Coroner's Finding: Donnelly, Christopher Ronald

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of Christopher Ronald Donnelly Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Christopher Ronald Donnelly (Mr Donnelly); b) Mr Donnelly died in the circumstances set out below; c) Mr Donnelly’s cause of death was Sudden Unexpected Death in Epilepsy (SUDEP); and d) Mr Donnelly died between 24 and 25 February 2020 at Margate, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Donnelly’s death. The evidence includes:  The Police Report of Death for the Coroner;  Affidavits as to identity and life extinct;  Affidavit of Dr Andrew Reid, forensic pathologist;  Affidavit of Mr Neil MacLachlan – Troup, forensic scientist of Forensic Science Service Tasmania;  Affidavit of Ms Kate Herbert;  Medical records obtained from Mr Donnelly’s general practitioner;  Medical records obtained from the Tasmanian Health Service; and  Report of the coronial medical consultant Dr Anthony Bell MB BS MD FRACP FCICM.

Background Mr Donnelly was born on 9 April 1951. He hails from Salford in England. At the date of his death Mr Donnelly was aged 68, he was married to Lynette Donnelly and both Mr Donnelly and his wife resided at Margate. Mr Donnelly was retired. Mr and Mrs Donnelly had just moved to this property in early February 2020. Prior to that time they were living with Mrs Donnelly’s sister in law in Rosetta. Mr Donnelly had smoked since he was in his teens.

Mrs Donnelly had in about the middle of February 2020 been taken to hospital by ambulance in respect of a medical emergency. From this point on Mr Donnelly was residing at home alone however his children were checking on him regularly.

Health The records of the general practitioner indicate in the 12 months prior to his death Mr Donnelly or his wife saw Mr Donnelly’s general practitioner on 5 occasions. The consultations were essentially with respect to seizures Mr Donnelly was suffering from and the medication required for that condition. He was diagnosed with chronic obstructive pulmonary disease (COPD) in 2012 along with depression and right hip osteoarthritis in 2013. Seizures are noted from 2015 onwards.

Ms Herbert says her father had numerous health concerns. He had been diagnosed with vascular dementia and seizures. The severity of the seizures fluctuated however his mental decline continued. He also had suffered from long-term depression. She says he was an alcoholic but ceased drinking about 10 years prior to his death.

There were 2 admissions to the Royal Hobart Hospital (RHH) in recent years. The first was between the 18 and 19 of July 2015 when he was diagnosed with a generalised tonic seizure. Mr Donnelly was next admitted to hospital between 25 and 26 September 2019 with an exacerbation of COPD and pneumonia.

The emergency records at the RHH indicate he was taken to hospital in May 2013 due to right hip pain at which time he was diagnosed with osteoarthritis, and on 18 July 2015 and 26 February 2016 with respect to seizures and on 25 September 2019 with respect to the exacerbation of COPD.

The outpatient records show that in relation to Mr Donnelly’s seizures he was first seen by the neurologist Dr Jones on 18 July 2015 and then again on 19 November 2015. Dr Hewer assessed Mr Donnelly and provided a very detailed report to the general practitioner dated 24 November 2016. She saw Mr Donnelly on 23 February 2017, 1 June 2017, 5 July 2019, 17 October 2019 and 23 January 2020. He was seen by Dr Cleary on 5 March 2019. In the notes

for the consultation on 17 October 2019 Dr Hewer records Mr Donnelly’s seizures occurred approximately 3 weekly. A recent seizure may have been provoked by a chest infection. He had stopped smoking cannabis and cigarettes in the past 3 months. Examination was normal. She did not think the valproate, which he had been prescribed, was adequately controlling his seizures “and he has reached the ceiling with this medication in terms of adverse effects. Given this I have elected to transition him over to Keppra… There is no issue with interactions with this medication and his pregabalin which he takes for post herpetic neuralgia. I discussed this with Dr Dean Jones, who has seen Chris in the past for his epilepsy. Dr Hewer’s notes for the consultation on 23 January 2020 noted Mr Donnelly had tolerated the change in medication well and his convulsive episodes had improved with him suffering only 2 seizures in the last 3 months and that related to him not taking his medication. He has had staring episodes with speech and motor arrest lasting 10 minutes with a prolonged post ictal period 2 to 3 times per week. However she notes he had been subject to significant stress and turmoil which involved moving to a share house and frequent visitors. He was unable to enjoy his usual solitude and he was unable to paint. He had been angry and sleeping poorly. As a result he and his wife were to move to a property closer to a daughter in Margate. At that consultation Dr Hewer discussed the possible influence the various social factors were having on his health and she thought it possible his sleep and stress would improve with the change of scene. She gave him a script to increase the Keppra dose if he did not settle. She thought he might be experiencing some psychiatric adverse effects with Keppra and it was possible this may worsen with the dose being increased but again until his living circumstances changed she said it was difficult to determine the actual cause of these symptoms.

Circumstances Leading to Death On 14 February 2020 Ms Herbert went to see her father as Mrs Donnelly had gone into hospital. She tried to encourage him to move to her cousin’s home for respite for both himself and Mrs Donnelly. She says he refused. She says he was quite lucid and was able to carry a conversation which had not been the case for a number of years. Ms Herbert says her father told her he needs some space and would stay at Margate. This she did not think unusual as he always had been one to isolate himself. He did however appear angry about his living situation and he was paranoid about his wife. Ms Herbert says at this time Mrs Donnelly had been working on renovating the house they owned with a view to selling it and she wanted to eventually buy a new property where her daughter would also live with her and Mr Donnelly to assist in caring for Mr Donnelly. Mr Donnelly was not happy with this. Ms Herbert says she and

her sister tried to reassure him over the next week that they would find a solution but she says he became fixated on these issues and he became angry. She intended to take him to his GP and get his medication reviewed but she says he passed away before she was able to do that.

Ms Herbert’s sister, Ms Lynch, and her brother, Timothy Donnelly, went to visit their father at approximately 4:20 PM on 25 February 2020. They went inside the address and found Mr Donnelly lying face down on his bed. A check for a pulse found no pulse was present. They then called emergency services.

Investigation After inspecting the scene and examining Mr Donnelly police found no suspicious circumstances surrounding his death. A note was found which is signed by Mr Donnelly and dated 24 February

2020. It is addressed to his wife. In that letter he expresses his anger at the situation in which he found himself and his unhappiness at living in Margate. In that letter he expresses the belief his wife was not acting in his best interests.

Dr Reid carried out a post-mortem examination on Mr Donnelly on 27 February 2020. He found there was no evidence of violence or injury, neglect or self-neglect which has caused or contributed to Mr Donnelly’s death. The results of toxicology did not contribute to Mr Donnelly’s death. There was a therapeutic level of an antidepressant found, a therapeutic level of paracetamol found and a sub therapeutic level of antiepileptic medication found. Dr Reid noted Mr Donnelly’s history of epilepsy and a purported history of dementia and says in his view the cause of death was SUDEP. This he says is a diagnosis of exclusion, given Mr Donnelly’s history of seizures, when there is an absence of sufficient evidence to explain an alternative cause of death. Dr Reid says there was no significant ischaemic heart disease and the changes of chronic bronchitis and emphysema found histologically would correlate with the clinical diagnosis of COPD but this condition was not sufficient to have caused Mr Donnelly’s death. I accept Dr Reid’s opinion.

Ms Herbert has expressed concern that Keppra was prescribed when Mr Donnelly had serious mental health issues and dementia. She has looked at the warnings on this medication and it identifies previous mental health issues are a concern when prescribing this medication. Given

this concern Dr Bell has examined this file. He noted the relevant past medical history at the appointments with Dr Hewer on 17 October 2019 and 23 January 2020. As to Keppra (Levetiracetam) he says it is relatively well tolerated. The most common adverse events include fatigue, somnolence, dizziness and upper respiratory infection. Most adverse events associated with this medication are mild-to-moderate in intensity and most often occur during the initial titration phase. Dr Bell goes on to say that neuropsychiatric side-effects can emerge beyond the initial titration period and may be the most common reason for the prescription of this drug ceasing. He quotes a post marketing survey of 354 patients in which sedation was the most common side effect, in 11% of patients, mood disturbance was not rare, at 5%, and was more likely to lead to discontinuation. Psychiatric adverse events for example behavioural disturbance or psychosis led to discontinuation in an additional 3%. Other anecdotal reports and observational studies describe increased agitation and aggression with this medication that may be problematic in some patients, particularly those who are intellectually disabled and/or who have baseline behavioural problems. Having considered the records Dr Bell concludes by saying the management of Mr Donnelly’s epilepsy was of a good standard. He says Dr Hewer was aware of the issues associated with Keppra. He says the good seizure control and the social circumstances in which Mr Donnelly found himself made continuation of this drug, in Dr Bell’s opinion, the better option. I accept Dr Bell’s opinion.

Comments and Recommendations Mr Donnelly died of natural causes in the circumstances set out above.

The circumstances of Mr Donnelly’s death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of Mr Donnelly.

Dated: 30 November 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner