Finding into death of Jeanette Bramley

FORM 37 — Rule 60(1)

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court Reference: 784/2010

Inquest into the Death of Jeanette BRAMLEY Hearing Dates: [st March 2011 Findings of: Stella Maree Stuthridge Place of death: Cobram

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court Reference; 784/2010 In the Coroners Court of Victoria at Shepparton

I Stella Maree Stuthridge, Coroner having investigated the death of

Details of deceased:

Surname: BRAMLEY

First name: Jeanette

Address: Room 18, Moira Shire Lodge 59 Warkil St | Cobram Vic 3644

AND having held an inquest in relation to this death on Ist March 2011 at Shepparton find that the identity of the deceased was Jeanette BRAMLEY and death occurred on 26/02/2010 at Cobram from

la UNASCERTAINED

in the following circumstances:

1. Having held and inquest on the 1 March 2011, I make the ; following findings: i

Ms Jeanette Bramley was born on the 1 October 1945.

On the 19th July 2006, she was admitted to the Moira Shire ' Lodge from Vahland House, Bendigo. Ms Bramley suffered / from chronic paranoid schizophrenia,

Ms Bramley was a person ‘in care’; as such, section 52 of the Coroners Act 2008 an Inquest must be held.

In 2008, Ms Bramlcy suffered a fall; she required a walking frame to assist her in getting around. In February 2010, there was a referral to a physiotherapist to assess whether the walking frame was necessary,

On the 23 February 2010, it was noted by staff at the lodge Ms Bramley was suffering pain on the left side of her breast.

She was given Panamax, for-pain relief and scttled well that evening,

Signature:

Date:

On 26 February 2010, Ms Bramley attended the Cobram Community House and returned to the lodge at 2.30pm. At

5 pm, Ms Bramley had dinner and then a cigarette and went to bed.

She was checked by Nurse Henley and scttled into bed. She was checked again at approximately 8.30 pm and seemed fine. Shortly after, Ms Bramley was found sitting on the floor with her head against the drawers. Nurse Henley immediately began CPR. This was continued for 50 minutes by hospital and ambulance staff. Shortly after, Ms Bramley was pronounced deceased.

Police attended and investigated the scene. A post mortem was completed by Dr Malcolm Dodd. The post mortem was unable to ascertain a cause of death. There was no natural disease, which would have accounted for Ms Bramley’s sudden death. Ms Bramley was prescribed Clozapine for her resistant schizophrenia. Dr Dodd notes that fatalities attributed to Clozapine have occurred where post mortem concentration of the drug have ranged from 3.7 to 12 mg/L.

Ms Bramley’s toxicology report reveals she had Clozapine in her blood at a tevel of 3.5 mg/L. Dr Dodd expressed the * view that Clozapine toxicity is a possible cause of death but beyond absolute proof.

1 am satisfied there were no issucs arising in respect of the care received by Ms Bramley at Moira shire Lodge. I am also satisfied there were no suspicious circumstances.

I find that the cause of Ms Bramley’s death is unascertained at this time.

29/03/2011