Finding into death of Dorothy Plumb

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court Reference: 3561/2010 Inquest into the Death of Dorothy Plumb

Delivered On: 24 May 2011 Delivered At: Latrobe Valley Court Hearing Dates: 24 May 2011 Findings of: F A Hayes Representation: ; [list representation]

Place of death/Suspected death: Drouin, Victoria CAU [name of SCAU member] 4

• Counsel Assisting the-Coroner——-—Senior Constable-Gibbons——--—-——-——

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court Reference: 3561/2010 In the Coroners Court of Victoria at Morwell

IF A Hayes, Coroner having investigated the death of:

Details of deceased:

Sumame: Plumb First name: .-. Dorothy Address: : 89 Church St DROUIN VIC 3818

— AND having held-an inquest in relation to this death on 24 May 2011

at Latrobe Valley Court find that the identity of the deceased was Dorothy Plumb and death occurred on 13 September 2010 at Church St Drouin 3818 SCO) 1 a la Ischaemic heart disease 1b Coronary artery atherosclerosis

in the following circumstances:

Ms Dorothy Plumb was aged 65 years when on 13 September 2010, she was found deceased in her home.

Ms Plumb lived at the Home Choices Residential Unit, 89 Church St, Drouin, part of the EW Tipping Foundation, where she had resided for approximately 34 years. Ms Plumb had an intellectual disability and was supported in her residential setting. Ms Plumb was in the custody or care of the Department of Human Services at the time of her death, Ms Plumb was independent in some practical aspects of her life, namely dressing and self care. She walked with the aid of a walking frame and enjoyed participating in activities outside of her home setting, Ms Plumb had limited verbal expression.

Ms Irene Lovell, Disability Support Worker, stated that she was working at Ms Plumb’s home on the evening of 12 September 2010. She noted that Ms Phimb ate very little of her evening meal and that she appeared “a bit

vague” and “‘tired”. Ms Lovell stated that she did not appear unwell or in distress. Ms Loveil helped Ms Plumb prepare for bed. Ms Plumb wished to retire to bed early that night and Ms Lovell helped her into bed at approximately 7pm. Ms Lovell checked on Ms Plumb twice that evening, the last time being sometime between 10.30pm and 11.00pm. She did not notice anything unusual.

On the morning of 13 September, Ms Lovell prepared Ms Plumb’s medication and took it to her. She found Ms Plumb, unresponsive, partially in and partially out of her bed. Ms Lovell alerted paramedics and commenced CPR, Attending paramedics confirmed that Ms Plumb was deceased.

Ms Plumb had a medical history of collapses, transient ischaernic attack, cataract surgery, hypertension, constipation, osteoporosis and urinary incontinence. She waé prescribed multiple medications, Ms Plumb was also said to have epilepsy.

An autopsy was performed by Dr Julie Teague, Forensic Pathology Registrar and Dr Sarah Parsons, Pathologist at the Victorian Institute of Forensic Medicine. Ms Plumb was found to have “significant natural disease affecting the cardiovascular system with triple vessel coronary artery atherosclerosis and increased fibrous tissue in the area of the atrioventricular node”. Dr Parsons stated that there was no evidence:of acute

_...ischaemic change, but the absence of that evidence may be.explained by...

death occurring rapidly after the myocardial ischaemia, Dr Parsons states that myocardial fibrosis “can precipitate cardiac arrhythmia, particularly when the fibrosis is in a critical area of the heart (such as part of the conduction system- the atrioventricular node in this case). Dr Parsons puts forward cardiac arrhythmia as the probable cause of Ms Plumb’s death. Ms Plumb also had an increased brain volume, often associated with intellectual disability and seizures.

Dr Parsons noted that both the Residential Unit medical records and the General Practitioner’s medical records failed to identify baseline medical conditions namely intellectual disability and epilepsy. In relation to this, Dr Parsons stated “the paucity of information pertaining to the deceased medical condition (particularly epilepsy or intellectual disability) makes it impossible to draw conclusions about either condition or have any real discussion about the possibility of sudden unexpected death in epilepsy

(SUDEP).”

Dr Parsons found no evidence of any injuries which may have caused or contributed to Ms Plumb’s death.

I find that Ms Plumb died of natural causes.

RECOMMENDATIONS:

Pursuant to section 72(2) of the Coroners Act 2008, I make thé following recommendation(s) connected with the death:

T recommend that residential units and general medical practitioners establish and maintain medical records which sufficiently identify the

diagnoses of baseline medical conditions in relation to people with intellectual disabilities.