Deceased
Jan Szustak
Demographics
84y, male
Coroner
Coroner John Olle
Date of death
2010-02-26
Finding date
2011-07-08
Cause of death
Aspiration pneumonia associated with vascular and Alzheimer dementia
AI-generated summary
An 84-year-old man with vascular and Alzheimer dementia died from aspiration pneumonia at Latrobe Regional Hospital. He had been under an Inpatient Treatment Order, but this critical status was not communicated to the receiving hospital due to administrative oversight. The death highlights the importance of accurate clinical handover and communication of mental health act orders between facilities. Clinicians should ensure that when transferring patients between hospitals, especially those under involuntary treatment orders, all relevant clinical and legal status information is explicitly documented and communicated. Aspiration risk in dementia patients requires vigilant monitoring and appropriate feeding precautions.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
FORM 37 Rule 60(1)
FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court Reference: 926/2010
Inquest into the Death of Jan Szustak : Delivered On: 8 July 2011
Delivered At: Latrobe Valley Law Court Hearing Dates: 8 July 2011
Findings of: ' HCH Alsop
Rule 60(1)
Section 67 of the Coroners Act 2008
Court Reference: 926/2010 In the Coroners Court of Victoria at Morwell 1H CH Alsop, Coroner having investigated the death of:
Details of deceased: Surname: Szustak First name: Jan Address: Andrews House Aged Care Facility Trafalgar
Vic 3824
AND having held an inquest in relation to this death on 8 July 2011
At Latrobe Valley Law Court
find that the identity of the deceased was Jan Szustak and death occurred on 26th February 2010
at Latrobe Regional Hospital Traralgon
from
ja) Aspiration pneumonia associated with vascular and Alzheimer dementia.
Section 4 and 15 of the act requires an investigation of the death of any person “in care”. I find that, despite the failure to communicate Mr Szusak’s status to Latrobe Hospital and his last admission, he was, for the purposes of this jurisdiction, “in care” at the time of his death.
Mr Szustak was aged 84 years at the time of his death. He had been suffering serious health problems for some time and was referred to Latrobe Regional Hospital in December 2008.
After some weeks there he was transferred to a residential care facility in January 2009,
Later that year he was referred back to Latrobe Regional Hospital and then
apparently due to a shortage of beds, to the Peter James Centre, At this time he
was subject to an Inpatient Treatment Order.
On 15 February 2010 he was admitted to Maroondah Hospital, having become unwell and was treated for aspiration pneumonia and other associated health problems,
Later that month he was returned to Latrobe Regional Hospital but, due to an unexplained administrative oversight, his status under the Inpatient Treatment Order was not communicated to Latrobe Regional Hospital.
He died on 26 February 2010.
The sole jurisdiction of this Court to determine the ‘cause of death’, which in this case is as set out above ie aspiration pneumonia associated with vascular and alzheimer dementia.
Signature: 44
Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…
A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…
A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries are for educational purposes only and must not be treated as legal documents. Report an inaccuracy.