Coroner's Finding: Cameron, Hugh Hutton

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Leigh Mackey, Coroner, having investigated the death of Hugh Hutton Cameron Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Hugh Hutton Cameron. Mr Cameron was 88 years of age (date of birth 23 May 1934) when he died. He lived with his wife, Zena, at Conningham. Mr Cameron and Zena married in 1956 and his death occurred just shy of their 66th wedding anniversary. Mr Cameron emigrated from Scotland to Australia, settling in Victoria, in the 1960s. During their marriage they had three children, Susan Barwick, Eleanor Redhead and Hugh Cameron. In 1998 they moved to Tasmania where they lived in their own home at Conningham.

Mr Cameron was a qualified butcher and worked in that trade for over 50 years.

He also undertook home handyman repairs. Zena describes Mr Cameron as a “very hard working man”.1 During his working years Mr Cameron suffered an injury to his ankle which required a fusion and caused difficulties with his gait.

Consequently he received a disability support pension.

Mr Cameron had a medical history of cardiac issues, had undergone bilateral hip replacements and, from approximately 2016, commenced to experience gradual cognitive decline principally impacting his memory. At times Mr Cameron experienced dizziness and in July 2021 suffered falls when he slipped on an icy concrete path causing pain in his hip and skin tears. Otherwise Mr Cameron was well. He enjoyed gardening and was to his family a “very caring gentle man”.2 Mr Cameron and Zena lived alone in their home at Conningham up until Mr Cameron’s death. They enjoyed the ongoing support of their children and were largely independent in their care, looking after each other’s needs, with support for cleaning, gardening and shopping, received from Christian Homes through an aged care package. An assessment undertaken on Mr Cameron’s care needs on 1 Affidavit of Zena Cameron sworn 9 September 2022 p2.

2 RHH medical records medical notes 13 August 2022.

10 May 2022 noted that whilst Mr Cameron had the capacity to walk “reasonable distances”3 he could, at times, be unsteady on his feet and had fallen in the garden the previous winter.

b) On 10 August 2022 Mr Cameron fell inside his home. He suffered an injury to his thumb. He and Zena travelled into the Emergency Department (ED) of the Royal Hobart Hospital (RHH) for Mr Cameron to be assessed. The thumb injury was diagnosed as a dislocation and was subsequently relocated. When examined at the ED, Mr Cameron denied suffering a head strike in the fall nor a loss of consciousness. He was alert and orientated to time person and place, looked well and had a Glasgow Coma Score (GCS) of 15. Mr Cameron was assessed as having suffered a fall at home without head strike4 and no scanning was undertaken of his brain. After some hours in the ED Mr Cameron and Zena returned home.

Over the next few days Mr Cameron felt tired. On 12 August 2022 he complained of a headache but was, however, in “good spirits”.5 In the early evening Zena was alerted that something was wrong when Mr Cameron failed to respond when she asked him a question. Zena called for an ambulance. Mr Cameron stood up from his chair and walked a few paces forward. Zena moved her walker in front of him and he lent on her shoulder before collapsing onto the ground bringing Zena down with him.

Whilst on the ground Mr Cameron experienced prolonged seizure activity. On arrival at the home paramedics from Tasmania Ambulance found both Mr Cameron and Zena still on the ground. Mr Cameron was observed to be experiencing tonic clonic seizures and was assessed initially as having a GCS of 6 which deteriorated enroute to the RHH to a GCS of 3. At the ED, CT scanning demonstrated a subdural haematoma (SDH). Discussion occurred with the family in which the event was explained to be life ending and the decision was made to provide comfort care and palliation.

c) I have been assisted by Dr Andrew Reid, Staff Specialist-Forensic Pathologist, who examined Mr Cameron and provided a report into the cause of his death.6 Dr Reid considers Mr Cameron’s death was caused by an acute traumatic left cerebral convexity SDH, probably suffered at the same time as Mr Cameron’s thumb injury on 10 August 2022, although he could not exclude the possibility of 3 ACAT assessment 10 May 2022 forming part of the RHH medical records.

4 RHH medical records emergency department notes 10 August 2022.

5 Affidavit of Zena Cameron sworn 9 September 2022 p3.

6 Opinion of the forensic pathologist dated 15 August 2022.

a separate episode of trauma as causative of the SDH noting that such an injury can occur following relatively minor trauma when there is a background of cerebral involution.7 I accept Dr Reid’s opinion and find that Mr Cameron’s cause of death was acute traumatic left cerebral convexity SDH.

d) Mr Cameron died on 14 August 2022 at Hobart, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Cameron’s death. The evidence includes:

• The Police Report of Death for the Coroner;

• Tasmanian Health Service Death Report to Coroner;

• Affidavit of identity;

• An opinion of the forensic pathologist regarding cause of death;

• Affidavit of Zena Cameron, Mr Cameron’s wife;

• Medical records of Mr Cameron; and

• Report of Dr Anthony Bell MD FRACP FCICM, medical advisor to the Coronial Division.

Comments and Recommendations Given Dr Reid’s findings together with the absence of any incident documented between the fall of 10 August 2022 and the 12 August 2022 collapse, the observation that between the two incidents Mr Cameron expressed tiredness and on 12 August 2022 a headache, I find it probable that a SDH was suffered by him in the fall on 10 August 2022. Accordingly, the circumstances of Mr Cameron’s death raise the question as to the standard of care given to him when he attended at the ED following his fall on 10 August 2022, specifically whether scanning of Mr Cameron’s brain ought to have, at that time, been undertaken, which may have revealed the existence of an SDH.

At the time of his examination at the ED on the 10 August 2022, Mr Cameron did not give a history of head strike, loss of consciousness and presented as alert and orientated. He had clearly suffered a dislocation injury to his thumb which was appropriately treated. Further investigations were undertaken to explore the cause of the fall through a blood test. However, whilst Mr Cameron’s assessment and treatment at the ED in respect of the fall generally and dislocated thumb specifically was thorough and appropriate, no scanning was undertaken of Mr Cameron’s brain.

7 Cerebral involution refers to the natural shrinking of the brain with age.

In considering the response of the ED to the presentation of Mr Cameron on 10 August 2022, I have been assisted by Dr Anthony Bell MD FRACP FCICM, medical advisor to the Coronial Division, who conducted a review of the RHH medical records. Dr Bell notes that a SDH is a form of intracranial haemorrhage characterised by bleeding into the space between the dural and arachnoid membranes surrounding the brain.8 SDH is commonly caused by trauma and in susceptible patients the trauma required to cause a SDH can be trivial. Patients who have cerebral atrophy, cerebral involution or other risk factors can be susceptible to SDH.9 Dr Bell concludes that it is probable that Mr Cameron’s SDH was suffered in the fall of 10 August 2022 noting the presence of age-related cerebral atrophy. At the time he presented at the ED following the fall he was lucid, alert and orientated. Symptoms of the SDH did not become evident until blood slowly accumulated in the subdural space and caused pressure effects on the brain. This occurred well after Mr Cameron had left the ED and returned home.10 Dr Bell has concluded following his review that there was no indication for scanning to have been conducted on Mr Cameron at the time he presented at the ED on 10 August 2022 and his care at the RHH at that time was appropriate.11 I agree with Dr Bell’s conclusions and determine that the circumstances of Mr Cameron’s death are not such as to cause 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 Cameron.

Dated: 30 June 2025 at Hobart Coroners Court in the State of Tasmania.

Leigh Mackey Coroner 8 Report of Dr Bell dated 21 September 2022 p2.

9 Opinion of the forensic pathologist dated 15 August 2022 and Report of Dr Bell dated 21 September 2022 p2.

10 Report of Dr Bell dated 21 September 2022 p2.

11 Report of Dr Bell dated 21 September 2022 p3.