Finding into death of Karen Frazer

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2018 5070

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Jacqui Hawkins Deceased: Karen Frazer Date of birth: 30 January 1962 Date of death: 8 October 2018 Cause of death: I(a) Cardiomegaly Place of death: 5 Chifley Drive, Dandenong North, Victoria, 3175 1 of 4

BACKGROUND

1. Karen Frazer was 56 years old at the time of her death. She lived in Dandenong North, in a group home managed by the Department of Health and Human Services (DHHS). Ms Frazer had lived in supported accommodation managed by DHHS for at least 15 years before her death and they were unable to locate any known family.

2. Ms Frazer’s medical history included high functioning intellectual disability, anxiety disorder, schizophrenia, hypertension, and chronic obstructive pulmonary disease, and she was a smoker. She also had suspected breast cancer, but was resistant to further investigations and treatment. She was prescribed multiple medications to manage these conditions.

3. Ms Frazer’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008.

4. The role of a coroner is to independently investigate reportable deaths to establish, 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. The law is clear that coroners establish facts; they do not lay blame or determine criminal or civil liability.1

5. In writing this Finding, I do not purport to summarise all the evidence but refer to it only in such detail as appears warranted by its forensic significance and the interests of narrative clarity.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased

6. Karen Frazer was visually identified by her carer, Donna Chapman, on 8 October 2018.

Identity was not in issue and required no further investigation.

Medical cause of death

7. On 15 October 2018, Dr Gregory Young, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an autopsy on the body of Ms Frazer and reviewed the Form 83 1 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.

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Victoria Police Report of Death, medical records from Langton Medical Centre, notes from Ambulance Victoria and the post mortem computed tomography (CT) scan.

8. Toxicological analysis of post mortem blood detected the presence of carbamazepine,2 paroxetine,3 olanzapine,4 chlorpromazine,5 diazepam and its metabolite nordiazepam.6

9. Autopsy showed an enlarged heart with biventricular hypertrophy, myocyte hypertrophy, myocardial fibrosis, and mild coronary artery atherosclerosis. The lungs showed acute and chronic bronchitis with patchy bronchopneumonia and an incidental old pulmonary thromboembolism and infarct. A benign intraduct papilloma was seen in the right breast.

10. Dr Young explained that cardiomegaly is the enlargement of the heart not in keeping with normal physiological change in the individual. Increased heart mass is correlated with increased cardiac mortality and morbidity, and is an independent risk factor for sudden death due to a cardia arrythmia (‘heart attack’). Cardiomegaly is commonly associated with hypertension.

11. Rib fractures were seen, consistent with cardiopulmonary resuscitation (CPR). However, there was no post mortem evidence of any other injuries which may have caused of contributed to Ms Frazer’s death.

12. Dr Young commented that on the information available to him, Ms Frazer’s death was due to natural causes.

13. Dr Young provided an opinion that the medical cause of death was 1(a) Cardiomegaly.

Circumstances in which the death occurred

14. On 8 October 2018, Ms Frazer awoke and ate breakfast as usual. At about 8.45am, she went to the bathroom.

15. At about 9.15am, Donna Chapman went to check on Ms Frazer as she had taken longer than usual. Ms Chapmen found Ms Frazer seated on the toilet, but slumped forward and unresponsive.

2 Carbamazepine is an antiepileptic drug that is clinically indicated for seizures, neuropathic pain, and bipolar disorder.

3 Paroxetine is an antidepressant medication indicated for the treatment of major depression, obsessive compulsive disorder, panic disorder, social phobia, generalised anxiety disorder and post-traumatic stress disorder.

4 Olanzapine is indicated for the treatment of schizophrenia and related psychoses. It can also be used for mood stabilisation and as an anti-manic drug.

5 Chlorpromazine is an antipsychotic and antiemetic.

6 Diazepam is a sedative/hypnotic drug of the benzodiazepines class.

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16. Ms Chapman commenced CPR and emergency services were contacted. Ambulance Victoria paramedics subsequently arrived and continued resuscitation efforts, however Ms Frazer could not be revived and was pronounced deceased at 10.51am.

FINDINGS

17. Having considered the evidence I am satisfied that no further investigation is required.

18. Pursuant to section 67(1) of the Coroners Act 2008, I make the following findings connected with the death:

(a) the identity of the deceased was Karen Frazer born 1 January 1962; and

(b) Ms Frazer died on 8 October 2018 from 1(a) Cardiomegaly; and

(c) in the circumstances described above.

I order pursuant to section 73(1B) of the Coroners Act 2008, that this finding be published o the Coroners Court of Victoria Website.

I direct that a copy of this finding be provided to the following: Department of Health and Human Services; and Senior Constable Rebecca Swan, Coroner’s Investigator, Victoria Police Signature: ___________________________________

JACQUI HAWKINS Coroner Date: 17 April 2020 4 of 4