Inquest into the Death of Bill PORTELLI

Coroners Act 1996 [Section 26(1)] Western Australia

RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref : 3/14 I, Barry Paul King, Coroner, having investigated the death of Bill Portelli with an inquest held at the Perth Coroner’s Court, Court 51, CLC Building, 501 Hay Street, Perth, on 6 February 2014 find that the identity of the deceased person was Bill Portelli and that death occurred on 22 March 2012 at Fremantle Hospital from bronchopneumonia while receiving palliative care for terminal carcinoma of the rectum in the following circumstances: Counsel Appearing: Sgt L Housiaux assisting the Coroner Ms A Preston-Samson , State Solicitors Office, appearing on behalf of Fremantle Hospital Table of Contents Inquest into the death of Bill PORTELLI

INTRODUCTION

1. Bill Portelli (the deceased) died on 22 March 2012 from bronchopneumonia while he was receiving palliative care at Fremantle Hospital.

2. As the deceased was an involuntary patient under the Mental Health Act 1996 at the time of his death, he was a ‘person held in care’ under section 3 of the Coroners Act 1996.

3. Section 22 (1)(a) of the Coroners Act 1996 provides that a coroner who has jurisdiction to investigate a death must hold an inquest if the death appears to be a Western Australian death and the deceased was immediately before death a person held in care.

4. An inquest to inquire into the death of the deceased was therefore mandatory. Consequently, an inquest was held on 6 February 2014 at which the deceased’s treating psychiatrist, Dr Kartikey Agarwal, and the Public Advocate, Ms Pauline Bagdonavicius, were called to give oral evidence.

5. Under s25(3) of the Coroners Act 1996, where a death investigated by a coroner is of a person held in care, the coroner must comment on the quality of the supervision, treatment and care of the person while in that care.

6. I have found that the relevant supervision, treatment and care provided to the deceased was exemplary.

THE DECEASED

7. The deceased was born on 28 April 1947 in the former Yugoslavia in what is now called Croatia. His name at birth was Branko Hajduc but he took on the name of Bill Portelli later in life because of a deluded belief that he was connected to a family of that name.1 1 Exhibit 1, Tab 8, p2 Inquest into the death of Bill PORTELLI

8. A personal history provided by the deceased in 2012 indicated that he had married a woman named Connie with whom he had one daughter, but that information was not confirmed by other evidence.2

9. In 1975 the deceased was diagnosed with chronic paranoid schizophrenia, from which he would suffer for the rest of his life. He also suffered from chronic obstructive pulmonary disease, hypertension, aortic aneurysm, obstructive sleep apnoea and atrial fibrillation.

10. The deceased was admitted to Graylands Hospital from 1977 to 1983 for attempted murder during a delusional psychotic episode. He was discharged to after-care under the Mental Health Act 1962 and managed by the Assertive Community Treatment Team at the Alma Street Centre at Fremantle Hospital.

11. For the next 29 years or so the deceased required numerous admissions to hospitals for his mental illness. While he was in the community he was treated by psychiatric nurses and provided with depot antipsychotic medication.3

12. The deceased lacked insight into his condition and took poor care of himself, including by smoking, drinking excessive amounts of coffee and maintaining an unhealthy diet. He often failed to comply with his medication regime, which would lead to an increase of his psychotic symptoms and a re-admission to hospital to manage his condition.

13. The deceased’s treating doctor in the community from February 2007 was Dr Enzo Almonte.

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14. Dr Almonte encouraged the deceased to attend for regular reviews of his medical conditions. In July 2011 2 Ex 1, Vol 1, Tab 14 3 Ex 1, Tab 8 Inquest into the death of Bill PORTELLI

Dr Almonte noticed that the deceased had lost weight.

Tests revealed renal function hyponatraemia and mild anaemia but chest x-rays did not identify significant pathologies.4

15. The deceased continued to lose weight. Another chest x-ray in November 2011 identified no new changes but significant iron deficiency anaemia was noted.

16. On 11 November 2011 the deceased was admitted to Fremantle Hospital where a CT scan of his abdomen showed several lesions in the bowel and abdomen as well as multiple small deposits in the liver.5

17. The deceased was diagnosed with likely colorectal cancer with liver metastasis. He refused to accept the diagnosis, believing that the symptoms he was suffering were caused by the Alma Street Centre, his depot medication and the devil.6

18. On 16 November 2011 the deceased’s case manager in the Assertive Community Treatment Team submitted an urgent application to the State Administrative Tribunal for a guardian to be appointed to make decisions in relation to the deceased’s accommodation, medical treatment and health care, and for any services he required. On 19 December 2011 the Public Advocate, Ms Bagdonavicius, was appointed limited guardian for the deceased. Ms Bagdonavicius delegated her authority to Jennifer Melville, guardian.7 22001122

19. Due to the deceased’s terminal illness, the Assertive Community Treatment Team decided not to continue the deceased’s psychiatric treatment, but the team monitored his mental state and risk issues following the cessation of antipsychotic depot medication. As the 4 Ex 1, Tab 8 5 Ex 1, Tab 8 6 Ex 1, Tab 9 7 Ex 1, Tab 9 Inquest into the death of Bill PORTELLI

deceased condition deteriorated, he was monitored daily for his pain levels, and the team liaised with Dr Almonte, Silver Chain Palliative Care and Ms Melville.8

20. By 12 March 2012 the Alma Street Centre and Silver Chain were no longer able to support the deceased at home. On 13 March 2012 he was admitted into Alma Street Centre for palliative treatment as an involuntary patient under the Mental Health Act 1996.9

21. At this time, the deceased was acutely delusional, believing that he was a doctor working in Saudi Arabia and denying that he could not cope at home despite being wheelchair bound and incontinent of faeces. At the Alma Street Centre he was placed on 15 minute observations and a ‘not for resuscitation’ order. A palliative care nurse saw him daily to review and alter his pain management.10

22. On 20 March 2012 the deceased developed symptoms of bowel obstruction and his condition deteriorated rapidly.11

23. The next day the deceased’s condition deteriorated further with increased vomiting, distended rigid abdomen, increased pain and the inability to take anything orally.12

24. The deceased died in the early hours of 22 March 2012.

CCAAUUSSEE AANNDD MMAANNNNEERR OOFF DDEEAATTHH

25. Chief Forensic Pathologist Dr C T Cooke conducted a post-mortem examination of the deceased on 26 March

26. Dr Cooke found cancer in the rectum with spread to the liver, left lung and spleen. The intestine above the cancer appeared to be distended. The lungs showed 8 Ex 1, Tab 9 9 Ex 1, Tab 11 10 Ex 1, Tab 9 11 Ex 1, Tab 9 12 Ex 1, Tab 9 Inquest into the death of Bill PORTELLI

emphysema and congestion with features of pneumonia.13

26. Microscopic examination confirmed the presence of bronchopneumonia in the lungs related to aspirated vomit and confirmed metastatic cancer in the liver, spleen and lung.14

27. Toxicological analysis showed a very high level of the opioid fentanyl, as is not unusual in end-stage palliative care where pain-killers are increased to reduce suffering.

28. Dr Cooke concluded that the cause of the deceased’s death was bronchopneumonia in a man receiving palliative care for terminal cancer of the rectum. I accept Dr Cooke’s conclusion as the cause of death.

29. I find that the manner of death was natural causes.

QQUUAALLIITTYY OOFF SSUUPPEERRVVIISSIIOONN,, TTRREEAATTMMEENNTT AANNDD CCAARREE

30. The evidence available to me consistently established that the supervision, treatment and care of the deceased while he was an involuntary patient at the Alma Street Centre was exemplary.

31. For example, Ms Bagdonavicius described Ms Melville’s view that the deceased received an exceptional level of service from the Alma Street Centre’s treating team and from Dr Almonte. Ms Bagdonavicius noted that the Alma Street Centre was providing seven day support to the deceased in order to ensure that his pain was under control. She described how staff would have to drive around Fremantle to find the deceased if he were not at home.

32. Ms Bagdonavicius also noted that the deceased was not an easy patient to treat but that he was afforded a high 13 Ex 1, Tab 4 14 Ex 1, Tab 4 Inquest into the death of Bill PORTELLI

degree of respect and sensitivity by Alma Street Centre staff.

CCOONNCCLLUUSSIIOONN

33. The deceased suffered debilitating mental illness, probably for over thirty years.

34. He also suffered medical problems, likely caused by lifestyle choices made because of his mental illness.

35. The deceased died at the age of 64 from the effects of those problems, especially colorectal cancer, despite receiving appropriate ongoing care and treatment at Alma Street Centre.

Barry King Coroner 24 February 2014 Inquest into the death of Bill PORTELLI