Deceased
Mariza Beretta
Demographics
52y, female
Coroner
Coroner David Ryan
Date of death
2020-01-27
Finding date
2021-08-11
Cause of death
Presumed SUDEP (Sudden Unexplained Death in Epilepsy)
AI-generated summary
Mariza Beretta, a 52-year-old woman with Trisomy 21 and early-onset Alzheimer's disease, died from presumed SUDEP (Sudden Unexplained Death in Epilepsy) at Royal Melbourne Hospital. She was diagnosed with genetic generalised epilepsy in September 2019 following a witnessed seizure and commenced on sodium valproate in December 2019. She suffered a second seizure in hospital in mid-December while face-down in bed. She was found unresponsive and not breathing at 4:15am on 27 January 2020, with clinical suspicion of an unwitnessed seizure. The coroner found the standard of care provided was reasonable and appropriate, including investigation of her new-onset epilepsy and appropriate antiepileptic treatment. No preventable factors were identified. The case highlights SUDEP risk in newly diagnosed epilepsy and the importance of seizure precautions in vulnerable patients.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
IN THE CORONERS COURT COR 2020 000493 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner David Ryan Deceased: Mariza Beretta Date of birth: 14 April 1967 Date of death: 27 January 2020 Cause of death: 1(a) Presumed SUDEP (Sudden Unexplained Death in Epilepsy) Place of death: Royal Melbourne Hospital, Royal Park Campus, 34-55 Poplar Street, Parkville, Victoria
On 27 January 2020, Mariza Beretta was 52 years old when she died at the Royal Melbourne Hospital. Ms Beretta is survived by her sisters, Rosanna Bergin and Alessandra Munro.
At the time of her death, Ms Beretta resided at Nelson House, a specialist disability accommodation in Coburg managed by Carinya Society. She moved to Nelson House approximately 10 years prior to her death. Ms Beretta was receiving National Disability Insurance Scheme (NDIS) funded and regulated support through Carinya Society. Her disability support services were transferred from the Department of Health and Human Services (DHHS) to the NDIS prior to 2018.
Ms Beretta was diagnosed with Trisomy 21 at birth and in November 2018, a cognitive assessment confirmed a diagnosis of early onset Alzheimer’s Disease for which she was prescribed donepezil. Ms Beretta’s medical history also included severe scoliosis, advanced spinal osteoarthritis, mild aortic stenosis, and mild mitral and tricuspid regurgitation.1
Due to her intellectual disability, Ms Beretta was unable to live independently and was supported by staff at her supported residential accommodation with all aspects of her daily living, including personal care, cooking, cleaning, community visits and appointments.
Ms Beretta participated in the Carinya Day Services Program every weekday from 9.00am to 3.00pm.2
The staff member alerted a colleague, who contacted emergency services. Ambulance Victoria paramedics arrived at approximately 8.30am and Ms Beretta was transferred to the Royal Melbourne Hospital for observation following a suspected seizure. She was later discharged that evening following neurological scans, a chest X-ray, and blood and urine tests.
2 Statement of Paulene Syamanond dated 24 December 2020.
over the weekend and contact emergency services if her condition deteriorated; however, Ms Munro insisted that she be seen by a doctor.
At approximately 3.35pm, Ms Beretta was accompanied to Harding Street Medical Centre to see Dr Taylor. Dr Taylor assured Ms Beretta’s family that her lethargy was “a very normal reaction after having a fit”. Dr Taylor acknowledged Ms Munro’s concern that fits were a listed side effect of her sister’s medication and Dr Taylor subsequently ceased Ms Beretta’s donepezil that day.3
On 29 September 2019, Ms Beretta underwent an electroencephalogram (EEG) at the Royal Melbourne Hospital Neurology Clinic, which indicated genetic generalised epilepsy.
On 25 September 2019, Ms Beretta complained of pain in her foot and back and was placed in a wheelchair. She was reviewed by Dr Taylor, who observed swelling and bruising. Staff were unable to confirm the details surrounding Ms Beretta’s injury.
On 26 October 2019, Ms Beretta was admitted to the Royal Melbourne Hospital where she was found to have a fractured right foot which was placed in a plaster.
On 11 November 2019, Ms Beretta was transferred to the hospital’s Aged Care ward.
On 4 December 2019, Ms Beretta was transferred to the Transitional Care Program (TCP) unit for rehabilitation with a view to discharging her back to Nelson House. Her plaster was removed and a moonboot fitted. According to emergency physician Dr Damien Tharmaratnam, Ms Beretta would weight bear against the advice of her treating doctors, but her pain was managed with intermittent paracetamol and she engaged well with allied health therapy.4
On the morning of 14 December 2019, Ms Beretta suffered a second seizure while in the TCP unit. Staff advised family that they found Ms Beretta face down in bed and that blood on the pillow indicated she had bitten her tongue. Ms Bergin observed that her sister “was not too bad and sparked up” when Ms Bergin gave her something to eat following the seizure. In her statement to police, Ms Bergin recalled that her sister preferred to sleep on her stomach.5 3 Statement of Paulene Syamanond dated 24 December 2020.
4 Statement of Dr Damien Tharmaratnam dated 19 May 2020.
5 Statement of Rosanna Bergin dated 2 May 2020.
Following a discussion with the neurology team, Ms Beretta was commenced on sodium valproate. She had not previously been prescribed antiepileptic medication.
On 25 December 2019, Ms Bergin collected Ms Beretta from the hospital and they returned to Ms Bergin’s family home for Christmas lunch. Throughout the day, Ms Beretta appeared to be “in high spirits, being very happy”. They returned Ms Beretta to the hospital at approximately 4.00pm.6
On 31 December 2019 and 1 January 2020, Ms Beretta’s sisters observed her again to be “in very high spirits”.
On 16 January 2020, Ms Beretta was reviewed by an orthopaedic surgeon. The surgeon advised that Ms Beretta was able to return to Nelson House and walk independently with a well-padded shoe. When Ms Beretta returned to the TCP unit, Ms Bergin was advised that she would remain for further rehabilitation before returning to Nelson House. According to Dr Tharmaratnam, Ms Beretta’s mobility was improving at this time.7
Ms Beretta’s 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.
Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Ms Beretta’s death. The Coroner’s Investigator conducted inquiries on my behalf, including 6 Statement of Rosanna Bergin dated 2 May 2020.
7 Statement of Dr Damien Tharmaratnam dated 19 May 2020.
taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence. Supplementary statements were also provided by Pauline Syamanond, Carinya Society residential supervisor, and Dr Ruth Taylor, Ms Beretta’s treating general practitioner (GP).
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. In the coronial jurisdiction, facts must be established on the balance of probabilities.8
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred
On 24 January 2020, Ms Bergin visited her sister and she again appeared in good spirits.9
Nursing progress notes from the Royal Melbourne Hospital indicate that Ms Beretta was “pleasant with staff” at approximately 8.00pm on 26 January 2020.10
At midnight on 27 January 2020, Ms Beretta was assisted to the toilet. She was last seen well at approximately 2.00am.11
At approximately 4.15am, nursing staff found Ms Beretta face down in bed, unresponsive, not breathing and with no detectable pulse. Nursing staff rolled her onto her back and she did not respond to a sternal rub. According to Dr Tharmaratnam, treating clinicians suspected that Ms Beretta suffered a further unwitnessed seizure as they observed a small amount of blood in her mouth and a pink tinge to her pillow.12
Staff alerted the overnight Hospital Medical Officer (HMO) and Ms Beretta was subsequently pronounced deceased at 4.50am.13 8 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.
9 Statement of Rosanna Bergin dated 2 May 2020.
10 Statement of Dr Damien Tharmaratnam dated 19 May 2020.
11 Statement of Dr Damien Tharmaratnam dated 19 May 2020.
12 Statement of Dr Damien Tharmaratnam dated 19 May 2020.
13 Statement of Dr Damien Tharmaratnam dated 19 May 2020.
Identity of the deceased
Medical cause of death
Forensic Pathologist Dr Brian Beer from the Victorian Institute of Forensic Medicine (VIFM) conducted an examination on 3 February 2020 and provided a written report of his findings dated 3 February 2020. Ms Beretta’s family expressed a strong preference against an autopsy or any invasive procedures being performed.
Dr Beer reviewed a post-mortem computed tomography (CT) scan, which revealed a persistent mid frontal suture with no fracture, mildly dilated cerebral ventricles, scoliosis and right-sided rib fractures.
Dr Beer did not identify any evidence of injury that would have caused or contributed to Ms Beretta’s death.
Toxicological analysis of ante-mortem samples identified the presence of paracetamol14 but did not detect valproic acid (sodium valproate). The Toxicology Report indicated that any detected levels of valproic acid fell below the 10mg/L limit for reporting, but did not indicate that Ms Beretta failed to receive her antiepileptic medications as prescribed.
Dr Beer provided an opinion that the medical cause of death was 1(a) Presumed SUDEP (Sudden Unexplained Death in Epilepsy). He considered that Ms Beretta’s death was due to natural causes.
14 Paracetamol is an analgesic drug available in many proprietary products either by itself or in combination with other drugs such as codeine and propoxyphene.
In essence, the concerns relate to the cause of the rib fractures identified by Dr Beer during his examination; the standard of care Ms Beretta received while in the TCP unit; and that Ms Beretta’s Goals for Care while in the TCP unit identified her as “not for resuscitation”.
Court staff have liaised with the family in relation to their concerns but in my view, the only issue which is sufficiently proximate to Ms Beretta’s cause of death which attracts the jurisdiction of the Court to investigate is the standard of care Ms Beretta received while in the TCP unit.
Enquiries were made of the Disability Services Commissioner (DSC), who confirmed that Ms Beretta’s death did not satisfy the criteria for a DSC investigation.
Having reviewed the available materials, including medical records from the Royal Melbourne Hospital, I am satisfied that the care provided by staff from Carinya Society and the Royal Melbourne Hospital was both reasonable and appropriate. I have not identified anything in the material that leads me to conclude that the standard of medical care Ms Beretta received, particularly while in the TCP unit, was anything other than satisfactory. The onset of her epilepsy was investigated and she received appropriate treatment following her diagnosis. I consider that no further investigation is required.
I convey my sincere condolences to Ms Beretta’s family for their loss.
Pursuant to section 73(1B) 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:
Rosanna Bergin, Senior Next of Kin Daniel Lewis, Royal Melbourne Hospital Senior Constable Brett Koochew, Coroner’s Investigator Signature: ___________________________________ Coroner David Ryan Date : 11 August 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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