Finding into death of Rosemary Auchettl

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: 2564 / 10

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of; ROSEMARY AUCHETTL

Delivered On: 16 August 2012 we Coroners Court of Victoria

• Delivered At: tgs Clivered At Level 11, 222 Exhibition Street Melbourne 3000 Hearing Dates: 27 April 2012 Findings of: HEATHER SPOONER; CORONER

Police Coronial Support Unit Leading Senior Constable John Kennedy

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1, HEATHER SPOONER, Coroner having investigated the death of ROSEMARY AUCHETTL

AND having held an inquest in relation to this death on 27 April 2012 at MELBOURNE find that the identity of the deceased was ROSEMARY AUCHETTL born on 17 April 1958 and the death occurred on 5 July 2010 , at 24 Canara Street, Doncaster East, Victoria 3109 from: la, RESPIRATORY FAILURE Ib. RECURRENT ASPIRATION PNEUMONIA

2. DOWNS SYNDROME

in the following circumstances: .

1, Ms Rosemary Auchettl was aged 52 when she died. She was a resident at a residential facility

for the intellectually disabled situate at 24 Canara Street, East Doncaster, Ms Auchettl had a

past medical history that included pulmonary fibrosis and a persistent cough.

2. Ms Auchettl was in the care of the Department of Human Services (DHS) so her death was

reportable pursuant to s.4(2) (c) and (e) of the Coroners Act 2008 (hereinafter referred to as

the Act). ‘It is also necessary for a Coroner to convene an inquest if the deceased person was

immediately before death placed in custody or care (s.52 (2) (b) of the Act),

3. A police investigation was conducted into the circumstances sutrounding the death. At the

Inquest, Leading Senior Constable Kennedy read the following summary to the court:

“Ms Auchettl was a 52 year old and suffers from Downs Syndrome and has been in care

facilities most of her life. She was a ward of the state under the care of the Department of

Human Services. She was transferred from Kew Residential Services in 2006 when it

closed down and sent to 24 Canara Street, Doncaster East, This address is a residential

home for intellectually disabled people run by the Department of Human Services.

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Due to her Downs Syndrome, Ms Auchettl was unable to talk and was profoundly vision impaired. She had a history of medical disorders, the most acute of which was recurrent aspiration pneumonia, chest infections and pulmonary embolism. Ms Auchettl was known

fo make slight gurgling noises when she breathed which was considered normal.

Ms Auchettl has had numerous visits to Box Hill Hospital to treat her Recurrent Aspirational Pneumonia. When she was last discharged from Box Hill Hospital on the

30" of June 2010, it was to be treated palliatively and not readmitted.

On Monday the 5" of July 2010 Ms Auchettl was sitting in her chair in the lounge area of the residential home. She was checked by a carer at approximately 4.00pm and was sleeping and appeared normal with breathing noises that were common with her condition. Two carers were nearby and preparing dinner in a kitchen near the lounge area, Three other residents were present and one was assisting the carers with making

dinner.

At approximately 4.30pm the carer checked on the deceased and noticed that there were no longer any breathing noises. The carer lifted the deceased’s hand and found it limp with no pulse, The carer was aware that the deceased was in palliative care and that a non-recuss order that existed and did not attempt any first aid. The carer contacted Eastern Palliative care and an ambulance attended as a matter of course and assisted with moving the deceased from the lounge area to her bedroom so other residents would

not become distressed.

Police attended the scene shortly after and an investigation was conducted.” Post Mortem Medical Examination

.4, A post mortem inspection and report was performed by Dr Michael Burke, Senior Forensic Pathologist at the Victorian Institute of Forensic Medicine, He formulated the cause of death

and made the following comments:

“Rosemary Auchettl was a 52 year old woman with a past history of Down's syndrome. and episodes of aspiration pneumonia, She had recently been in a major teaching hospital and had issues of respiratory distress associated with shortness of breath. She was referred to

palliative care. Ms. Auchettl was fed by her carers at 3.30pm and when checked half an hour -

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. later was noted to have laboured breathing. She was found deceased half an hour later, An

ambulance was initially called however a ‘do not resuscitate’ order was in place.

The external examination showed no evidence of any injury.

The postmortem CT scan showed increase basal markings within the lungs, There was no

Intracranial pathology.

The medical record indicates a long history of respiratory issues, culminating in palliative

care,

In absence of a full postmortem examination and in the circumstances a reasonable cause of death would appear to be I (a) Respiratory failure, 1 (b) Recurrent Aspiration Pneumonia 2

Down's Syndrome.”

5. It is apparent that that-Ms Auchettl was unfortunately suffering from chronic aspiration

pneumonia in the period leading up to her final demise and respiratory failure.

I direct that a copy of this finding be provided to the following:

The family of Rosemary Auchettl, Constable Craig Allpress, Doncaster Police Station, Investigating Member,

Department of Human Services.

Signature:

HEATHER SPOONER CORONER Date: 16 August 2012

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