Inquest into the Death of Davies, Adriana Elise

Coroners Act, 1996 [Section 26(1)]

Western Australia

RECORD OF INVESTIGATION INTO DEATH Ref No: 33-07

I, Alastair Neil Hope, State Coroner, having investigated the death of Adriana Elise DAVIES, with an Inquest held at Perth Coroner’s Court on 4 Decentber 2007 and 17 July 2013 find that the identity of the deceased person was Adriana Elise DAVIES and that death occurred on 12 October 2005 at Sir Charles Gairdner Hospital as a result of brain swelling and dural venous thrombosis in association with

low grade glioma of the brain in the following circumstances -

Counsel Appearing :

Sgt Sorrell assisting the State Coroner

Mr Dominic Bourke appeared for Dr Griffies Mtr Keith Bradford appeared on behalf of the family of the deceased

INTRODUCTION

Adriana Elise Davies (the deceased) was a 46 year old medical practitioner working in Albany in Western

Australia.

The deceased died on 12 October 2005 at Sir Charles

Gairdner Hospital following a transfer from Albany Hospital.

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A post mortem examination was conducted on the deceased by Chief Forensic Pathologist, Dr C T Cooke, on 14 October 2005 and following results of further investigations on 13 June 2007 he formed the opinion that the cause of death was brain swelling and dural venous sinus thrombosis in association with low grade glioma of the

brain.

In a brief explanation of his findings Dr Cooke noted that examinations showed swelling of the brain and subsequent neuropathology examination confirmed the presence of a low grade tumour (low grade glioma) in the brain. There was brain swelling with evidence of compression of the brainstem, due to a blood clot in the main veins on the surface of the brain (dural venous sinus thrombosis). He noted that there is a described association between dural venous sinus thrombosis and brain swelling which may result in compression of the vital centres (controlling the heart and respiration) in the brainstem,

which may be fatal.

The deceased had been in a relationship with Kerry Moir for a number of years and following her death Mr Moir raised a number of concerns in relation to her medical

treatment in the period before her death.

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In particular Mr Moir was concerned about her treatment after he took her to the Casualty Section at Albany Hospital at about 8am on 10 October 2005 and left her there to see a Dr Michael Griffies, her general

practitioner since 31 October 2002.

In the context of Mr Moir’s concerns First Class Constable Shannon Narrier of the Coronial Investigation Unit wrote to Dr Griffies and asked him to provide answers to a number of Mr Moir’s questions. Dr Griffies declined to

provide those answers.

On 6 July 2007 as State Coroner I wrote to Dr Griffies enclosing a copy of the questions asked by Mr Moir and again asked Dr Griffies to provide answers to those

questions.

Dr Griffies was advised that in the event that he did not answer the questions and an inquest was held, a coroner would have the power to order him to answer the

question pursuant to Coroners Act 1996 (WA) s46.

Dr Griffies still did not answer the questions asked and

for that reason this inquest was held on 4 December 2007.

At the inquest Mr D J Burke appeared to represent Dr Griffies and Mr K J Bradford appeared to represent the

interest of the family.

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At the inquest Mr Burke advised that Messrs Jackson McDonald, Solicitors, had been instructed by RiskCover in relation to a civil claim brought by Mr Moir in the District Court of Western Australia against Dr Griffies. In those proceedings Dr Griffies was indemnified by RiskCover. It appears that Messrs Jackson McDonald advised Dr Griffies that he should not volunteer answers to Mr Moir’s questions given that Mr Moir was pursuing those District Court

proceedings.

Mr Burke advised that Dr Griffies felt obliged to follow that advice, but intended to fully cooperate with the

investigations.

In that context it was necessary for Dr Griffies to be

called to give sworn evidence.

At the conclusion of Dr Griffies’ evidence the matter was adjourned and advice was sought from Mr Bradford as to whether there were further issues which should be the subject of oral evidence. On 12 February 2008 the Coroner’s Court received a submission from Bradford and Co in respect of taking the matter forward. On 18 April 2008 I, as State Coroner, responded to those submissions and sought further advice from Mr Bradford so that the

inquest could be progressed.

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From that time until this date no response has been received from Mr Bradford or Bradford and Co. On 28 February 2013 the Manager Listing with the Coroner’s Court wrote to Mr Bradford advising that if no response was to be received by 29 March 2013 it was intended that a finding would be made based on the evidence contained on

file.

It was in the above somewhat unsatisfactory circumstances that the police investigation file and reports obtained have been received into evidence and these findings are made. As no adverse findings are to be made in

these circumstances, no further submissions were sought.

THE PAST RELEVANT MEDICAL HISTORY OF DR DAVIES

In 2000 Dr Davies was diagnosed as having Bipolar Affective Disorder and she was admitted to the Hollywood Clinic in November 2000.

In 2001 Dr Davies had a seizure following which a CT scan at Fremantle Hospital showed the presence of a right sided space occupying lesion of the brain thought to be a possible low grade glioma. She was transferred to Sir Charles Gairdner Hospital on 23 May 2001 for an MRI but discharged herself from hospital prior to that test being

carried out.

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From 31 October 2002 the deceased started to consult Dr Michael Griffies as her general practitioner. He saw her on 21 occasions in his surgery for management of her

migraine, bipolar disorder, brain tumour and other matters.

In July 2005 the deceased saw Mr Wayne Thomas, Neurosurgeon, at the request of Dr Griffies, for advice regarding management of her brain tumour. He ordered an MRI scan of the brain which was done on 7 July 2005. This revealed a mass effect in the right cerebral hemisphere mainly confined to the temporal lobe. The mass effect did involve thickening of the cortex. He reported to Dr Griffies that the imaging report suggested that there was a diffuse

intrinsic neoplasm such as a glioma.

In a letter dated 8 July 2005 he advised Dr Griffies that it would be important for her to repeat the scan from time to time and he had suggested that she undergo another cranial MRI scan in 12 months. He advised, ‘Should she develop neurological symptoms of concern between now and then or bad headaches other than her

migraine the scan could be brought forward’.

In September 2005 Dr Davies developed lightheadedness and spinning sensations which she put down to stress. She saw Dr Griffies who put her symptoms down to

migraine.

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On 6 October 2005 the deceased told Mr Moir that she

felt unwell and wanted an early night.

On Saturday 7 October 2005 she stayed in bed all day.

She said that when she put her head up she felt pressure and a pulsating pain. She said the pain would come in waves and that this was different from a migraine as it was

an outward pressure pain.

This pain continued through to the morning of 10 October 2005 and at about 8am Mr Moir took the deceased to the Casualty Unit at Albany Hospital. He left her at the hospital because she had to wait for Dr Griffies to

finish his rounds to see her.

Dr Griffies did see her at about 8.40am and she left the hospital at 8.55am.

When Dr Griffies saw the deceased she was in a lot of pain and was in a darkened room because she was

photophobic.

Dr Griffies formed the diagnosis that she was suffering

from a migraine headache.

Dr Griffies made no notes as to how he came to that

conclusion.

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At the inquest Dr Griffies was asked:

If this was a migraine, it would have been a pretty severe one, wouldn’t it?---Yes. !

Dr Griffies was asked what made him so confident that the deceased was suffering from a migraine to which he

responded:

The fact that it was — she had a past history of migraines: and it was pulsatile: that she had it for two or three days; that she had photophobia. She didn’t like the light. She had been vomiting.

She had been nauseating.?

Dr Griffies was referred to an account of Mr Moir contained in his statement in which he claimed that the deceased had told Dr Griffies that, It was not a migraine’.

According to this account she told Dr Griffies that she ‘didn’t go blind with migraines and she said, “I can’t bloody

see you”.’

In evidence Dr Grifies claimed he could not specifically remember the deceased telling him that what she was suffering from was not a migraine and he considered it

unlikely that the conversation was in those terms.

Whatever was said, it is clear that Dr Griffies did not conduct any comprehensive neurological examination or any examination of the optic fundi for papilloedema, a swollen appearance of the optic nerve on the retina which

indicates the presence of raised intra-cranial pressure.

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The deceased was sent home and during the day she

self injected with Stemetil.

The deceased presented again that evening and was seen by the on call doctor, Dr Broughton, who admitted her

to the hospital for pain relief.

Dr Broughton’s entry into the Integrated Progress Notes timed at 6.15 that night records:

Different sort of headache from usual migraine, frontal and pulsatile, worst on forward posturing. Associated nausea and a little vomiting.

Dr Broughton noted that on examination she had

‘knitted brows’ and was holding her head.

Dr Broughton’s notes indicate that in the neurological examination ‘fundi look okay but poor view’. This indicates

that the optic fundi had been examined.

Dr Griffies reviewed the deceased on the ward the next morning, 11 October 2005, and after discussion with her decided to try a different form of pain relief. He ordered a CT scan and left the ward. He claimed that her headache was mostly left sided and his diagnosis was still an atypical migraine although he then had to consider that her brain tumour might have been contributing to the pain, although

the tumour was on her right side.

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In evidence Dr Griffies advised that he still did not conduct any neurological assessment of her and stated that was because she had been assessed the night before by

Dr Broughton.

When asked why he did not conduct his own assessment of her and only relied on what Dr Broughton had done ten to twelve hours earlier, Dr Griffies gave evidence that this approach was adopted because, ‘.. it wasn’t going to change what I did and it would cause her

pain and inconvenience’s.

Dr Griffies obtained the report of the CT scan that afternoon and claimed that it reported no obvious change from the last report that the radiologist had on hand

although he did not have access to other previous films.

It appears that the deceased developed signs suggestive of coning as soon as she got back to the ward after the CT scan. Other doctors attended and organised her transfer by the Royal Flying Doctor Service to Sir Charles Gairdner Hospital where she subsequently failed to respond to any treatment and passed away the following

day, on 12 October 2005.

ét. 11

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In the above circumstances and in the context of the post mortem examination report, it is clear that the deceased died as the result of brain swelling and thrombosis. In a report from Austin Pathology it was noted that diffusely increased cellularity extended into the right basal ganglia and thalamus. The diagnosis in part was that there were features consistent with death due to acute cerebral swelling, with widespread vascular congestion, evidence of brainstem compression and early perivascular midline haemorrhage formation, together with focal anoxic ischaemic type neuronal damage consistent with survival for

some hours after an acute event.

In my view it is clear that the pain which the deceased referred to for most of the period from 7 October 2005 until she died on 12 October 2005 was not migraine pain but was caused by the serious problems with her brain which

resulted in death.

I find that the death arose by way of natural causes.

A N HOPE STATE vfapns

17 ie

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