Finding into death of Eileen Frances Wilson

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67. of the Coroners Act 2008 Court reference: 3663/09 |

Inquest into the Death of EILEEN FRANCES WILSON

Delivered On: 1 June 2010 ; Delivered At: 436 Lonsdale Street, Melbourne 3000 Hearing Dates: 1 June 2010 :

Findings of: JOHN OLLE

Representation: N/A .

Place of death: William Angliss Knox & Angliss Hospital

Albert Street, Ferntree Gully, 3156

SCAU: Leading Senior Constable King Taylor -

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FORM 37° Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008

Court reference: 3663/09 In the Coroners Court of Victoria at Melbourne I, JOHN OLLE, Coroner having investigated the death of: Details of deceased:

Surname: WILSON

First name: EILEEN

Address: 44 Crusoe Drive, Lysterfield 3156 AND having held an inquest in relation to this death on 1 June 2010 at Melbourne

find that the identity of the deceased was EILEEN FRANCES WILSON and death occurred on 28th July, 2009

at William Angliss Knox & Anpliss Hospital Albert Strect, Ferntree Gully, 3156

from

la. ASPIRATION PNEUMONIA COMPLICATING END STAGE DEMENTIA

1b. DOWNS SYNDROME

in the following circumstances: *

1. Eileen Wilson was aged 52 ycars at the time of her death. She lived in a Department of

Human Services care facility situated at 44 Crusoe Drive, Lysterfield.

2. A comprehensive coronial brief has been prepared, I am satisfied that the summary prepared by the coronial investigator, Leading Senior Constable Clausen, fully and accurately

the circumstances of death of Eileen Wilson.

3, From the summary, I-note:

“In late 2007 Eileen WILSON was diagnosed with Alzeimers Dementia and it was noted . that her health was progressively declining, The diagnosis was made by Dr Jennifer

TORR at the Centre for Developmental Disability Health Victoria.

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In February 2008, Eileen WILSON was transferred to 44 Crusoe Drive in Lysterfield Jrom another DHS facility unit at Normanby Street in Oakleigh so that additional support could be given to her due to her dementia.

In late June 2009 DHS staff noticed that Eileen’s health was deteriorating. She became very unsteady on her feet and she was leaning to her left quite a bit. She often became very confused and disorientated.

On the and of July 2009, DHS staff found that Eileen was unable jo stand up and that she was very confused. Staff were unable to get her up and they felt that medical assistance was requlred, An ambulance attended at the unit and transported Eileen to the Angliss Hospital in Ferntree Gully,

Eileen then spent the next 27 days in the hospital so that she could be given a higher level of care. Whilst in hospital, chest x-rays were conducted and Eileen was diagnosed with Aspiration Pneumonia and was treated with Cefriaxone and Metronidazole. She did riot respond to antibiotics and she continued to deteriorate. The hospital made some arrangements to have Eileen moved into a nursing home but the move was called off by the hospital because she suddenly deteriorated further. The hospital also looked at transferring Eileen to palliative care but that was also called off because she was too sick to be transferred. :

Al 1.15pm on the 28th of July, 2009, Eileen WILSON was found not breathing and with no pulse. The medical registrar was notified at the time and pronounced that Eileen WILSON was deceased. Police were called to the hospital and, as Eileen WILSON was in the care of DHS, a report of death was prepared at the request of the coroner.

There were no suspicious circumstances surrounding Eileen WILSON’s death,"

Medical Examination

4, On the 29th July, 2009, Dr Noel Woodford, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an external examination of Eileen Wilson.

5. Dr Woodford noted that Eileen Wilson was a 53-year-old female with a history of Down’s syndrome and Alzheimer’s disease, She had been admitted to the Angliss Hospital approximately a month prior to her death due to increasing care requirements. He was aware she

was under the care of Department of Human Services. ©

6. Dr Woodford commented:

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‘In addition to the above external ‘examination, I have reviewed the Police Form 83 summary of circumstances, a medical deposition and clinical notes, and a post-mortem CT scan. On the basis of this information, and given the family’s preference that no autopsy be performed, I am of the opinion that a reasonable cause of death in the circumstances might be formulated as follows.

fa, Aspiration pneumonia complicating end-stage dementia.

ib, Down’s syndrome"

Finding

7. I am satisfied the circumstances of death of Eileen Wilson have been appropriately investigated, All persons entrusted with her care have fully co-operated with the coronial ‘investigation, There is no basis to criticise the manner in which she was cared for throughout her life. A statement from Ms Wilson's GP is included in the brief,

8. I find that Hileen Wilson died of aspiration pneumonia complicating end-stage dementia and Down’s syndrome.

Signature:

John Ol!

Coroner Date: 1 June 2010

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