Joy, Michael Joseph

INQUESTINTOTHECAUSEANDCIRCUMSTANCESSURROUNDINGTHEDEATHOFMICHAELJOSEPHJOY QUEENSLAND COURTS CORONERS COLJRT OF QUEENSLAND CITATION: INQUESTINTOTHE DEATH OFMICHAELJOSEPHJOY COURT: CORONERSCOURT.

FILENo: MACKAYCOR00000839/07(8) DEllVEREDON: 24 April 2009.

DELIVEREDAT: MACKAY HEARING DATES: 15 - 17April 2009 Findings of: ROSSRISSON, CORONER

CATCHWORDS: DEATH IN CARE.

REPRESENTATION: ASSISTING: Mr. S.J.HAMLYN-HARRIS.

FORMACKAY& Mr. W.G. COOPER,SolicitorofBill Cooper& Associates.

DISTRICTEDUCATION CENTRE: FORDISABILITY Mr. c.J. CLARK,Barrister, instructed by the State Crown SERVICES Law Office.

QUEENSLAND: 1/8

INQUESTINTOTHECAUSEANDCIRCUMSTANCESSURROUNDINGTHEDEATHOFMICHAelJOSEPHJOY These are my findings into the causeand circumstances surrounding the death of Michael JosephJOY.

zs" Mr. Joy'sdeath was reported to me asCoroner at Mackay on the February 2007. It was reported asa death due to natural causes those causes being unknown! and asa death in care", As I considered the death to be a reportable death I was required to undertake an investigation.3 Theinquiriesforthe purposes ofmyinvestigation were undertaken firstly byConstableJodie LBrennan, who provided the initial report in form 1 and subsequently by Detective Senior ts" Constable Michelle Goodman nee Allen. Her report dated the July 2007 contained a number of statements from people who were involved in some manner and other attachments such asareport, dated the i" March 2007 prepared by Mr. Peter Rice who was at the relevant time the Chief ExecutiveOfficerofthe Mackay and District Education Centre zs" (MADEC) and a Critical Incident report, dated the February 2007, prepared by Ms.

Charmaine Arnold who at the relevant time was a Program ResourceOfficer with Disability ServicesQueensland, Mackay.

The medical cause of death was established by an autopsy undertaken by Dr. Peter zs" FitzPatrick, Pathologist ofMackay on the February 2007.

As I decided that Mr. Joy's death was a death in care, in circumstances that raised issues about hiscare Iwas required to hold anInquest", A pre inquest conference was held on the 11th December 2008 and I heard evidence over rs" three daysfrom the April 2009. Given leaveto appear at the Inquestwere MADECwho was represented Mr. Bill Cooper solicitor and Disability Services Queensland who were represented by Mr. C.Clarkofcounsel.

Where an Inquestisheld section 45 ofthe CoronersAct 2003 requires the followingfindings to bemade if possible: - I CoronersAct2003 section 8(3)(e) 2CoronersAct2003 section 8(3) (f).

3CoronersAct2003 section 11(2).

4CoronersAct2003, section 27(1)(a)(ii).

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INQUESTINTOTHECAUSEANDCIRCUMSTANCESSURROUNDINGTHEDEATHOFMICHAElJOSEPHJOY

• who the deceasedis;and

• howthe person died; and

• when the person died; and

• where the person died; and

• what causedthe person to die.

How the person died means bywhat means or inwhat circumstancesthe person died and what causedthe person to die refers to the medical causeof death.

Inmakingmy findings Imust notinclude inthem astatementthat aperson isor may be guiltyofan offence orcivilly liable forsornethlng." Ialsomay, ifIthinkappropriate, comment upon anything that related to

• public health or safety; or

• the administration of justice; or

• waysto prevent deaths from happeningin similar circumstances inthe future." Again Icannot include in any comment Imight make, any statement that a person isor may beguiltyofanoffence or civilly liable forsomething.' Iam not conducting atrial and no party hasaright to appear at an Inquestand the purpose of an Inquest is lito seek out and record as many facts concerning the death as the public interest requires." In making my findings I only have to be satisfied on the balance of probabilities although "the seriousness ofthe allegation, the inherent unlikelihood ofan occurrence ofaparticular description or the gravity of the consequences flowing from a particular finding'} 9are matters which I must take into account in deciding if a matter has been proved on the balance ofprobabilities.

Michael JosephJoywas 43 years ofageat the time ofhisdeath having been born on the 1st March 1963. He was at that time residing at Unit 7, 26 Martin Street, North Mackay. This unit, which was provided by the Department of Housing, was one that was designed especiallyto accommodate persons who require the useofawheelchairfor mobility.

5Coroners Act2003, section45(5).

6CoronersAct2003, section46(1).

7CoronersAct2003, section46(3).

8RvSouth London Coroner; exparteThompson (1982) 126SJ 625 per Lane Cl 9BrigginshawvBrigginshaw(1938)60C.L.R. 336 3/8

INQUESTINTOTHECAUSEANDCIRCUMSTANCESSURROUNDINGTHEDEATHOFMICHAELJOSEPHJOY Mr. Joy suffered from Wilson's disease which is an inherited disorder in which too much copper accumulates inthe body. Hehadabrother andsister who hadalsosuffered from the disease and he contracted this at about the age of eleven years. Wilson's disease is a gradually debilitating diseasewhich haddeprived Mr. Joyofthe useofhislegs,requiring the use of awheelchair, and which was causing his upper body capabilities to deteriorate. Mr.

Joy's speech was also affected to the extent that Colin Bruce Joy his designated carer needed to be speakingto hisolder brother faceto face to be able to understand him. Asa result Mr. Joycould not communicate usingthe telephone.

Whilst Mr. Joy'scondition severely restricted hisability to carefor himselfit did not confine him to his unit. Although he was very limited as to what he could do he attended at the Endeavour Foundation regularly and had received his 25 year service award from that organisation. He also attended regularly at the Mt. Pleasant tavern where he was looked after by the patrons whose financial contribution had enabled the purchase of the wheelchairthat hewasusing.

Mr.Joyhadmoved into the unitat MartinStreet inSeptember 2006and atthis stagehewas being provided with care by several community organizations including OZCARE which provided personal care Monday to Friday, Pres-care which provided 1.5 hours of domestic assistanceeach week and three hours each fortnight for assistance with banking, shopping and similaractivitiesand MADEC.

OZCARE was providing hygiene servicesat the request ofMr. loy's doctorand this consisted of a morning service which included showering, shaving and general body hygiene. MADEC was providing a Night Attendant CareService(NAC)Which,becauseofthe servicesinvolved, was also referred to as a "tuck in" service. This simply involved a short visit, perhaps of about 10 minutes, where a check was made to see if he was in bed, had taken his medication, that the lightswere out andthe unitsecure.

This "tuck in" service had been in place sincethe 9thJanuary2006 and, whilst there were a substantial number of visits made when Mr. Joy was not home this did not create any problems. It wassimply amatterofthose workers calling backif they hadtime later in their shift.

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INQUESTINTOTHECAUSEANDCIRCUMSTANCESSURROUNDINGTHEDEATHOFMICHAElJOSEPHJQY During Octoberand November2006 Mr. Joyhadanumberoffalls. Asaresult ofhisproblem offalling, Mr. Joyspent sometime in the Mackay Base Hospital being discharged from there on 15th November2006.

Becauseof hiscondition he had a"VITALIJ call device. This isasmall device which could be worn round a person's neck like a necklace. When it was activated by being pushed it initiated a telephone call to a central location where the user of the device could be identified and, if they then could not be contacted by telephone, the Ambulance Service could becalled to attend attheir location.

Because of his problem with falls and also the fact that he was burning himself frequently when preparing anevening meal or ahot drink Mr. Joywasfaced with the prospect ofbeing placed inappropriately in a Nursing Home. Mr. Joy's condition clearly required greater assistancethan what he was receiving and, after a period ofemergency funding, Mr. Colin Joy obtained from Disability ServicesQueensland a recurrent funding package of $52,373 through the Adult Lifestyle Support Program. This occurred in December 2006 and during that month and January 2007 there were discussionsbetween Mr. Michael JOYI Mr. Colin Joy, Ms. Jo Richardson Supports Facilitator of Disability Services Queensland and service providers asto provision ofacarepackagebasedonthe amount offunding available.

Ultimatelyit wasagreedthat MADEC would provide 34hoursofcareper week andthat such care would consist of two hours of a morning and two hours of an afternoon seven daysa week making a total of 28 hours per week with the remaining six hours of care per week being usedfor communitycontact suchasgoingto the movies. Obviously with only 34hours ofcare being provided duringthe week there remained alarge period oftime when Mr. Joy if notcaredfor byfamily orfriends would beleftto careforhimself The NACor "tuck in" servicewasseparate and would continue asit had been provided. That zs" service was rostered separately. Bythe time that the day time service started on the January 2007the NACservice hadbeen inplacesinceJanuary2006.

When the day time service commenced there was ageneral idea of the hours of care that were to be provided although no care plan had been drawn up. Also there had not been enough time for any regular pattern to develop. Whilst MADEC hadto adapt to the needsof 5/8

INQUESTINTOTHECAUSEANDCIRCUMSTANCESSURROUNDINGTHEDEATHOFMICHAElJOSEPHJOy their clients a regular pattern as to the provision of care did contribute to the smoother funning ofthe service.

As part of the provision of its day time care service MADECoffice staff prepared a weekly roster matching clients with carers at agreed hours for the provision of care. At the time of zs" that Mr.Joywent on this roster for the week commencing the January 2007- the time of the commencement of the day time service to him - there were problems with their preparation. The problems were that they were not produced in a timely fashion for the carers and that clients were missed. It seems that with the more long term client with a regular pattern of care, the carers would point out when a client had been missed off the roster.

It is clear that Mr. Joy was missed off the roster for the 16th February 2007 in the week iz" commencing the February 2007 and on that date both the morning and afternoon serviceswere not provided. Whilst he wason the roster for Sunday the 18th February 2007 he did not receive the afternoon service as the carer failed to attend. Mr. Joy was again missedoffthe rosteron the 24th February 2007which isofcoursethe dayofhisdeath.

is" Whilst there isadispute asto whether or not the roster forthe week commencing the February 2007 wasthe first one she had prepared, it isclear that Ms. Shelley George in her role asDisability Coordinator prepared this roster. It isnot clear from the evidence whether this roster was checked by Ms. Karen Langtree who was Disability Manager and Ms.

George's supervisor. Ms. George was clearly dissatisfied with the training she received and the system in placeforthe preparation ofthe weekly rosters.

Onthe nightofthe 24th February 2007, Ms.CareenThereseCOOK andJanethaSophia JANSENVANVUUREN were rostered to provide the "tuckin" servicefor Mr. Joy.They arrived at hisunitat 26Martin Street, North Mackay at about 8.40 p.m. and Ms.JansenVan Vuuren attended at the unit whilst Ms.Cookwaited inthe car.Asthe front doorwas unlocked Ms.JansenVanVuuren entered the unitand ongetting no responsewhen she called outto Mr.Joyshelooked through the unitandfound him lying on hissideinthe foetal position onthe bathroom floor. Hispants were down and hiswheel chair wasjustin front ofwhere hewas lying.

Ms. JansenVanVuuren thinking at this stagethat Mr. Joy hadsimply fallen went out to the car to get Ms. Cookto come and help. Ms. Langtree was contacted and when it was shortly 6/8

INQUESTINTOTHECAUSEANDCIRCUMSTANCESSURROUNDINGTHEDEATHOFMICHAelJOSEPHJOY realized that there was something terribly wrong with Mr. Joy the ambulance was contacted. Whilst some faint signs of life might have been detected Mr. Joy could not be revived.

The evidence does not disclose where Mr. Joy's "Vital" call was at this time or what happened to it except thatat some stageit was returned to the organization that provided.

zs" Dr. FitzPatrick who conducted an autopsy on Mr. Joyon the February 2007 determined the cause of death as intra abdominal haemorrhage due to traumatic rupture of splenic blood vesselsdue to fall. He listed asother significant conditions contributing to the death but not related to the condition directly leading to the death as probable portal hypertension and Wilson's disease.Dr.FitzPatrickcould not saywith certainty if afall caused the rupture or the rupture caused a fall. Heconsidered that, in light of Mr. Joy's history of falls it wasmore likely hefell causingthe rupture.

Dr. Fitzpatrick could not give any indication of when this rupture may have occurred although he considered that Mr. Joy would have lost consciousness within a matter of minutes afterthe rupture.

Mr. Joywas missedoffthe roster becauseofhuman error. Thesystem in placeat thattime in February 2007 in relation to the preparation and checkingofrosters wasnotsuchasfar as possibleto ensure thatsuchanerrorwasdetected.Thefact that Mr. Joywasarelatively new client asfar asthe daytime serviceprovided byMADECwas concerned should not, asit appearsto have been, afactor inwhetheror notthat errorwasdetected.

The evidence suggests that whilst it took some time for there to be improvements in the system for the checking of rosters it was improved. The system now in place at MADECis computer based with the software flagging any client who may have been missed. Sucha system of course depends upon the information as to clients and agreed services being correctlyimputed at thestart.

Becausethe servicesthat MADECwasobliged to provide to Mr. Joyfor hiscarewere of limited duration eachdayMr. Joy'scarewould atothertimes haveto be provided byothers or hewould haveto take careofhimself. Apartfrom concluding that most likely Mr. Joyfell duringdaylight hours it isnotpossibleto determine evenanapproximatetime when that may have happened. Therefore, it isnot possibleto conclude that Mr. Joybeing leftoffthe 7/8

INQUESTINTOTHECAUSEANDCIRCUMSTANCESSURROUNDINGTHEDEATHOFMICHAElJOSEPHJOY daytime careservice roster forthe 24th February2007contributedto hisdeath inthe sense that if the contracted carehadbeenprovided hemayhavereceived medical assistance sooner andthus may havebeensaved.

It of course would only be natural that Mr. Joy'sfamily andfriends might harbour anagging doubtthat if agreedserviceshadbeen provided Mr. Joymight not havedied.

Theevidence does not raiseanyconcerns asto the involvementofDisability Services Queensland in the provision ofservicesbyMADECto Mr. Joyeitherbefore or after his death. Thedepartmentonly becameaware ofproblems aboutthe provision ofthe agreed servicesto Mr. Joyafterhisdeath.

With the introduction of the Disability Services Act 2006, the Minister has power to promulgate disability service standards, which would include administrative procedures of the service providers, which have legislative force and can be enforced by an external certification body known asQualityAssurance.

Thefindings that Iam required to make,ifpossible,bysection 45ofthe CoronersAct2003 are: ThedeceasedisMichael JosephJOY; and Mr.Joydied in the bathroom ofhisunitwhen hefell asheapparentlyattemptedto get out ofhiswheelchair; and Mr. Joydied on the 24th February2007; Mr. Joydied in hisunit at 7/26 Martin Street, North Mackayin the StateofQueensland; and.

Thecauseofhisdeath wasintra abdominal haemorrhage dueto traumatic rupture of splenic blood vesselsdueto afall.

Nothing hasbeen raisedinthe evidence upon which Icanappropriately comment pursuant to section 46 ofthe Act related to:

• public health or safety; or

• the administration ofjustice; or

• waysto preventdeaths from happening insimilarcircumstances in the future.

The Inquest isnow closed.

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