Finding into death of Shane Peter Kerstjens

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 5240/07

Inquest into the Death of SHANE PETER KERSTJENS

Delivered On: 4 October 2011

Delivered At: Melbourne

Hearing Dates: 4 October 2011

Findings of: JANE HENDTLASS

Representation: Sgt David Dimsey assisting the Coroner

Place of death/Suspected death: Bundoora Extended Care Centre, Bundoora, Victoria 3083

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 5240/07 In the Coroners Court of Victoria at Melbourne I, JANE HENDTLASS, Coroner having investigated the death of: Surname: KERSTJENS First name: SHANE Address: Bundoora Extended Care Centre, Bundoora, Victoria 3083 AND having held an inquest in relation to this death on 4 October 2011 at Melbourne find that the identity of the deceased was SHANE PETER KERSTJENS and death occurred on 27th December, 2007 at Bundoora Extended Care Centre, Bundoora, Victoria 3083 from

la. PULMONARY THROMBOEMBOLISM 1b. DEEP CALF VEIN THROMBOSIS

in the following circumstances:

1. Shane Peter Kerstjens was 42 years old when he died. He had lived in 24 hour supported accommodation at 25 Peugeot Pursuit in Mill Park for 26 years. This is a group home managed by the Department of Human Services Disability Accommodation Service North and West

Metropolitan Region. Mr Kerstjens also attended day services with Ivanhoe Diamond Valley

Centre in Macleod five days a week.

2. Mr Kerstjens’ medical history also included cerebellar dystrophy which is associated with slow degeneration, intellectual disability and autism, He was unsteady on his feet but he was able to walk around at home alone or with a walker. His last recorded fall was on

11 April 2005. On 2 February 2007, Mr Kerstjens underwent a Client Health Management

Review which concluded "No Need to Follow Up".

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3. Mr Kerstjens attended the general medical practice at Plenty Road Medical Clinic. His psychiatrist was Dr Kernutt at Mountain View Consulting Rooms, Dr Kernutt prescribed

ranitidine, benzatropine, trifluoperazine, thioridazine and quetiapine with clozepam as required,

4. At about 3pm on 6 September 2007, Mr Kerstjens was laughing and attempting to throw kitchen equipment around at home when he fell and complained of pain in his leg. An ambulance was called and he was transferred to the Northern Hospital with a fractured tibia and fibula, At Northern Hospital, a plaster cast was applied and he underwent surgery on the next day. Mr Kerstjens remained in bed and, until 4 December, he was prescribed clexane to prevent

thrombosis.

5, On 12 September 2007, Mr Kerstjens returned to theatre for the tibia nail replacement.

He vomited on induction of anaesthesia and was commenced on antibiotics. However, Mr

Kerstjens recovered from surgery.

6, On 4 October 2007, Mr Kerstjens was transferred to Bundoora Extended Care Centre for rehabilitation. On 25/26 December, Mr Kerstjens had overnight leave home with his family. At 9.40am on 27 December, Mr Kerstjens was reviewed by the consultant: he was well, alert and

cheerful.

7. At 2.16pm on 27 December 2007, Mr Kerstjens was found unresponsive face down on

the floor at Bundoora Extended Care Centre. He was unable to be revived.

9. The forensic pathologist who performed the autopsy formed the opinion that the cause of death was pulmonary thromboembolism and deep calf vein thrombosis. Toxicological analysis

detected diazepam, paracetamol, quetiapine, thioridazine and valproic acid metabolites.

10. Accordingly, I find that Shane Kerstjens died from undiagnosed pulmonary

thromboembolism and deep calf vein thrombosis.

4 October 2011

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