Coroner's Finding: Kolega, Sime

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign King at Adelaide in the State of South Australia, on the 28th day of February and the 22nd day of May 2024, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Sime Kolega.

The said Court finds that Sime Kolega aged 54 years, late of 15 Cronin Avenue, Port Lincoln, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 8th day of April 2021 as a result of multi-organ failure and sepsis complicating fulminant pneumonia with empyema (operated). The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Sime Kolega was born on 17 August 1966 and died at the Royal Adelaide Hospital on 8 April 2021 aged 54 years.

1.2. A pathology review was undertaken by Dr Jane Alderman of Forensic Science South Australia and discussed with Dr Karen Heath.1 The suggested cause of death was ‘multi-organ failure and sepsis complicating fulminant pneumonia with empyema2 (operated)’, and I so find.

2. Reason for inquest 2.1. This was a mandatory inquest pursuant to Section 21 of the Coroners Act 2003, as at the time of his death Mr Kolega was in lawful custody under the supervision of the 1 Exhibit C2a 2 A collection of pus in the space between the lung and the inner surface of the chest wall (pleural space)

Department for Correctional Services. He had been sentenced on 13 January 2021 in the Port Lincoln Magistrates Court to 3 months and 15 days imprisonment to be served on home detention.

3. Social background 3.1. Mr Kolega was born in Croatia and lived on an island with his mother, father and five siblings. He went to school until 14 or 15 years of age and then became a fisherman.

3.2. At about the age of 24, he obtained an Australian visa and travelled to Port Lincoln where his brother had already settled. He returned to Croatia a few years later, then in 1994 returned permanently to Port Lincoln where he continued his career as a fisherman until the time of his death.

3.3. He met his wife Leah Stewart-Douglas, and they married in 1995 before having a son in 1997, Samuel Kolega. The marriage ended in 2001 and Mr Kolega maintained contact with his son.

4. Medical history 4.1. Mr Kolega was a heavy smoker and medical notes indicate that he would smoke up to 60 cigarettes per day, which contributed to a persistent cough. He was prescribed Flixotide and Ventolin inhalers for asthma.

4.2. In 2007 he was diagnosed with myalgia (muscle pain) which was an ongoing complaint.

4.3. In 2009 while unloading trawl nets he suffered a back injury described as lumbago.

4.4. In 2018, again while lifting nets, he suffered another back injury resulting in lumbar back pain for which he took tramadol and Lyrica.

4.5. Mr Kolega’s son reports that he appeared malnourished when he last saw him around Christmas of 2020 and that he did not have a healthy diet.3 Mr Kolega was also a heavy drug and alcohol user for much of his life.

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5. Events leading up to death 5.1. Mr Kolega’s general practitioner, Dr Raj Dhaliwal based at the Lincoln Medical Centre, has provided an affidavit.4 He stated that on Monday, 29 March 2021 Mr Kolega called the practice asking for his medication.

5.2. Dr Dhaliwal did not like giving Mr Kolega prescriptions without seeing him, so he told his staff to request Mr Kolega attend for an appointment.

5.3. On the afternoon of 1 April 2021 Mr Kolega saw Dr Dhaliwal. He stated he was not feeling well and that he needed scripts for his medication.

5.4. Dr Dhaliwal described Mr Kolega as not being his usual self and appearing a 'little high' and slurring his speech. Dr Dhaliwal noted he was afebrile with a clear chest and oxygen saturations of 96%. Dr Dhaliwal observed that he had bilateral pedal oedema which caused concern, resulting in Mr Kolega being referred for blood testing to investigate the cause.

5.5. Mr Kolega did not get a blood test on that date.

5.6. Of note is that this appointment occurred at 4:36pm. The SA Pathology collection centre at the Lincoln Medical Centre, where this appointment took place, had closed at 4pm. The nearest collection centre was a 1.1-kilometre walk from the Lincoln Medical Centre, in the opposite direction from Mr Kolega’s home. That collection centre closed at 5:30pm.

5.7. The next day was Good Friday and neither collection centre was open, although the Port Lincoln Hospital was open 24 hours.

5.8. On 3 April 2021, SA Ambulance Service attended Mr Kolega’s home address at 11:08am where he reported to paramedics a deteriorating cough and pain in the lower chest. Paramedics also noted he had a fever and peripheral oedema.

5.9. Hospital notes indicated that he presented with severe respiratory distress and required a left chest drain under general anaesthetic. He was placed on a ventilator and did not regain consciousness.

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5.10. Mr Kolega was in a critical condition requiring ICU level care and was flown by Medstar to the Royal Adelaide Hospital (RAH).

5.11. Upon presentation at the RAH, he was in respiratory failure and septic shock secondary to a staph aureus infection. He was stabilised with heavy antibiotics and another chest drain was inserted.

5.12. On 7 April 2021 Mr Kolega had surgery to remove infected tissue from his left pleural space. Following this surgery he deteriorated rapidly making ventilation very difficult.

He was placed on maximal medical support with no chance of recovery.

5.13. Registered Nurse Joannies Yap5 was working as a bedside nurse in the ICU with the sole duties of observing and tending to Mr Kolega. She was present when he arrived at RAH ICU and stated that he was sedated and on a ventilator from the time of his arrival until his death. At no point was RN Yap able to communicate with Mr Kolega due to his condition.

5.14. At about 4:12pm on 8 April 2021 Dr Michael Farquharson removed the breathing tube from Mr Kolega and administered sedatives for comfort.

5.15. At 4:26pm on this same date Mr Kolega was pronounced deceased by Dr Brana Moloney.

6. Concluding remarks 6.1. Dr Michael Farquharson, who treated Mr Kolega in the ICU, provided a statement detailing the care of Mr Kolega at the Royal Adelaide Hospital.6 In his opinion Mr Kolega’s native immunity would have been impaired due to his health and lifestyle.

He also stated that if Mr Kolega had presented to hospital earlier, and commenced a course of antibiotics sooner, the outcome would have been different.

6.2. This investigation did not establish any issues that contributed to his death other than the omission of Mr Kolega having a blood test as requested by his general practitioner.

6.3. The SAPOL investigating officer, Detective Brevet Sergeant Britta Rivett, made the observation that the opening hours of the blood collection centres in Port Lincoln after 5 Exhibit C1a 6 Exhibit C4

hours and on public holidays could have limited Mr Kolega's opportunity to obtain a blood test, which may have diagnosed pneumonia at an earlier time. However, I note that the Port Lincoln Hospital was open had Mr Kolega decided to pursue medical care as a matter of urgency on the public holiday.

6.4. I make no recommendations.

Key Words: Death in Custody; Home Detention; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 22nd day of May, 2024.

State Coroner Inquest Number 08/2024 (0715/2021)