Coroner's Finding: Stephens, Vicki Lavinia

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of Vicki Stephens Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Vicki Lavinia Stephens (Ms Stephens); b) Ms Stephens died in the circumstances set out further in this finding; c) Ms Stephens’ cause of death was klebsiella pneumonia sepsis and rhabdomyolysis after a fall at home; and d) Ms Stephens died on 4 February 2022 at the Royal Hobart Hospital (RHH) at Hobart, Tasmania.

In making the above findings, I have had regard to the evidence gained in the comprehensive investigation into Ms Stephens’ death. The evidence includes the police report of death, affidavits establishing identity and life extinct, an opinion of the forensic pathologist, an affidavit from one of Ms Stephens’ daughters, Janelle Smith, medical records and reports, records from Ambulance Tasmania (AT), and forensic evidence.

Although Ms Stephens’ daughters initially objected to any post mortem being conducted, Ms Nicky Stephens on behalf of her sister Janelle Smith and herself, advised my associate Senior Constable Alisha Barnes in writing, that they “are okay with the less invasive procedure to happen, only if needed.” She advised they did not wish for a full autopsy to take place as they “are happy with the level of care from the hospital and do not require and (sic) further information regarding her passing.” The advice I received from the forensic pathologist is that he needed to perform a limited autopsy which consisted of an external examination, a review of medical records and the police report of death and taking photographs. I therefore directed him to perform a limited autopsy.

Ms Stephens was 65 years of age and she lived alone at the date of her death. She received assistance from a carer on a regular basis. Ms Stephens had a number of pre-existing health difficulties which included asthma, chronic obstructive pulmonary disease, high blood pressure,

ischaemic heart disease and she had previously undergone a spinal fusion. There is also a history of heavy alcohol use and alcoholic hepatitis. Ms Stephens suffered a number of falls.

The records provided by AT reveal that when ambulance personnel arrived at approximately 19:00 hours on 3 February 2022 Ms Stephens was found on the floor of her home. The history provided by Ms Stephens to the attending paramedics was that she had fallen at approximately 17:00 hours when she felt her legs collapse from underneath her. She indicated she did not strike her head and nor did she lose consciousness. The fall had prompted her to phone AT.

Ms Stephens advised she had a recent noticeable decline in her strength and mobility which meant she was unable to get herself off the couch/bed and this resulted in a reduced oral intake which caused generalised lethargy and an unwell feeling. There was generalised pain in the spine through to the chest and pain in the right leg with some bruising to the right knee. She indicated her pre-existing generalised osteoarthritic pain had worsened over the past few days and there was a slurring of her speech which her carer indicated was abnormal and had progressed over the past few days. Ms Stephens reported she was feeling extremely weak and unsteady on her feet prior to the fall. She was progressively hypotensive and tachycardic on route to the RHH where she was taken for further investigation.

Upon arrival at hospital Ms Stephens indicated she had been unwell for days. She was admitted through the emergency department at which time it was noted there was evidence of multiple organ failure. She remained in that department until she was moved into the ICU on 4 February

2022. She was extremely unwell with worsening metabolic acidosis. Despite intensive medical therapy her condition continued to deteriorate and after discussion with the family a palliative approach was instituted. Ms Stephens continued to deteriorate and she passed away.

In his report the forensic pathologist, Dr Donald Ritchey, says in summary Ms Stephens had a fall at home with prolonged time on the floor. She was admitted to the RHH with an infection that led to pneumonia and sepsis whereby the body’s response to the infection damaged its own organs. This led to multiple organ failure due to rhabdomyolysis. Other conditions which Dr Ritchey notes contributed to Ms Stephens passing included atherosclerotic and hypertensive cardiovascular disease, alcoholic hepatitis and alcohol dependence.

I accept Dr Ritchey’s opinion.

Comments and Recommendations The circumstances of Ms Stephens’ death are not such as to require 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 Ms Stephens.

Dated: 23 March 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner