Finding into death of Diane Young

Rule 60(2)

FORM 37

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008

Court Reference: 3698/2010

Inquest into the Death of DIANE YOUNG

Delivered on: Delivered at: Hearing dates: Findings of Representation:

Place of death/suspected death:

SCAU;

31 March 2011 Wangaratta 31 March 2011

Coroner Armour

Room 2, Blackwood Cottage, Sydney Road, Beechworth, Victoria, 3747

Page | of 4

FORM 37 Rule 60(2)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court Reference: 3698/2010 In the Coroners Court of Victoria at Wangaratta I, SUSAN JANE ARMOUR, Coroner,

having investigated the death of:

Details of deceased:

Surname: YOUNG First name: DIANE Address: Room 2, Blackwood Cottage, Sydney Road, Beechworth, Victoria, 3747

AND having held an inquest in relation to this death on 31 March 2011 at Wangaratta:

find that the identity of the deceased was DIANE ROSEMARY YOUNG, born 23 August 1938 and the death occurred on 25 September 2010 at Room 2, Blackwood Cottage, Sydney Road, Beechworth, Victoria, 3747

from: l(a) BRONCHOPNEUMONIA

I ISCHAEMIC HEART DISEASE AND CORONARY ARTERY ATHEROSCLEROSIS

in the following circumstances:

I. Ms Diane Young was a 72 year old woman who at the time of her death was a resident of Blackwood Cottage, Sydney Road, Beechworth, a psychiatric facility attached to the Beechworth Hospital. She had been admitted there on an informal basis on 14 September 2005 on referral from the Aged Persons Psychiatric Service after having been a resident of St Catherine’s Hostel in

Wangaratta. She suffered from a mild intellectual disability and had a long history of

• schizophrenia and psychogenic polydipsia (excessive fluid intake). Her-pa

included asthma, hypertension, hyperlipidemia, gastro-oesophageal reflux disease, ulcerative

oesophagiatis, iron deficiency anaemia, hyperthyroidism and aortic stenosis.

2. Ms Young was a person in care as defined by section 3(d) of the Coroners Act 2008 (“the Act’). Accordingly, her death was reportable pursuant to section 5(c) of that Act and section 52(2)(b) of the Act provides that an inquest into her death is mandatory. This inquest has

proceeded by way of summary as to the circumstances of her death.

3. Ms Young was seen by her Geriatrician, Dr Alan Randall, on 23 September 2010 who was asked to examine her legs. Dr Randall noted that Ms Young had swelling resembling lymphoedema rather than pitting oedaema associated with heart failure, she did not exhibit shortness of breath and she was conversing normally and reported no pain. On that occasion he

also re-referred Ms Young to a speech pathologist to reassess her swallowing.

4. On the evening of 24 September 2010 Ms Young was noted as being well although she did vomit upon drinking a glass of water after dinner. However, she tended to eat very quickly and swallow without chewing in addition to drinking excessive amounts of fluid and, at times, this would lead to her vomiting. She was checked regularly during the night and nothing untoward was observed. However, when she was checked at 6.15am on the morning of 25 September 2010 by Ms Elaine Jensen, the Assistant Nursing Unit Manager at Blackwood Cottage, Ms Young was

found to be unresponsive and cool to the touch.

5. Ms Jensen contacted the Assistant Chief Nursing Officer, Ms Jill Watkins RN, who attended the Unit and then called Dr Rodda who attended at 6.40am. Senior Constable Philip Jones (33519) of Victoria Police attended later that morning around 9.25am and commenced an investigation. He subsequently prepared an Inquest Brief for the Coroner in which he concluded

that Ms Young’s death, although unexpected, was not suspicious.

6. An autopsy was performed Dr Yeliena F Baber, Forensic Pathologist with the Victorian Institute of Forensic Medicine, who reviewed the circumstances of Ms Young’s death and provided a written report of her findings. Dr Baber noted that the cause of death was natural and due to bronchopneumonia. There were changes in the heart which were significant enough to cause death in isolation, however no acute event was seen within the heart. In her opinion, the pneumonia was more significant, particularly given there was no evidence of repair or resolution in the lungs on

histology, suggesting that it was an acute infection.

7. Toxicological analysis of post-mortem blood showed the presence of prescribed medications

within therapeutic levels,

8. Having considered all of the available evidence, J am satisfied that Ms Diane Young died on 25 September 2010 of natural causes, namely bronchopneumonia with a contributing factor being

ischaemic heart disease and coronary artery atherosclerosis.

Signature:

SUSAN JANE ARMOUR Coroner

Date: 31 March 2011