Finding into death of Aleksander Kojic

IN THE CORONERS COURT Court Reference: COR 2018 1290

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Kate Despot Deceased: Aleksander Kojic Date of birth: 21 August 1971 Date of death: 19 March 2018 Cause of death: 1(a) Cardiomegaly Place of death: 16 Wordsworth Avenue, Clayton South, Victoria, 3169

INTRODUCTION

1. On 19 March 2018, Aleksander Kojic was 46 years old when he collapsed at the Yooralla Supported Residential Service (SRS) where he resided and passed away. The SRS located at 16 Wordsworth Avenue Clayton South, is a supported service for people with intellectual or physical disabilities.

THE CORONIAL INVESTIGATION

2. Mr Kojic’s death was reported to the Coroner as he was considered to be “a person placed in custody or care” under section 3(1) of the Coroners Act 2008 (the Act) and therefore fell within the definition of a reportable death.

3. 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.

4. At the request of the Coroner who formerly had conduct of this investigation, Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Mr Kojic’s death.

The Coroner’s Investigator conducted inquiries and submitted a coronial brief of evidence.

5. This finding draws on the totality of the coronial investigation into the death of Aleksander Kojic 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.1 1 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.

BACKGROUND

6. Mr Kojic was described as a very friendly and lovely guy2 who was independent, very quiet but set in his ways. Mr Kojic enjoyed collecting magazines and books, watching movies and attending a local disco on a Thursday evening3.

7. Mr Kojic had a very supportive family who regularly telephoned and visited him at the SRS.

Mr Kojic would often spend time away from the SRS, staying with his parents at their home.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

8. On 19 March 2019 at approximately 7.50am, Mr Kojic was at the SRS facility in Clayton South when he collapsed opposite the laundry. A member of staff called emergency services and initiated cardiopulmonary resuscitation until Metropolitan Fire Brigade members and Ambulance Victoria Paramedics arrived. Despite their efforts, Mr Kojic was unable to be revived and was pronounced deceased at the scene.

Identity of the deceased

9. On 19 March 2018, Aleksander Kojic, born 21 August 1971, was visually identified by his sister, Katarina Kojic.

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

Medical cause of death

11. Forensic Pathologist Dr Malcolm Dodd from the Victorian Institute of Forensic Medicine (VIFM) performed an autopsy on 21 March 2018 and provided a written report dated 11 May 2018.

12. Dr Dodd commented as follows: “The immediate cause of death in this case is one of cardiac arrest in a man with significant cardiac enlargement.” “The heart weighed 802 g and had a pattern of moderate biventricular dilation.” 2 Coronial Brief statement of Ms Donna Roberts.

3 Coronial Brief statement of Ms Samantha D’Cruz.

“Cardiac enlargement of this magnitude predisposes to spontaneous lethal arrythmia (cardiac arrest).” “There is no evidence to suggest that this death was due to anything other than natural causes.”

13. Toxicological analysis of post-mortem blood and vitreous humour samples detected the presence of glucose, chlorpromazine, duloxetine and dothiepin.

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

15. I accept Dr Dodd’s opinion.

FINDINGS AND CONCLUSION

16. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Aleksander Kojic, born 21 August 1971; b) the death occurred on 19 March 2018 at 16 Wordsworth Avenue, Clayton South, from Cardiomegaly; and c) the death occurred in the circumstances described above.

17. Having considered all of the circumstances I am satisfied that Mr Kojic’s death was due to natural causes.

18. Pursuant to section 73(1B) of the Act, I order that this finding be published on the court’s website.

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

• Dragan & Maria Kojic, Senior Next of Kin;

• Dr Donna Henderson, Clayton Road Doctors; and

• Leading Senior Constable Emma Lukins, Coroner’s Investigator, Victoria Police

Signature: ___________________________________ Coroner Kate Despot Date : 17 January 2023 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.