Deceased
Geoffrey Alan Locks
Demographics
50y, male
Coroner
Deputy State Coroner Caitlin English
Date of death
2019-01-04
Finding date
2021-12-21
Cause of death
Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (treated)
AI-generated summary
A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleeding occurred at 21:49 on 3 January, he texted his wife rather than activating his alarm immediately. The alarm was activated at 00:54 on 4 January. MePACS staff attempted voice contact but Mr Locks could not respond verbally. Critical issue: MePACS did not have documented communication preferences despite knowing he was non-verbal. Staff asked open-ended questions futilely before contacting his wife and then requesting ambulance at 01:05. Paramedics arrived 1:13 but faced access delays due to a concurrent police incident. Though no delay occurred once ambulance was appropriately requested, earlier activation or streamlined non-verbal protocols might have expedited response. Hospital discharge care was appropriate; death was likely not preventable despite earlier ambulance arrival.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT Court Reference: COR 2019 0056
OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Caitlin English, Deputy State Coroner Deceased: Geoffrey Alan Locks Date of birth: 26 January 1968 Date of death: 4 January 2019 Cause of death: 1(a) Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (treated) Place of death: St Vincent’s Hospital, 41 Victoria Parade, Fitzroy, Victoria
Mr Locks’ death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent, or result from accident or injury.
The role of a 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 purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.
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.
As part of my investigation, I obtained statements from MePACS (Peninsula Health).
Mr Locks’ wife, Roslyn Atkinson, also assisted my investigation by submitting her concerns in writing.
2 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.
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased
Medical cause of death
Forensic Pathologist, Dr Gregory Young, from the Victorian Institute of Forensic Medicine (VIFM), conducted an examination on 8 January 2019 and provided a written report of his findings dated 15 February 2019.
The post-mortem examination revealed a defect in a small calibre artery in the left side of the tracheostomy site, likely a thyroid branch of the left carotid artery.
Dr Young provided an opinion that the medical cause of death was “1(a) Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (treated)”.
Circumstances in which the death occurred Mr Locks’ medical history
A repeat positron emission tomography6 in May 2018 suggested low volume recurrent disease; a biopsy in June 2018 was suspicious of recurrent SCC.7 Lengthy discussions 3 The TNM system is the most widely used cancer staging system. T: Size and extent of the tumour. N: The number of lymph nodes which have cancer. M: Whether the cancer has metastasised.
4 Squamous cell carcinoma (SCC) develops when the flat cells in the top layer of skin (called squamous cells) grow and divide in an uncontrolled way.
5 Voice box.
6 PET stands for positron emission tomography. The machine detects pairs of gamma rays which are emitted indirectly by a tracer (positron-emitting radionuclide) which is placed in the body on a biologically active molecule. The images are reconstructed by computer analysis. The activity of an injected radionuclide labelled glucose analogue, Fluorine-18deoxyglucose (FDG), as a means to discriminate benign from malignant tissues accurately.
7 The multidisciplinary notes from the team meeting dated 15 November 2018, indicates Mr Locks multiple failures to attend in May 2018, June 2018.
occurred regarding the suitability for total laryngectomy8 given Mr Locks’ social and mental health issues.
Mr Locks’ medical history also included an aortic valve repair (AVR)9 at age seven years, redo sternotomy, tissue AVR on 10 October 2018, acquired brain injury10 following a motor vehicle accident,11 Attention Deficit Hyperactivity Disorder,12 schizophrenia, type two diabetic mellitus, treated hepatitis C, and he was hepatitis B positive.
Mr Locks lived by himself, smoked cigarettes and cannabis daily, had a had a body mass index (BMI) of 30 kg/m²,13 and was stable on the methadone program.14
Mr Locks subsequently underwent a salvage laryngectomy and left two to three node dissection and left hemithyroidectomy and free flap on 31 October 2018. The surgery was successful and uneventful. Post-operatively Mr Locks received assistance from multiple health services including speech pathology, dietician, physiotherapy, occupational therapy, pastoral care with ongoing medical and nursing review and care.
On 12 November 2018, speech pathology reviewed Mr Locks and documented that he was using iPad with a ‘speak it’ text to speech app to communicate, particularly over the phone with his mother. He was not interested in using servox with oral adaptor, which is a speech aid for patients post laryngectomy. In her correspondence, Ms Atkinson stated that Mr Locks was not confident using the app to communicate as he was “technologically challenged” and preferred to physically write his messages or text using his mobile phone.
On 23 November 2018, hospital liaison staff spoke with Mr Locks about transferring to ‘The Cottage’15 prior to going home. Mr Locks felt that he was independent enough with stoma care and level of support at home that a stay at The Cottage was unnecessary but agreed that he needed to wait for the alarm to be installed before returning home.
8 The removal of the larynx and separation of the airway from the mouth, nose, and oesophagus.
9 The valve between the aorta (the large blood vessel that carries oxygen-rich blood away from the heart to the rest of the body and left ventricle).
10 Following the ABI, Mr Locks experienced paranoid ideation, auditory hallucinations, significant mood instability (attempted suicide 11 times impulsively, including attempted hanging).
11 The Speech Pathology outpatient appointment from 13 September 2018 stated, “severe difficulties with learning and memory deficits and executive function are concerns”.
12 ADHD is a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.
13 BMI is an index of weight-for-height that is commonly used to classify underweight, overweight and obese adults. A BMI of 30 to 34.99 kg/m² is Grade I obesity.
14 Treatment for chronic pain in right femur from the motor vehicle accident.
15 Mr Locks was known to the cottage staff as he had attended The Cottage after his AVR in October 2018.
On 27 November 2018, Mr Locks wanted to be discharged home and was reluctantly transferred to The Cottage.
A MePACS alarm and key safe was organised and installed on 27 November 2018. MePACS is a 24/7 personal alarm service designed for individuals with chronic conditions, the elderly, or those recovering from surgery. The individual pushes the button on the base unit or their pendant and receives a call within two minutes (using a voice-voice contact through the alarm base unit). Using the voice-to-voice mode, MePACS staff can broadcast their voice into the patient’s house through the alarm base unit. If the client is verbal and conscious, they can speak back to the unit, which contains a microphone. If there is no answer from the client, MePACS staff will telephone the client and then determine the action required. MePACS clients are also required to nominate at least one emergency contact. Ms Atkinson was Mr Locks’s nominated contact. MePACS has advised that of their 39 500 clients, 39 are non verbal.
On 28 November 2018, Mr Locks self-discharged himself. The Cottage organised a general practitioner appointment with Dr Dean Membrey to organise his methadone and nebuliser.
There was confirmation with his case manager that MePACS was installed, and allied health services were notified of Mr Locks’s self-discharge.
Events from 28 November 2018 to 3 January 2019
Dr Membrey reviewed Mr Locks on 28 November 2018. He noted that Mr Locks was “fairly independent with stoma care” and “has organised a MePACS alarm”. Dr Membrey last reviewed Mr Locks on 19 December 2018 at which time he noted slight erythema around the stoma site.16 Mr Locks otherwise appeared well.
Mr Locks was scheduled to receive twice-weekly visits from registered nurses from St Vincent’s Hospital in the Home (HITH) service during December 2018 for supervision and education with stoma care. The nurses utilised his key safe, which contained a fob, to gain access to the building.17 At times, Mr Locks was not present, despite a text message sent prior to staff attending.
16 Dr Membrey has documented the “slight redness from 3-7 o’clock around stoma”. The autopsy findings note “haemorrhage from left upper part of tracheostomy site; defect in small calibre artery”.
17 Mr Locks resided in apartment 307. Key fobs are used with access control systems programmed to manage entry through an automatically locked door or facility.
On 30 December 2018, the HITH nursing entry noted a visit could not be conducted the following day due to staff shortages and that Mr Locks had not been home during their visits since 6 December. This information was conveyed to Mr Locks.
On 3 January 2019, HITH arranged with Mr Locks to visit him at 2.30pm, however he was not at home when they arrived. He thereafter did not respond to their text messages.
Events during 3 and 4 January 2019
During the evening of 3 January 2019, Mr Locks was at home and text messaging his wife, Ms Atkinson, who lived separately from her husband. In her correspondence with the Court, Ms Atkinson stated that Mr Locks began sending her texts and images of himself bleeding out from 9.49pm. She provided me a copy of these images, which are quite graphic and clearly show Mr Locks bleeding heavily. It is unclear why he did not activate his MePACS alarm at that time.
Ms Atkinson noted that Mr Locks appeared to be in out and of consciousness as she was not receiving timely responses to her text messages. She noted that this may explain why he was delayed in activating his MePACS alarm. It appears from the content of text messages that Ms Atkinson did not know Mr Locks’ address in order to call for an ambulance. He finally provided her with his address at 12.46am and said he would activate his alarm.
The MePACS records indicated the following contacts were made with Mr Locks on the morning of 4 January 2019: 12:54:19am Mr Locks activated an emergency alert on his MePACS alarm system 12:54:46am MePACS staff unsuccessfully attempted to call Mr Locks via the voice-tovoice mode. He was pressing his alarm multiple times, which meant voice-tovoice contact could not connect 12:55:05am MePACS staff unsuccessfully attempted to call Mr Locks via the voice-tovoice mode 12:55:20am Mr Locks answered a voice-to-voice mode call from MePACs but was unable to speak. Staff noted that they would try to text him and if there was no response, they would organise someone to check on him 12:56:09am Staff contacted Mr Locks on his mobile
1:02:32am MePACS telephoned Ms Atkinson who advised that Mr Locks had been bleeding since 9.30pm and he was sending her photos of this. After Ms Atkinson advised she was unable to attend Mr Locks’s apartment, staff requested Ambulance Victoria attend 1:05:19am MePACS contacted Ambulance Victoria and provided details of the location of the key safe containing the fob and the code required to access it 1:11:44am Staff advised Mr Locks that an ambulance was on its way
The Ambulance Victoria records from 4 January 2019 indicate they received a call to attend Mr Locks’s home at 1.06am and were at the scene by 1.13am. On arrival, there were delays in attending Mr Locks as the paramedics were unable to gain access to level three of the building because the fob did not work. Whilst communicating with dispatch about how to gain access, the paramedics were then informed of a second case in progress at the same building involving an assault. Shortly after, Victoria Police members arrived and advised the paramedics not to access level three as location of the offender was unknown.
The police members subsequently obtained the fob and threw it out of the window to the paramedics, allowing access to Mr Locks’ apartment.
The paramedics reached Mr Locks at 1.31am. The door to Mr Locks’ apartment was unlocked, and paramedics noted blood on the front door. They heard stertorous respirations from the rear of the apartment. Furniture was blocking access, making it difficult to attend Mr Locks.
Upon attending Mr Locks, the paramedics noted that he was covered in blood, which appeared to be coming from tracheostomy stoma. He was breathing and making eye contact and moving all four limbs and rocking back and forwards. He was extricated immediately without assessment.
Mr Locks was extracted from the apartment by wheelchair and then placed onto stretcher and into the ambulance at 1.38am. Mr Locks was ventilated via his stoma site initially, but when chest rise and fall or end tidal carbon dioxide trace18 was lost Mr Locks was intubated via the stoma site with a size six endotracheal tube.19 18 Waveform capnography represents the amount of carbon dioxide (CO2) in exhaled air, which assesses ventilation. It consists of a number and a graph. The number is capnometry, which is the partial pressure of CO2 detected at the end of exhalation. This is end-tidal CO2 (ETCO2) which is normally 35-45 mm Hg.
19 This occurred between 1.36am and 1.39am.
(a) that Mr Locks was not fit for discharge from hospital given he had told her he was bleeding from his stoma, he had a brain injury, and had no means of communication;
(b) that MePACS did not immediately dispatch an ambulance upon receiving the initial alert from Mr Locks;
(c) Mr Locks was non-verbal and could not respond to calls from MePACS; and
(d) whether Mr Locks’ death was preventable if an ambulance had arrived sooner.
In light of these concerns and in order to assist my investigation, I obtained statements from Sheryl Nelson, Operations Manager at MePACS, and advice from the Court’s Health and Medical Investigation Team (HMIT) who reviewed Mr Locks’s medical records and the statements from Ms Nelson.
The HMIT is staffed by healthcare professionals, including practising physicians and nurses.
Importantly, these healthcare professionals are independent of the health professionals and institutions under consideration. They draw on their medical, nursing, and research experience 20 High potassium level.
21 A commonly identified endpoint in medical assessment to signify hypoxic (inadequate oxygen) brain injury. Fixed and dilated pupils are a poor neurological sign suggestive of a severe insult to the brain.
22 Lactate is indicative of tissue hypoxia, hypoperfusion, and possible damage. Lactic acidosis is characterized by lactate levels >5 mmol/L and serum pH <7.35.
23 An arterial blood gas, (specific blood test) measures PH, partial pressure of carbon dioxide and lactate.
24 pH is a logarithmic measure of hydrogen iron concentration, that is, the acidity or alkalinity of a solution. The normal pH range in human blood is 7.35-7.45.
25 Outlined in her email of 18 March 2019 and her letter of 30 January 2021.
to evaluate the clinical management and care provided in particular cases by reviewing the medical records, and any particular concerns which have been raised.
Whether Mr Locks was fit for discharge from hospital
Mr Locks self-discharged himself from The Cottage at St Vincent’s Hospital on 28 November 2018, after an uneventful laryngectomy 28 days prior. Mr Locks had care from multiple allied health services and on discharge was self-caring with his stoma.
On self-discharge, The Cottage ensured that Mr Locks had an appointment with his general practitioner, informed allied health services and his case manager, and HITH was organised.
Post self-discharge, Mr Locks was absent when HITH attended despite organised scheduled days and times having been discussed.
Whether there was a delay in MePACS requesting an ambulance
Whether MePACS’s policy and procedures were followed
Ms Nelson provided me with a copy of the MePACS Policy and Procedure: Handling Medical Emergency Events in place at the time of Mr Locks’s death (dated July 2018). Ms Nelson noted the MePACS policy and procedure was followed and there was no delay in requesting an ambulance attend Mr Locks.
Ms Nelson explained that when a client activates their pendant, it is categorised as a ‘medical emergency’, which triggers the application of the above policy, which expressly states:
Not all requests for assistance will require an Ambulance. It may be appropriate to call the client’s nominated contact or Personal Alert Victoria response agency in circumstances that you have determined do not require emergency assistance.
The policy requires that once a client has activated their alarm, MePACS must use the voiceto-voice mode to attempt to make contact. If the client does not respond, staff must attempt to contact the client via telephone. Ms Nelson explained that Mr Locks activated his pendant at 12.54am, and staff attempted to use the voice-to-voice contact mode on two occasions but were unable to get through because Mr Locks was pressing his pendant at the same time, which blocked their call. Voice-to-voice mode was activated seconds later, but Mr Locks did not respond, and a staff member then called him on his mobile.
Once the client answers, MePACS staff will then attempt to determine the nature of the emergency. If the client is unable to speak, an attempt to make contact in other ways such as the client making a noise by hitting a floor or wall. Staff will determine the type of assistance required and inform the client of the actions they will take. Ms Nelson noted that when Mr Locks did not verbally (or otherwise) respond during the call to his mobile at 12:56am, staff informed him that they would organise someone to check on him. They also sent him a text message at this time.
If a staff member indicates that they will arrange for a nominated contact to check on a client, the staff member is then required to call the nominated contact. This occurred in Mr Locks’ case and Ms Atkinson was contacted at 1:02am. Once the staff member had spoken to Ms Atkinson, a decision was made to call for an ambulance. MePACS then called for an ambulance at 1:05am.
Ms Nelson confirmed that MePACS staff had acted in accordance with the policy.
(a) the identity of the deceased was Geoffrey Alan Locks, born 26 January 1968;
(b) the death occurred on 4 January 2019 at St Vincent’s Hospital, 41 Victoria Parade, Fitzroy, Victoria, from tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (treated); and
(c) the death occurred in the circumstances described above.
COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death:
I am satisfied that when it was determined an ambulance was necessary, there was no delay in MePACS requesting an ambulance. There was a delay with the circumstances surrounding the building at the time of the paramedics’ attendance, however this was unavoidable.
I note that MePACS does not have a specific policy for non-verbal clients. Ms Nelson noted that some non-verbal clients will specify their preference about how to communicate with MePACS staff. For example, some clients use a speech-output device or are assisted by a service animal. These instructions are to be documented on a client’s file.
Despite Mr Locks indicating he was non-verbal in his application for the MePACS alarm, Mr Locks’ file did not contain any such instructions.
Ms Nelson provided me with a recording of a previous call made to Mr Locks on 29 November 2018 after he activated his MePACS alarm. Despite Mr Locks’s non-verbal status being known, the MePACS staff member asked Mr Locks open-ended questions such as, “Are you ok?” and “Do you need help?”. Mr Locks can be heard breathing, but he does not otherwise respond. After no response from Mr Locks, the staff member indicated they would contact Mr Locks on his mobile. This same sequence of events is repeated in the recording of 4 January 2019.
To my mind, the futility of this line of questioning and the step taken to contact Mr Locks on his mobile when he clearly had no way of responding could have been bypassed or streamlined in two ways:
(a) Mr Locks’s preference for communication with MePACS in the event of an emergency had been discussed, agreed upon, and noted in his file. For example, if it was agreed that Mr Locks would communicate by banging on the wall or floor, a MePACS staff member could have asked him to do this if he required an ambulance; and
(b) Mr Locks’s preference for steps to be taken in an emergency had been discussed, agreed upon, and noted in his file. For example, if Mr Locks had a preference that Ms Atkinson be contacted first or entirely bypassed.
communication and for MePACS to plan their response to him in the event of a medical emergency. Had this information been recorded, the request for ambulance attendance may have occurred earlier. However, I am not satisfied that Mr Locks’ death would have been prevented had an ambulance arrived earlier.
RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendations:
I convey my sincere condolences to Mr Locks’ family for their loss.
Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.
I direct that a copy of this finding be provided to the following: Roslyn Atkinson, senior next of kin St Vincent’s Health Peninsula Health (MePACS) (care of HWL Ebsworth) Senior Constable Joel Butler, Victoria Police, reporting member Signature: ___________________________________ Caitlin English, Deputy State Coroner Date: 21 December 2021 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
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