Record of Investigation into Death
Coroners Act 1995
Coroners Regulations 1996
I, Stephen Raymond Carey, Coroner, having investigated the death of
Mark Leslie GREEN
WITHOUT HOLDING AN INQUEST
Mark Leslie GREEN ("Mr Green") died at 9.25 pm on 27 December 2009 at the Royal Hobart Hospital.
Mr Green was born in Cessnock, New South Wales on 19 April 1980 and was aged 29 years at the time of his death.
Mr Green was a married person who was employed as a kitchen hand.
I find that Mr Green died as a result of blunt trauma of the head that resulted from a fall down stairs. A significant contributing factor was mixed drug intoxication (alcohol, ecstasy and cannabis). At the time of his death Mr Green was being attended by a medical practitioner.
Circumstances Surrounding the Death :
On the evening of 25 December 2009 Mr Green was present at an apartment occupied by Mr George Falconer, a friend of Mr Green. Also present were Ms Meg Collins, Mr Astro Labe, and Mr Jonathan Daniels. The group sat outside on a balcony area of the apartment and were drinking alcohol from approximately 6.30 pm and possibly some or all were consuming illicit drugs. It is apparent that the group all became significantly intoxicated. At some stage during the evening, estimated to have been between 10.00 pm and 10.30 pm, Mr Green has fallen down some concrete steps leading from the balcony area to the footpath below. The male persons present upon being informed by Ms Collins that Mr Green had fallen, then proceeded to check upon his condition then carried him back up to the balcony and laid him out on a bench in that location. Apparently some cursory inspection was made of him and no obvious injuries were discerned and save for checking that he was breathing, he was left in that location. The response by this group of people was obviously less than what was reasonably called for in the circumstances, given the significant fall that Mr Green had taken. Some attempts were made to wake him and this was unsuccessful but he was noted to be snoring and so he was left on the bench whilst the group continued to socialise.
Messrs Labe and Daniels left this residence shortly after 2.00 am and there is no indication as to whether or not they further checked upon Mr Green’s condition at any time between when he was placed on the bench and when they left the residence. Mr Falconer had gone to bed at some stage after Mr Green’s fall and he awoke again at approximately 2.00 am finding Messrs Daniels and Labe waiting for a taxi. He then left the residence and went for a walk, returning to his unit at approximately 2.40 am when he noticed Mr Green still lying on the bench in the balcony area at the top of the stairs where he had been placed earlier. He noted that Mr Green was having trouble breathing as he was lying on his back and was gargling. He rolled Mr Green’s head to the left to clear his airway at which time Mr Green coughed blood. He then retrieved pillows and a blanket to make Mr Green more comfortable and immediately telephoned for an ambulance to attend. According to Tasmanian Ambulance Service documentation the initial call was received at 3.09 am and the ambulance arrived at the residence at 3.18 am. After carrying out preliminary examination and some treatment, Mr Green was conveyed to the Emergency Department of the Royal Hobart Hospital, arriving at 3.48 am. Upon arrival his temperature was low at 32.8 degrees, heart rate 90, blood pressure 210/120, respiratory rate of 14 and
Upon arrival his temperature was low at 32.8 degrees, heart rate 90, blood pressure 210/120, respiratory rate of 14 and 02 saturation of 100%. Mr Green was intubated and placed on a ventilator. Two 10mg boluses of hydralazine were given to lower his blood pressure with good effect. He was actively warmed and was kept sedated with morphine and mydazolan infusion.
Mr Green was taken to the CT scanner and a non contrast CT of his brain was performed. The verbal report by the Radiology Registrar given at the time was a "severe picture" with a large subdural haemorrhage and 15 mm of midline shift, with associated subarachnoid haemorrhage. There was also noted to be a large parenchymal haemorrhage centred within the posterior fossa involving the brain stem, and skull fracture. Mr Green’s situation was discussed by Dr Marcus Yong, the Registrar of Emergency Department, at the time with the on-call Neurosurgery Registrar who, after viewing the CT scan results and discussing the case with the Neurosurgery Consultant, provided advice that the prognosis was very poor and that surgery was not an option.
Mr Green was transferred to the Intensive Care Unit.
When initially reviewed at approximately midday on 26 December by Dr Turner, Director of Critical Care Medicine, there was an absence of brain stem reflexes, however brain death could not be confirmed at that time because Mr Green was hypothermic and had elevated blood alcohol. On 27 December he was noted to have low blood alcohol level, a normal body temperature and had no metabolic issues. At that point two sets of brain death testing were performed which confirmed brain death. He was pronounced brain dead by brain death testing at 11.30 am..He was withdrawn from treatment and allowed to suffer a cardiac arrest at 9.25 pm on 27 December 2009.
Comments and Recommendations :
Due to the intoxicated state of all persons on the night of 25 December 2009 when Mr Green had his fall, insufficient attention was given to the possibility that he had suffered a significant injury, although Mr Green’s injuries were severe and quite possibly fatal regardless of medical intervention. However this was by no means certain had there been a rapid neurosurgical intervention. Dr D Ritchey, the Forensic Pathologist who conducted the autopsy upon Mr Greens explains that Mr Green had a skull fracture and a large subdural haematoma (SDH). The skull fracture was not displaced and had not directly injured the brain. The SDH produced a mass effect displacing the brain and caused it to swell. This happened over time, and it was this swelling of the brain in response to the SDH that caused the brain herniation (shifting of the brain between compartments) resulting in death. Timely neurosurgical evacuation of the SDH may have altered the outcome. The failure of those other persons present when Mr Green suffered his injury to more positively act to assess his health state could well therefore have contributed to his death.
This tragic case once again highlights the social and personal effects of alcohol abuse.
Before concluding I wish to convey my sincere condolences to the family of Mr Green.
This matter is now concluded.
DATED : The 5 day of July 2010 at Hobart in the state of Tasmania
Stephen Raymond Carey