Finding into death of Manpreet Kaur

IN THE CORONERS COURT COR 2024 003444 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Paul Lawrie Deceased: Manpreet Kaur Date of birth: 16 September 1999 Date of death: 20 June 2024 Cause of death: PULMONARY AND MILIARY

TUBERCULOSIS Place of death: Melbourne Airport Arrival Drive Terminal 2, Melbourne Airport Victoria 3045 Keywords: Tuberculosis, access to free treatment

INTRODUCTION

1. On 20 June 2024, Manpreet Kaur was gravely ill when she boarded an international Qantas flight at Melbourne Airport at approximately 9.00am. Shortly before take-off, she collapsed and became unresponsive. Despite the resuscitation efforts of cabin crew, firefighters and paramedics, Manpreet could not be saved and was declared deceased at 10:30am. She was 24 years old.

2. Manpreet was an Indian national living in Wollert, Victoria, with a cousin and at least one other housemate. She had come to Australia in 2020 on a student visa and, more recently, had been working as a contractor for Australia Post.

THE CORONIAL INVESTIGATION

3. Manpreet’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. Sgt Kimberley Broadfoot was assigned as the Coronial Investigator for the investigation of Manpreet’s death and, together with other police members, conducted inquiries on my behalf.

7. This finding draws on the totality of the coronial investigation into the death of Manpreet Kaur. 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 Circumstances in which the death occurred

8. Two months prior to her death, Manpreet received multiple medications sent from India by post. Among Manpreet’s documents was a prescription from the Community Health Centre in Lehragaga, Punjab, India. The prescription was dated 10 April 2024 and included: Amoxycillin2; Pantoprazole, Cefixime (antibiotic), B complex vitamins; cofsils cough syrup; povidone iodine solution (and others that are illegible). The prescription was filled at a pharmacy in Lehragaga and, according to the invoice, the various medications were sent on 13 April 2024. I am satisfied that the prescription and order for the antibiotics and other medications are consistent with Manpreet seeking relief from a respiratory illness at that time.

9. On 19 May 2024, Manpreet consulted with Dr Syed Arif Ahmed GP at the Group One Medical Clinic in Epping. Her patient records reveal that she presented with a sore throat and partial loss of voice. Manpreet reported a “chesty cough” productive of mucus over the previous five to six days. There was no fever, and Manpreet reported no difficulty breathing and there was no wheeze present. Dr Arif recorded that, on examination Manpreet “looks well” and “throat fine”, albeit that harsh breath sounds were also noted. Manpreet’s vital signs were within reasonable parameters, and Dr Arif’s ultimate impression was that she was suffering from a viral upper respiratory tract infection. The treatment plan was recorded as “REST FLUIDS

AND REVIEW IF ANY WORSE OR NEW SYMPTOMS TO SEE ANY DR IF THAT HAPPENS IMMEDIATELY”. There was no prescription for medication, but a medical certificate was issued excusing Manpreet from work for the next two days. This appears to be the last contact Manpreet had with a medical practitioner prior to her death.

10. Manpreet’s cousin reported that Manpreet had been sick for months and had not recently sought medical care. She was not able to eat properly because of what was thought to be a throat infection. In the week before her death, Manpreet had not been eating at all and drinking 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.

2 Shipped as Novaclav-625 tablets

only cold tap water. Approximately three days before her death she ate a single piece of papaya but vomited immediately.

11. It remains unclear why Manpreet did not return to Dr Ahmed or seek other medical help in the weeks before her death, when she must have been very unwell and deteriorating. It is possible that she was concerned about the status of her visa, or that admission to hospital may have complicated her situation.

12. On 18 June 2024, a return ticket for Manpreet to fly from Melbourne to New Delhi was purchased from India through a travel agent. The return flight was booked for 24 July 2024.

13. On the morning of 20 June 2024, Manpreet was driven (via a rideshare service) to Melbourne Airport by her cousin and her housemate. She had to be assisted at every stage.

14. At autopsy, it was revealed that Manpreet was emaciated and weighed a mere 26 kg3. This description is in stark contrast to her healthy appearance in her identification photo as a contractor for Australia Post. I am satisfied that she had been seriously ill for several weeks and her deterioration over that period must have been apparent to those in regular contact with her. By 20 June 2024, it should have been obvious to her cousin and housemate that she needed emergency medical care and was in no way fit to embark on a 12 to 13 hour international flight. To be clear, this observation does not extend to the airline ground crew or cabin crew who, in the circumstances of their duties and limited contact with Manpreet, could not be expected to deduce that her presentation was due to an acute illness.

15. At approximately 9.00am, Manpreet boarded Qantas flight QF69 to New Delhi. She was in an airline wheelchair assisted by ground staff, and then by cabin crew. According to the member of the cabin crew greeting passengers as they boarded the aircraft, she seemed “very fragile” and would not verbally confirm anything but would nod her head. She was pale and very quiet. The cabin crew member lifted her from the wheelchair to her seat and fastened the seatbelt for her.

16. At approximately 9.30am, after all passengers had boarded the aircraft, the cabin crew began the safety briefing. As the aircraft was taxiing, a passenger sitting next to Manpreet raised the alarm. Manpreet had slumped over and was apparently unresponsive. Members of the cabin crew rendered first aid with portable oxygen and a mask. They also applied a defibrillator, but the device indicated “shock not advised”. Crew members continued cardio pulmonary 3 Body mass index of 11.7

resuscitation for seven to ten minutes before paramedics arrived and Manpreet was evacuated to the terminal building. Notwithstanding these efforts, she could not be revived and was pronounced deceased at 10:30am.

Identity of the deceased

17. On 24 June 2024, Manpreet Kaur, born 16 September 1999, was visually identified by her friend, Gurdip Singh Grewal.

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

Medical cause of death

19. Associate Professor Linda Iles, Head of Forensic Pathology at the Victorian Institute of Forensic Medicine conducted an autopsy on 24 June 2024 and provided a written report of her findings dated 13 August 2024.

20. The post-mortem examination revealed severe cachexia4 [emaciated at 26 kg / 149 cm – BMI of 11.7]. There was significant damage to the left lung (lower lobe) consistent with tuberculosis pneumonia and the appearance of a miliary pattern of infection in the right lung.

21. Toxicological analysis of post-mortem samples did not identify the presence of any alcohol or other common drugs or poisons. Microbiological analysis revealed Mycobacterium tuberculosis (TB) in both lungs.

22. Associate Professor Iles provided an opinion that the medical cause of death was PULMONARY AND MILIARY TUBERCULOSIS.

23. I accept Associate Professor Iles’ opinion.

4 A metabolic syndrome related to underlying illness and characterised by muscle mass loss (with or without fat mass loss) – also known as “wasting syndrome”.

FINDINGS AND CONCLUSION

24. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Manpreet Kaur, born 16 September 1999; b) the death occurred on 20 June 2024 at Melbourne Airport Arrival Drive Terminal 2, Melbourne Airport Victoria 3045, from PULMONARY AND MILIARY

TUBERCULOSIS; c) the death occurred in the circumstances described above.

COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.

25. The tragedy of this case is compounded by the fact that treatment for tuberculosis is provided free of charge in Australia to anyone who needs it, regardless of Medicare eligibility or residency status. In Victoria, services for treatment are provided through the Victorian Tuberculosis Program, run by the Doherty Institute as a joint venture between the Royal Melbourne Hospital and the University of Melbourne.

26. The need remains for all agencies connected with the Victorian Tuberculosis Program, including the Department of Health, to ensure that their outreach to the Victorian public is as effective as practicable, particularly to persons who are non-residents or are from culturally and linguistically diverse communities.

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

I thank the Coronial Investigator and those assisting for their work in this investigation.

Pursuant to section 73(1B) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I direct that a copy of this finding be provided to the following: Paramjeet Kaur & Gurjeet Singh, Senior Next of Kin The Doherty Institute Department of Health, Victoria Qantas Airways Limited Sgt Broadfoot, Coronial Investigator Signature: ___________________________________ Coroner Paul LawrieCORONER PAUL LAWRIE 17 September 20254 September 2025 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.