CITATION: Inquest into the death of Isabelle Manyita [2007] NTMC 015
TITLE OF COURT: Coroner’s Court
JURISDICTION: Darwin
FILE NO(s): D0071/2005
DELIVERED ON: 12 March 2007
DELIVERED AT: Darwin
HEARING DATE(s): 31 August 2006
1 September 2006
FINDING OF: Mr Greg Cavanagh SM
CATCHWORDS:
Septicaemia death, medical treatment both before onset of Septicaemia and afterwards
REPRESENTATION:
Counsel
Assisting: Mr Tom Berkley
Health & Community Services: Mr Kelvin Currie
Judgment category classification: B
Judgement ID number: [2007] NTMC 015
Number of paragraphs: 30
Number of pages: 9
IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN
TERRITORY OF AUSTRALIA
No. D0071/2006
In the matter of an Inquest into the death of
ISABELLE MANYITA
ON 28 APRIL 2005
AT ROYAL DARWIN HOSPITAL
FINDINGS
12 March 2007
Mr Greg Cavanagh SM:
1. Isabelle Manyita (hereinafter called the deceased) died at 1747 hours on 28 April 2005 in the Accident and Emergency Depart of the Royal Darwin Hospital (RDH).
2. A public inquest into her death pursuant to Section 15 of the Coroners Act (the “Act”) was held in Darwin on 31 August and 1 September, 2006. Counsel Assisting me was Mr Tom Berkley. The family of the deceased was not represented. The Northern Australian Aboriginal Justice Agency (NAAJA) was notified of the holding of the Inquest. The Department of Health and Community Services was represented by Mr Kelvin Currie. I thank Counsel for their assistance.
3. Ten witnesses were called to give evidence at the Inquest. Those witnesses were Detective Senior Constable Lisa Bayliss of the Northern Territory Police Service, who investigated the death of the deceased and produced a thorough and comprehensive report that was tendered at the Inquest as Exhibit “1”; Gregory William Childs, the de-facto husband of the deceased; his brother Graham Allan Childs, who lived with the deceased and her de-facto husband at the relevant time; Graham Bristow, a friend who saw the deceased on the day of her death; Peter Rankine, a neighbour who tried to revive the deceased; Constable Dale Howe, a member of the Northern Territory Police Service who also tried to revive the deceased; Stuart Eric Anderson, a paramedic with St Johns Ambulance Service who treated the deceased; Evelyn Joyce Clark, a social worker who knew the deceased and her de-facto husband; Dr Othman Abdul Hamid, a medical practitioner who treated the deceased prior to her death; Dr Vino Sathianathan, the Deputy Medical Superintendent at the Royal Darwin Hospital; and Dr. Terrence Sinton, a Forensic Pathologist.
4. In addition to their evidence I formally admitted into evidence a number of statements from other witnesses, police records, the post mortem report and the deceased’s medical records.
FORMAL FINDINGS
5. The deceased was known as Isabelle Manyita, a person I find to be identical with Isobel Ngalbulbul Rabinjini, born at Oenpelli in the Northern Territory of Australia on 7 May 1973.
6. The deceased died at RDH at 1747 hours on Thursday, 28 April 2005.
7. The cause of death was Septicaemia following Acute Osteomyelitis following Fractures of the Left Leg
8. The particulars required to register the death are:
a. The deceased was female;
b. The deceased was Isabelle Manyita, who was named Isobel Ngalbulbul RABINJINA at birth;
c. The death was reported to the Coroner;
d. The cause of death is set out in (7) above;
e. An autopsy was conducted at RDH on 29 April 2005 by a Forensic Pathologist;
f. The Forensic Pathologist was Dr Terrence Sinton;
g. The mother of the deceased was Nancy Julinwanga Jilwanga Elewanga Rabinjina, and the father is not recorded on the deceased’s birth record;
h. The usual place of residence of the deceased at the time of her death was 3 Noltenius Circuit, Gray, in the Northern Territory of Australia;
i. The deceased did not have an occupation.
RELEVANT CIRCUMSTANCES SURROUNDING DEATH
9. In the last few years prior to her death the deceased had an on-again, off-again relationship with Gregory William Childs. The deceased had one son from that union, James, who was 2 years old at the time of her death. For about 2 years prior to her death the deceased mostly lived with Childs, and his brother Graham Childs, at 3 Noltenius Circuit, Gray. Both the deceased and Gregory William Childs lived alcoholic lifestyles and were known to Police Gregory William Childs was then, and is now, on a disability pension for disabilities arising from his alcoholism.
10. At some time in April 2005 the deceased returned to 3 Noltenius Circuit, Gray after having been living elsewhere for a short time. The only evidence of the date of her return came from Gregory Childs. He was unable to give the exact date of her return, and it is unnecessary for me to make a finding on that point, but I accept that it was probably within seven days of her treatment at RDH on 22 April, 2005. In sworn evidence Gregory Childs described Isobel on her return as having a dirty bandage on her left leg covering a festering scrape down the length of her left shin. Childs said that he changed the bandage and put ointment on the scrape on her left leg. The re-union of Childs and the deceased was achieved because Childs wanted someone to help look after their son, and his children from another union, and had decided to “forgive” the deceased and give her “another chance”.
11. On Friday 22 April 2005 the deceased attended the Accident and Emergency Department (A & E) of RDH in company with Gregory Childs. She was ultimately treated by Dr. Othman Abdul Hamid who diagnosed a closed fracture of her tibia and fibula and applied a plaster cast to her leg. She was given analgesia (morphine) for pain. The patient history was given by Gregory Childs, who told Dr. Hamid that about 4 weeks prior the deceased had injured her leg and then on 22 April 2005 she had fallen whilst walking on rocks. In evidence Childs said that the latest injury occurred at his block at Dundee Beach, and that he drove the deceased to RDH from that location.
12. At RDH the deceased was loud, intoxicated and uncooperative. She was in severe pain. She could speak English but was uncommunicative with Dr. Hamid concerning her medical condition. According to the evidence of Dr Hamid, the deceased only wanted to go home, and did not want to be admitted to hospital. Dr Hamid assessed the deceased as likely to abscond if she were admitted, and noted that assessment on her medical records. Dr Hamid decided to let the deceased go home, even though she would normally be admitted with such an injury. He discussed a medical management plan for the deceased with the senior registrar, Dr. Hardeep Salaria.
13. Due to the intoxication of the deceased, Dr Hamid chose to explain the medical management plan to Gregory Childs. Dr Hamid gave evidence that the medical management plan consisted of advice on plaster care, what warning signs to look out for if something was wrong, and that he had made an appointment for the deceased with the fracture clinic on the next Wednesday, 27 April 2005. He said that Childs appeared to understand his advice, and that the deceased was provided panedine forte for her pain.
14. In his sworn evidence Gregory Childs initially denied that he had been given any advice by Dr Hamid as to how to manage the deceased’s medical condition, although in cross-examination from Mr Currie he conceded that he might have been told some of the things in the management plan deposed to by the doctor at the Inquest.
15. I find that Dr Hamid was a credible and reliable witness, and I prefer his evidence to that of Gregory Childs concerning the treatment of the deceased, and Dr Hamid’s efforts to communicate a plan for the medical management of the deceased’s fractured left leg. I also find that an appointment was made for the deceased to attend at the RDH fracture clinic on 27 April 2005, that the time and date of the appointment was communicated to Childs, and that the deceased did not appear for that appointment.
16. The deceased returned that afternoon, 22 April, 2005, to 3 Noltenius Circuit Gray, where she spent most of her time for the next six days lying on a sofa bed in the lounge room of that residence. She was being cared for by the deceased who would give her Panadol or Nuerofen for pain. The deceased was not eating much.
17. A few days after returning home the deceased requested Childs to take her to RDH. She was in severe pain. Childs deposed that he took the deceased to RDH, and that she was being loud in the car on the way to hospital. Upon arrival Childs entered A & E to get a wheelchair for the deceased, and noticed that A & E was full of people. He said in evidence that he considered that it would be too embarrassing to wait in A & E for a prolonged period with the deceased because of her demeanour. He returned to his car, and during their return home he purchased more pain-killers for the deceased.
18. I am unable to determine whether this second visit to RDH was an attempt to attend the appointment at the fracture clinic, or in response to a request from the deceased because she was in pain. Childs described the visit as his response to a request from the deceased that he take her to the hospital. I am satisfied that Gregory Childs was trying to remember, as best he could, the details of his activities with the deceased in the days prior to her death, but that the accuracy of his recollection suffered due to his alcoholism and associated mental disabilities.
19. During the period 22 – 28 April 2005 Childs noticed that the deceased had progressively become very quiet. Childs thought that this was because she was resting, and he did not turn his mind to the possibility that the deceased’s medical condition was worsening until 28 April 2005.
20. On 28 April 2005 Gregory Childs invited his friend Graham Bristow to 3 Noltenius Circuit Gray to view the condition of the deceased. Bristow gave sworn evidence that he told Childs that the best thing Childs could do for the deceased was to take her to hospital. Childs drove Bristow back to his domicile at 15 mile camp. Childs stayed there for a short while, conversing with Bristow, and expressed his worry over the deceased’s medical condition to Bristow.
21. Upon his return to 3 Noltenius Circuit, at sometime after 1500 hours, Childs, in company with his eldest daughter, observed that and deceased was hot to his touch. Childs observed her breathing by the rise and fall of her stomach. She was uncommunicative, although her eyes were open. He asked her if she wanted to go to hospital. He is not sure, but thinks that the deceased may have nodded “yes”. He observed the rise and fall of her stomach stop. He put his head to the deceased’s chest and at first could hear a heartbeat. There was a loud beat and he heard no more. He started to panic and ran out the door to ring 000 on his mobile telephone. Having done that, he came back in to the lounge-room and attempted to revive the deceased using “mouth to mouth” resuscitation. He hailed Peter Rankine, a neighbour, who was riding past on his pushbike. Rankine entered and commenced cardio-pulmonary resuscitation (CPR). Police attended and they themselves attempted to resuscitate the deceased with the aid of a face mask. The St Johns Ambulance arrived and further attempts were made by paramedics to resuscitate the deceased. A faint pulse was detected by the paramedics and the deceased was taken to RDH by ambulance, where she was pronounced dead at 1747 hours, shortly after her arrival.
22. On 28 April, 2005 Police had been dispatched to 3 Noltenius Circuit at about 1640 hours. Constables Howe and Schrieber arrived within minutes of that dispatch call, having been in the general area at the time the dispatch call was made. An ambulance was dispatched to the residence at about 1643 hours, and arrived at the scene at about 1658 hours. The ambulance left the scene at 1711 hours and arrived at RDH at 1729 hours. I regard the reaction times of the Northern Territory Police and St Johns Ambulance as highly commendable.
23. An autopsy was performed on the body of the deceased by Dr Terrence Sinton, Forensic Pathologist, commencing at 0915 hours on 29 April 2005. I accept the evidence of Dr Sinton that the deceased would have been in severe pain as the septicaemia and osteomyelitis that killed her took hold in the days before her death.
24. I also accept that there is no evidence that either of those conditions were present at the time of the deceased’s treatment at RDH on 22 April 2005. Septicaemia is known for its rapid onset, and the streptococcus pyogenes that cause it are found in the bodies of most people. Dr Sinton gave evidence that the infection of the deceased would have been most likely caused by poor hygiene at home in combination with the presence of some minor wound. I find that it is more likely than not that the infection took hold at some time after the deceased left RDH on the evening of 22 April 2005.
CONCLUSION
25. The cause of the deceased’s fractures are uncertain. As part of a very thorough Police investigation, rumours of the fracture being the result of an assault were properly investigated, and found to be without a provable factual foundation. There is no reason for me not to accept the account of Gregory Childs that the deceased complained of “clicking” in her left leg upon her return to 3 Noltenius Circuit, and that she twisted her left leg whilst falling on rocks at Dundee Beach on 22 April, 2005.
26. I find that the clinical treatment of the deceased at RDH was timely and appropriate. How far a doctor should go in determining the likelihood that a medical management plan will be carried out is a matter of judgment for that doctor. Dr Hamid was not aware of Gregory Childs’ mental difficulties, but in any event I am satisfied that a follow up appointment with the fracture clinic was made by the doctor for 27 April 2005, and that fact was communicated to Childs along with a medical management plan for the injury to the deceased’s left leg.
27. It is true that in most cases patients presenting with the deceased’s injury would have been admitted as an in-patient, but no criticism can be laid at the door of RDH or Dr Hamid for not admitting the deceased to hospital in the circumstances of this case, and particularly where the deceased did not want to be admitted. The failure to admit the deceased to hospital did not affect the appropriateness of the clinical response to her injury. There was simply nothing at the time to suggest to Dr Hamid that the deceased’s broken left leg could, on its own, be a life threatening injury.
28. It would be inappropriate in these proceedings to be judgmental about the deceased’s life-stye or her relationship with her de-facto partner, Gregory Childs. I am satisfied that when it seemed to Childs that the deceased had stopped breathing at 3 Noltenius Circuit, Gray on the afternoon of 28 April 2005, Childs tried his best to get her medical assistance. I am also satisfied that Childs was, on 28 April 2005, genuinely concerned over the deceased’s medical condition. It is sad that Childs could not recognize that the deceased was in mortal danger from infection in the preceding days. He cannot, however, be criticized for that failure.
29. A friend of Childs and the deceased, Mr Peter Rankine, also tried his best to resuscitate the deceased, as did the first attending Police at the scene. Both Rankine and the attending Police are to be commended for their efforts in what must have been difficult and stressful circumstances for them.
30. No recommendations are called for in this case.
Dated this 12th day of March 2007
_________________________
GREG CAVANAGH
TERRITORY CORONER