Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Robert Pearce, Coroner, having investigated the death of

Donald Martin BREEN



(a) The identity of the deceased is Donald Martin Breen, born 16 August 1933.

(b) The cause of Mr Breen’s death is intra-cerebral haemorrhage.

(c) Mr Breen died at 5.35am on 5 May 2011 at the North West Regional Hospital in Burnie, Tasmania.

(d) No other person contributed to the cause of his death.


1. Donald Martin Breen died on 5 May 2011 aged 77.  He was born 16 August 1933.  At the time of his death he was married to Ila Margaret Breen.  They had four children then aged between 51 and 40.

2. Until 1990 Mr Breen was employed at Tioxide.  In 1993 he suffered a major heart attack.  He underwent coronary artery bypass surgery in 1994 and angioplasty and stenting in the Launceston General Hospital in 2007.  He was under the care of his general practitioner Dr S I Emmett of Ulverstone.

3. In December 2010 Dr Emmett referred Mr Breen to cardiologist Dr George Koshy with complaints of increasing shortness of breath and a comment that his medical condition was “deteriorating recently”.  Dr Koshy noted Mr Breen’s extensive history of coronary artery disease and that he was already being treated with medications including beta blocker and the oral anticoagulant Warfarin. 

4. Dr Koshy prescribed the beta blocker Carvedilol at the dose of 6.25mg twice daily.  He reviewed Mr Breen on 18 April 2011 and reported no intolerance to his medications.  Mr Koshy recommended an increase of the dose of Carvedilol to 25mg twice daily.  According to Dr Koshy this was to maximise therapeutic benefit of the therapy for persistent heart failure as well as to achieve adequate control of Mr Breen’s atrial fibrillation which, if not adequately controlled, would “be detrimental for the patient in terms of survival”.  He said he discussed with Mr Breen the side effects of Carvedilol including slowing of the pulse and dizziness.

5. According to Mr Breen’s family he, thereafter, felt less well and experienced some dizziness and weakness, although there is no evidence that this was reported to Dr Koshy.

6. On 3 May 2011 Mr Breen fell at home.  He lost consciousness.  In the fall he suffered a laceration to the back of his head.  He was taken to the North West Regional Hospital by ambulance.  He was admitted to the hospital under the general medical team for observation.  His scalp laceration was stapled and a CT scan initially reported no evidence of intra-cranial bleeding.  However during 4 May 2011 Mr Breen’s condition deteriorated.  He suffered altered sensation in his arms and speech difficulties.  A further CT scan was ordered and carried out at about 9.15pm.  The report of that scan reads, in part, "large left intra-axial haematoma with surrounding vasogenic oedema and associated swelling.  There is sulcal effacement but there is no mid line shift, no transtentorial herniation.  There is overlying scalp laceration and haematoma suggesting recent trauma.  The bleed has increased significant (sic) in size when compared to the previous CT of 03.05.2011".

7. Mr Breen was seen by the medical registrar.  He was given Vitamin K and fresh frozen plasma (to assist in reversing the effects of Warfarin).  Transfer to the Royal Hobart Hospital for neurosurgical care was arranged.  The registrar noted in a letter he wrote to medical staff at the RHH that when he compared Mr Breen’s head CT scan from that evening to the one undertaken 3 May 2011: “now that I review the first CT scan there is an 0.5cm x 0.5cm bleed in the same place”.

8. Initially there were no neurosurgery beds available at the RHH and Mr Breen was to be sent to the Emergency Department.  However Mr Breen’s condition quickly deteriorated and he died at 5.35am on 5 May 2011.

The Investigation

9. The coronial investigation has included a review of the medical records of the North West Regional Hospital and consideration of reports from Dr Emmett, Dr Koshy and Dr Ip, the Director of Medical Services at the hospital.  All of the evidence collected during the investigation has been reviewed by the State Forensic Pathologist and a research nurse engaged by the coroner.

10. A post mortem examination conducted by Dr Lawrence revealed a large intra-cerebral haemorrhage and secondary haemorrhages in the brain stem.  There is no evidence of frontal cortical contusion and it is likely, according to Dr Lawrence, that it was a primary intra-cerebral haemorrhage due to a combination of a natural weakness in the vessels and anti-coagulation rather than a traumatic haemorrhage.  He reviewed CT scans with the assistance of another clinician.  Dr Lawrence reached the view that, based on its location, the absence of cortical contusions and the absence of oedema on the first scan, the haemorrhage was likely to have been spontaneous.  That is, it was not related to the trauma suffered by Mr Breen when he fell and struck his head.  The spontaneous haemorrhage continued to bleed because Mr Breen was taking Warfarin.  According to Dr Lawrence while Mr Breen did fall on his head it appears unlikely that this fall contributed significantly to the brain damage or death.  By the time the brain haemorrhage was positively identified at the hospital Mr Breen was too unstable to be transferred to Hobart for surgery.

11. At a relatively early stage of the investigation Mr Adrian Breen, one of Mr Breen’s sons, wrote to the coroner expressing concern about the circumstances of his father’s death.  Mr Breen expressed a general concern, but more particularly about whether the increase in the dosage of Carvedilol was appropriate, whether Mr Breen ought to have been given a further warning about possible side effects of Carvedilol, and whether Mr Breen’s treatment at the North West Regional Hospital was appropriate, in particular, whether the intracranial cerebral bleed should have been discovered earlier and whether the management of Warfarin was appropriate.

12. As I have already explained the evidence does not support the proposition that the haemorrhage was the result of a fall.  I accept Dr Koshy’s explanation for the increase in the dose of Carvedilol, that some warning was given and that Mr Breen had previously taken other beta blocker medication without clinical issues.  It is established that the existence of the intracranial bleed on the first CT was missed; however the evidence of it was relatively small.  If it had been discovered it may have been possible for the clinicians to have ceased and reversed the effect of the Warfarin and treated him more aggressively for the intra-cerebral bleed.  Whether it would have made any substantial difference to the outcome is conjectural.

13. It is natural and understandable that Adrian Breen and his family should be concerned about Mr Breen’s death.  However I have concluded that most of the concerns expressed by him have been adequately answered by the investigation.  To the extent that issues remain they do not warrant an inquest.  Thus I have decided not to hold an inquest into Mr Breen’s death.  That is so partly because it is not the function of a coroner under the Coroner’s Act 1995 to attribute moral or legal blame or responsibility for the death of a person.  The coroner’s principal function is to investigate and find facts relevant to determining the identity of the deceased person, when and where a death occurred, how a death occurred and the cause of death.  The coroner must also find whether any other person contributed to the cause of death.  The facts, once determined, speak for themselves.

14. In this case the investigation has sufficiently disclosed the identity of the deceased person, the time, place, the relevant circumstances concerning his death and the particulars needed to register his death under the Births, Deaths and Marriages Registration Act.  The evidence does not justify a conclusion that another person contributed to Mr Breen’s death.  I do not consider that an inquest is likely to elicit any further information concerning the issues that I am required to determine.

Comments & Recommendations

15. I see no need to make any further comment or recommendation.

I convey my sincere condolences to Mr Breen’s family.

DATED: 29 June at Launceston in Tasmania


Robert Pearce