June 2018 at the Latrobe Regional Hospital in Traralgon West

from ischaemic heart disease and cardiomegaly; and

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

Pursuant to section 73(1B) of the Act, | direct that this finding be published on the Internet.

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

(a) Mrs Wilma Gray, senior next of kin.

(b) Dr Simon Fraser, Chief Medical Officer, Latrobe Regional Hospital.

(c) Ms Cayte Hoppner, Director of Mental Health, Latrobe Regional Hospital

® Section 52(3A) of the Act.

(d) Dr Neil Coventry, Office of the Chief Psychiatrist.

(e) Senior Constable Bradley Gallagher, Victoria Police, Coroner’s Investigator.

Signature:

ae

/ SIMON’ McGREGOR

CORONER Date: 27 March 2019