Finding into death of Peter John Evans

IN THE CORONERS COURT COR 2020 003449 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Catherine Fitzgerald Deceased: Peter John Evans Date of birth: 19 April 1966 Date of death: 29 June 2020 Cause of death: 1(a) Complications of metastatic non-small cell lung carcinoma 2 Cardiomegaly Place of death: Austin Health, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084

INTRODUCTION

1. On 29 June 2020, Peter John Evans was 54 years old when he died at the Austin Hospital.

Mr Evans had been living at Thomas Embling Hospital, a secure mental health hospital that treats patients from the criminal justice system.1

2. Mr Evans had a medical history of bilateral Dupytren’s contracture, paranoid schizophrenia and stage 3 non-small cell lung carcinoma.

THE CORONIAL INVESTIGATION

3. Mr Evans’ 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 death of a person in care or custody is a mandatory report to the Coroner, even if the death appears to have been from natural causes, as was the case with Mr Evans.

4. 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.

5. 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.

6. This finding draws on the totality of the coronial investigation into the death of Peter John Evans including evidence contained in the coronial brief. 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.2 1 Meaning Mr Evans was a person placed in custody or care, pursuant to section 3(1) of the Act.

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 Circumstances in which the death occurred

7. In January 2020, Mr Evans was diagnosed with non-small cell carcinoma, which was treated with chemotherapy and radiotherapy.

8. On 13 June 2020, Mr Evans was admitted to the Austin Hospital with worsening breathlessness and was treated for both radiation pneumonitis and an infection, and improved.

Physicians noted that he had developed a supraclavicular lymph node and his medication was changed. Mr Evans was treated concurrently for a pulmonary embolus. He was discharged.

9. Mr Evans re-presented to the Austin Hospital on 26 June 2020 with worsening hypoxia. His condition deteriorated, with new changes on his chest x-ray and computed tomography chest scan. Due to the speed of progression, Mr Evans’ treating oncologist thought the changes were probably due to an infection. Despite the administration of antibiotics and steroids, Mr Evans continued to clinically deteriorate.

10. On 29 June 2020, physicians recommended that Mr Evans transition to palliative care, to which he agreed. Mr Evans passed away a few hours later.

Identity of the deceased

11. On 29 June 2020, Peter John Evans, born 19 April 1966, was visually identified by his son, Peter Hynam.

12. Identity is not in dispute and requires no further investigation.

Medical cause of death

13. Forensic Pathologist Dr Yeliena Baber from the Victorian Institute of Forensic Medicine (VIFM) conducted an autopsy on 3 July 2020 and provided a written report of her findings dated 30 October 2020.

14. The post-mortem computed tomography scan showed a right occipital infarction, small hypodense nodule in the right parietal lobe, bilateral hilar masses, changes in both lungs, small pleural and pericardial effusions and multiple subcutaneous metastases in the abdominal region.

15. At autopsy, the heart was enlarged at 560 grams. The expected weight for a man of this age, weight and height should be 426 grams with an upper limit of 549 grams. Dr Baber explained that a feature of this condition (cardiomegaly) is that myocardial oxygen demand eventually becomes greater than supply, resulting in irreversible ischaemia (heart attack) or terminal cardiac arrythmia. The main causes of cardiomegaly are hypertension, valve disease, inherited cardiomyopathies and obesity.

16. Dr Baber was of the opinion that the death was due to the combined effect of widespread metastatic carcinoma within the lungs and the associated organising pneumonia. These features were present in both lungs. Both these pathologies would have a detrimental effect on the heart.

17. Toxicological analysis of post-mortem samples was non-contributory and consistent with hospital care.

18. Dr Baber provided an opinion that the medical cause of death was 1 (a) Complications of metastatic non-small cell lung carcinoma, with the contributing factor of cardiomegaly, and was due to natural causes.

19. I accept Dr Baber’s opinion.

FINDINGS AND CONCLUSION

20. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Peter John Evans, born 19 April 1966; b) the death occurred on 29 June 2020 at Austin Health, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, from complications of metastatic non-small cell lung carcinoma; and c) the death occurred in the circumstances described above.

I convey my condolences to Mr Evans’ 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:

Peter Hynam, Senior Next of Kin Pauline Chapman, Austin Health Signature: ___________________________________ Coroner Catherine Fitzgerald Date : 25 May 2022 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.