Deceased
Ian Richard Ford
Demographics
68y, male
Coroner
Coroner H C Alsop
Date of death
2009-08-10
Finding date
2010-06-07
Cause of death
Pneumonia in setting of chronic obstructive pulmonary disease and ischaemic heart disease
AI-generated summary
Ian Richard Ford, a 68-year-old man with chronic obstructive pulmonary disease and ischaemic heart disease, died from pneumonia at home on 10 August 2009, five days after discharge from hospital on a Community Treatment Order for a mental health admission. He had been admitted following behavioural changes in the context of recurrent chest infections. His case manager reviewed him on 30 July and 5 August, noting mental state improvement. His wife observed rattling breathing at 2pm on the day of death; he was found not breathing at 7pm. The coroner found all appropriate care was taken by medical practitioners and family. No clinical errors or preventable factors were identified.
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Specialties
FORM 37 Rule 60(1)
Section 67 of the Coroners Act 2008 Court Reference: 3897/2009 In the Coroners Court of Victoria at Sale
I Mr H.C. Alsop, Coroner having investigated the death of:
Details of deceased:
Surname: Ford
First name: Ian Richard
Address: 5283 Maffra-Traralgon Road Tinamba VIC 3860
AND having held an inquest in relation to this death on 7 June 2010 at Sale find that the identity of the deceased was lan Richard Ford and death occurred on 10 August 2009 at 5283 Maffra-Traralgon Rd, Tinamba 3860 from
1a Pneumonia in setting of chronic obstructive pulmonary and ischaemic heart disease
in the following circumstances:
Mt Ford was admitted to Latrobe Regional Hospital in July 2009 following a change in behaviour in the context of a history of chest infections. :
He was the subject of an Involuntary Treatment Order made in the same month,
He was discharged home on a Community Treatment Order on 29 July 2009. He was reviewed by his case manager, Registered Nurse Bromley, on the 30" July and 5 August 2009 at which time a general improvement in his mental state was noted.
On the 10” August 2009, Mr Ford’s wife noted his breathing to be “a bit rattley” at 2.00pm.
She checked again at 7.00pm and discovered he was not breathing.
The cause of his death is as set out above.
I formally find that all appropriate care was taken of Mr Ford, both by the medical practitioners and professionals by whom he was treated and also by Mrs Ford.
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