Finding into death of Loreta Maria Del Rossi

IN THE CORONERS COURT COR 2024 002832 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Judge John Cain, State Coroner Deceased: Loreta Maria Del Rossi Date of birth: 8 September 1925 Date of death: 22 May 2024 Cause of death: 1(a) Multi-organ failure following amanita poisoning Place of death: Eastern Health Wantirna Hospital, 251 Mountain Highway, Wantirna Victoria 3152 Keywords: Wild mushrooms; death cap mushrooms; foraging

INTRODUCTION

1. On 22 May 2024, Loreta Maria Del Rossi was 98 years old when she passed away at Eastern Health Wantirna. At the time of her death, Loreta lived in Bayswater, Victoria, with her adult son, Nicola Del Rossi.

2. Loreta migrated to Australia from Italy with her son and daughter, in December 1955. Loreta had her own vegetable garden in her son’s backyard, where she grew multiple vegetables for use in the meals she prepared for herself and her son. She was known to regularly collect wild edible grasses such as dandelion, milk thistle and cat’s ear.

THE CORONIAL INVESTIGATION

3. Loreta’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.

4. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

5. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.

6. Victoria Police assigned Senior Constable Peter Thomson officer to be the Coroner’s Investigator for the investigation of Loreta’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, and investigating officers – and submitted a coronial brief of evidence.

7. This finding draws on the totality of the coronial investigation into the death of Loreta Maria Del Rossi including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for

narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased

8. On 22 May 2024, Loreta Maria Del Rossi, born 8 September 1925, was visually identified by her grandson, Jeremy Del Rossi.

9. Identity is not in dispute and requires no further investigation.

Medical cause of death

10. Forensic Pathologist Adjunct Associate Professor Sarah Parsons, from the Victorian Institute of Forensic Medicine (VIFM), conducted an examination on 23 May 2024 and provided a written report of her findings dated 6 August 2024.

11. The post-mortem examination revealed findings consistent with the reported circumstances.

12. Examination of the post-mortem CT scan showed widespread peripheral oedema, bilateral small pleural effusions and calcified hilar nodes.

13. Toxicological analysis of ante-mortem samples identified the presence of ondansetron, alphaamanitin and beta-amanitin. The amatoxins are a series of nine peptide toxins produced by the Amanita, Galerina and Lepiota genera of mushrooms. The most toxic amatoxins are α-, β-, and y-amanitin, which are notably produced by the Amanita phalloides species, widely known as the ‘death cap’ mushroom. α-, β-, and y-amanitin exhibit high human toxicity and can be lethal due to potent and selective inhibition of RNA polymerase.

14. The estimated lethal dose of amatoxins in humans is 0.1 mg/kg. As such, a 50g mushroom may contain a potentially fatal quantity of anatoxins for a 70kg adult.

15. Adjunct Associate Professor Parsons provided an opinion that the medical cause of death was multi-organ failure following amanita poisoning.

1 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

16. I accept Adjunct Associate Professor Parsons’ opinion as to the medical cause of death.

Circumstances in which the death occurred

17. In about April 2024, Loreta informed Nicola that there were some mushrooms growing in the front yard of their home and asked him if he thought they would be safe to pick and use in a meal. Loreta stated that she would pick, wash, clean and test them before cooking and eating them. Nicola recalled the mushrooms his mother picked were white in colour.

18. Loreta picked and prepared the mushrooms as she advised Nicola she would. Nicola prepared a meal of rice and tuna, which contained the mushrooms that Loreta picked. Both Nicola and Loreta did not fall ill after consuming the meal and did not experience any other negative effects.

19. Shortly before 15 May 2024, Loreta found more mushrooms growing in the same location in the front yard. She told her son that she would pick them and prepare them in the same way she had done one month earlier. On 15 May 2024, Nicola prepared the same meal of tuna and rice, with the mushrooms his mother picked earlier. They both ate the meal that night, did not feel unwell, and went to bed as per their usual routine.

20. At about 2.00am on 16 May 2024, Nicola awoke and heard Loreta getting up to use the bathroom. Nicola initially did not think anything was wrong, however later that morning between 3.00am and 4.00am, he got out of bed to ask if his mother was alright. Loreta replied that the mushrooms were not good and that she had been vomiting since about 2.00am. Nicola thought this may have been a simple case of food poisoning, as he had not experienced any ill effects himself.

21. At about 5.00am, Nicola’s alarm sounded so he got up and started getting ready for work. At about 6.00am, he felt unwell and also started vomiting. Loreta instructed Nicola to call for an ambulance, so Nicola called 000. An ambulance arrived quickly and transported both Loreta and Nicola to the Angliss Hospital. Nicola was later transferred to the Austin Hospital for treatment, whilst Loreta remained at the Angliss Hospital.

22. Angliss Hospital staff discussed Loreta’s case with the Austin Hospital toxicology team, who recommended activated charcoal, n-acetylcysteine and silibinin for 48 hours, and continuous bloods monitoring. Despite aggressive treatments, Loreta’s condition continued to deteriorate, and she told staff that she was in significant pain. Given her deterioration, and in line with Loreta’s wishes, active treatments were withdrawn, and Loreta was transferred to Eastern

Health Wantirna for palliative care and symptom management on 20 May 2024. Loreta passed away on 22 May 2024.

PUBLIC SAFETY CAMPAIGNS ABOUT WILD MUSHROOMS

23. On 5 April 2024, shortly before Loreta picked and consumed the poisonous mushrooms, the Victorian Department of Health (DoH) published a health advisory on their website about the dangers of picking and consuming death cap and yellow-staining mushrooms. The DoH advised the public not to pick or eat wild mushrooms in Victoria, unless they are an expert in that area. The DoH also recommended removing any mushrooms growing from gardens to prevent accidental ingestion by pets and children. I also note an X/Twitter post from May 2022 in which the DoH warned Victorians that poisonous mushrooms were growing in Victoria at that time.

24. The Department’s ‘Better Health’ website2 similarly describes yellow-staining mushrooms and death cap mushrooms, how they can be identified and advises consumers to avoid eating any mushroom that has not been purchased from a supermarket or green-grocer. The website advises anyone who believes they may have consumed a poisonous mushroom to immediately contact the Victorian Poisons Information Centre (VPIC) for advice, or to call 000/present to a hospital in an emergency.

25. Wild mushrooms typically grow in Victoria in autumn, as the weather becomes wetter and cooler. The yellow-staining mushroom is often confused for edible mushrooms that can be purchased in supermarkets and are the most commonly eaten poisonous mushroom in Victoria.3 The death cap mushroom is usually whitish, yellow, pale brown or green in colour and often grow under oak trees in Victoria.4

26. Consuming yellow-staining mushrooms can cause abdominal cramps, nausea, vomiting and/or diarrhoea. Consuming death cap mushrooms can cause violent stomach pains, nausea, vomiting and/or diarrhoea. Even if initial symptoms subside, serious liver damage may occur that can lead to death.5 2 Better Health: Mushroom Poisoning - https://www.betterhealth.vic.gov.au/health/healthyliving/mushroom-poisoning; accessed 19 September 2024.

3 Ibid.

4 Ibid.

5 Department of Health: Poisonous mushrooms growing in Victoria – Health Advisory - https://www.health.vic.gov.au/health-advisories/poisonous-mushrooms-growing-in-victoria; accessed 19 September 2024.

27. I commend the DoH for publishing a health advisory regarding the consumption of wild mushrooms, however I believe that additional public awareness is merited. I therefore recommend that the DoH, in conjunction with the VPIC, design an annual advertising campaign that can be released each year in early autumn, when wild mushrooms are prevalent in Victoria highlighting the dangers of consuming wild mushrooms.

FINDINGS AND CONCLUSION

28. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Loreta Maria Del Rossi, born 8 September 1925; b) the death occurred on 22 May 2024 at Eastern Health Wantirna Hospital, 251 Mountain Highway, Wantirna Victoria 3152, from multi-organ failure following amanita poisoning; and c) the death occurred in the circumstances described above.

RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendations:

(i) That the Department of Health, in conjunction with the Victorian Poisons Information Centre, design and run an annual advertising campaign that can be released each autumn, to warn Victorians about the dangers of consuming wild mushrooms.

I convey my sincere condolences to Loreta’s family for their loss.

I direct that a copy of this finding be provided to the following: Nick Del Rossi, Senior Next of Kin Department of Health Eastern Health Victorian Poisons Information Centre Senior Constable Peter Thomson, Coroner’s Investigator

Signature: ___________________________________ Judge John Cain State Coroner Date: 28 October 2024 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.