Deceased
Carolyn Veronica Dean
Demographics
77y, female
Coroner
Coroner Jonathan G Klestadt
Date of death
2010-05-20
Finding date
2011-01-24
Cause of death
Sudden Unexpected Nocturnal Death in Epilepsy (SUDEP)
AI-generated summary
Carolyn Veronica Dean, a 77-year-old with intellectual disability and epilepsy, died from a catastrophic epileptic seizure whilst using the toilet at a disability support home. She fell forward during the seizure, sustaining a significant head laceration. No evidence of natural disease was found at autopsy. The coroner concluded death resulted from sudden unexpected nocturnal death in epilepsy (SUDEP), a recognised phenomenon. Key clinical lessons include: recognition that seizures occurring in bathrooms/toilets carry high risk of fatal injury; need for appropriate supervision protocols in disability services for residents with epilepsy; consideration of seizure alert systems; and awareness of SUDEP as a real risk requiring counselling and preventive strategies. Earlier intervention or modified bathroom design may have prevented this tragedy.
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Specialties
Error types
Rule 60(1)
Section 67 af the Coroners Act 2008
Court Reference: 1895/2010
Inquest into the Death of Carolyn Veronica Dean’
Delivered On:
Delivered At:
Hearing Dates:
Findings of:
Place of death/Suspected death:
24 January 2011 Portland
24 January 2011 Jonathan Klestadt 77 Blair St, Portland
Prosecutor Sgt Sandra Skilton _
FORM 37 Rule 60(1)
Section 67 of the Coroners Act 2008 Court Reference: 1895/2010 In the Coroners Court of Victoria at Portland : T Jonathan Klestadt, Coroner having investigated the death of:
Details of deceased:
Surmame: Dean First name: Carolyn Veronica
AND having held an inquest in relation to this death on 24 January 2011 at Portland find that the identity of the deceased was Carolyn Veronica Dean and death occurred “on or about 20/05/2010 at Portland from
la Epilepsy
in the following circumstances:
Carolyn Veronica Dean suffered from an intellectual disability and epilepsy, among other less debilitating medical conditions, She resided in a disability Support services home rua by the Department of Human Services in Blair Street, Portland and had done for approximately ten years prior to her death. The facility caters for seven permanent residents and is staffed by carers at all times. Ms.
Dean was able to look after her own needs and is reported to have required only very modest amounts assistance,
At about 8,00am the morning of Thursday the 20th of May 2010 Ms, Dean was ‘ound by staff in the toilet shared by her and another resident, She had last been : observed by the night duty carer in her bed at about 10.30pm the previous evening,
it appears that she had gone to the toilet at some time in the morning and had suffered an epileptic seizure whilst seated on the pan. This has caused her to fall forward striking her forehead and nose on the floor causing a significant laceration which bled profusely. In falling she had blocked the inward opening door which had to be lifted off its hinges to gain access to the deceased. :
Paramedics were called immediately on discovery of the deceased but were unable o revive her. At autopsy no findings were made which indicated that death was as a result of any natural disease process, despite a familial history of heart disease.
It was further the opinion of the pathologist that the traunia observed to the head of the deceased was due to the fall from the toilet. In the circumstances it was the pathologist’s opinion that the cause of death was a catastrophic epileptic seizure,
n his report to me he states, “Sudden death in epilepsy where no obvious cause is evident....is a well described phenomenon,”
am satisfied that there are no suspicious circumstances surrounding the death of Ms. Dean, and that her death was as a result of natural causes,
Signature:
Date: pan Of / Dai
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