Finding into death of John William Brown

_ a SPOOL |

Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 1913/09

Inquest into the Death of JOHN WILLIAM BROWN

Delivered On: 17th February, 2011

Delivered At: 222 Exhibition Street, Melbourne 3000 Hearing Dates: 17th February, 2011

Findings of: JOHN OLLE

Place of Death: Werribee Mercy Hospital, Werribee 3030

Police Coronial Support Unit (PCSU): Sergeant Tracey Weir

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Rule 60(1)

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

Court reference: 1913/09 In the Coroners Court of Victoria at Melbourne 1, JOHN OLLE, Coroner having investigated the death of: Details of déceased:

Sumame: BROWN

Firstname: JOHN

Address: Werribee Mercy Hospital, Werribee, Victoria 3030 AND having held an inquest in relation to this death on 17th February, 2011 at Melbourne find that the identity of the deceased was JOHN WILLIAM BROWN and death occurred on 8th April, 2009

at Werribee Mercy Hospital, Werribee, Victoria 3030

from

la, CONSISTENT WITH GASTRO-INTESTINAL MALIGNANCY,

PROBABLY CARCINOMA OF THE PANCREAS

in the following circumstances:

1. John Brown was aged 55 years at the time of his death. He was an involuntary paticnt at

Werribee Mercy Hospital, Werribee.

2, A coronial brief has been prepared. The following summary prepared by the coronial

investigator is an-accurate summation of the circumstances of death of Mr Brown.

“John William Brown was born on 19/10/1953 and passed away at the Werribee Mercy

Hospital’s palliative care unit on 08/04/200. He is survived by his mother Dorothy Jean

Brown and two brothers, Gary and Malcolm Brown. ‘the deceased.never married and

did not father any children. The deceased was a smoker of cigarettes for his entire adult

life.

The deceased was diagnosed with schizophrenia in the early 1980's and was frequently

admitted to psychiatric institutions from the time he was diagnosed until his passing in

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housing commission home located in Liverpeol Street, Footscray. According to the deceased’s brother Gary Brown, the deceased kept only a very small circle of friends and preferred to keep to himself. He was an active participant in a local Footscray church, which assisted him with donations of clothes and various other assistance. He was also secretive and did not trust establishment. The deceased’s main form of income was by way of a disability pension. The deceased’s only dealings with police were as a missing person in May of 2008 and as a victim of a damage to his home in June of 2008.

The deceased was diagnosed with pancreatic cancer in October 2007. This was diagnosed after he presented at the Western Hospital in Footscray. After numerous tests, Dectors at the hospital concluded that there was no further treatment options for the deceased as his cancer was terminal.

The deceased was admitted to the Werribee Mercy Psychiatric ward on 14/10/2009 as an involuntary patient. Prior to this date, his condition was being monitored with a community treatment order. The deceased was transferred to the Gabrielle Jennings centre for palliative care on 17/11/2008. This unit is located within the Werribee Mercy hospital, This transfer was due to the Psychiatric ward being ill. equipped to deal with the deceased's deteriorating health and the need for assistance in the common daily activities of everyday life.

Whilst at the Palliative care unit the deceased remained an involuntary patient. The deceased on occasion absconded from the palliative care unit but was always found close by staff an escorted back to the unit without issue. The deceased remained an involuntary patient as it was the conclusion of his treating Doctors that if it was revoked the deceased was not of sound mind to properly care for himself and his terminal condition, On one occasion when he absconded, he was located beside the railway lines, which are located

opposite the Werribee Mercy Hospital.

"From March 2009 the deceased's health deteriorated rapidly to the point where he was

unable to walk unassisted and required increased assistance with his day.to day life. He was unable to even light his own cigarettes. The deceased remained bed bound from 03/04/2009 and became unresponsive on 05/04/2009. The deceased was found by nursing staff at 4,30am on 08/04/2009 to have passed away.

According to his treating Doctor in the palliative care unit, the deceased did not endure the side effects normally attributed to Pancreatic cancer. He displayed little pain and his health deteriorated relatively slowly to begin with until March of 2009. According to Dr.

Charlton, the deceased’s death was expected due to his terminal pancreatic cancer.

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—Dr’s-contemplated revoking the deceused’s involuntary status in the week prior to his ~

passing, however decided not to as they considered it somewhat disingenuous.

As the deceased was an involuntary patient at the time of his passing it is considered to be a death in custody."

Post Mortem Medical Examination

3. On the 11th of April 2009, Professor Stephen ‘Cordner, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an external examination on the body of John Brown,

4, Professor Cordner found the cause of death to be consistent with gastrointestinal malignancy, probably carcinoma of the pancreas.

Finding

[ find that the cause of death of John William Brown was gastrointestinal malignancy, probably carcinoma of the pancreas,

• John Olle prone _ Date: bruary 2011

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court Reference: 4850/09 Inquest into the Death of Peter Greenhill

Delivered On: 8th December 2010 Delivered At: Ballarat Hearing Dates: 8th December 2010 Findings of: M. Kay Robertson

i Place of death: Ballarat Base Hospital

Rule 60(1)

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court Reference: 4850/09 In the Coroners Court of Victoria at Ballarat IM. Kay Robertson, Coroner having investigated the death of:

Details of deceased:

Surname: Greenhill First name: Peter Address: 68 Churchill Ave Ararat Vic 3377

AND having held an inquest in relation to this death on 8th December 2010 at Ballarat Law Courts find that the identity of the deceased was Peter Greenhill and death occurred on 11 October 2009 at Ballarat Base Hospital

from

‘la Sepsis and acute renal failure

ib Pneumonia

2 Severe intellectual disability and spina bifida

in the following circumstances:

Mr Peter Greenhill was 57 years of age. Since 1995 he had lived at 68 Churchill Street Ararat, a Department of Human Services Community Residential Unit.

Mr Greenhill had an history of spina bifida ,thoracic scoliosis, urinary incontinence, right nephrostomy, retinal detachment, leg ulceration, right inguinal hernia repair, asthma and intellectual disability.

On the 8" of October, 2009 Mr Greenhill arrived back at the Residential Unit from his day placement in obvious pain and having trouble breathing. At 4:30pm, Mr Greenhill was taken to Ararat Medical Centre from where he was admitted to Ararat Hospital suffering atrial fibrillation and hypoxia. His condition deteriorated and Mr Greenhill was transported to Ballarat Health Services Intensive Care Unit on 10% October, 2009,

Further tests led to a diagnosis of chest sepsis and septic shock, respiratory failure, rapid atrial fibrillation, acute renal failure and electrolyte imbalance, Mr Greenhill was sedated and treated with antibiotics, anti- thrombotic, anti-arrythmic medication and inotropes, Mr Greenhill’s condition continued to deteriorate and he passed away during the afternoon of 11" of October, 2009.

Dr. Anthony Roberts reviewed the medical records and conducted an external examination. He concluded the cause of death was sepsis and acute renal failure and pneumonia,

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q Derewber 20/0 .