Finding into death of Rosemary Jane Berg

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: 4363/10

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of ROSEMARY JANE BERG.

Delivered On: 23 January 2012 Delivered At: Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne Hearing Dates: 23 January 2012 Findings of: IAIN TRELOAR WEST, DEPUTY STATE CORONER

Police Coronial , Support Unit: Senior Constable Kelly Ramsey

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I, TAIN TRELOAR WEST, Deputy State Coroner having investigated the death of ROSEMARY

BERG

AND having held an inquest in relation to this death on 23 January 2012 at Melbourne

find that the identity of the deceased was ROSEMARY JANE BERG born on 16 October 1954

and the death occurred on 13 November 2010

at Thomas Embling Hospital, Yarrabend Road, Fairfield, Victoria 3078

from: la. METASTATIC LUNG CANCER

in the following circumstances:

1. Rosemary Berg, was a 55 year old female who resided as an involuntary forensic patient at the Barossa Unit of the Thomas Embling Hospital, Fairfield. Ms Berg had been admitted to the hospital on 12 May 2004, following her killing of a female friend. On 15 August 2005, she was found unfit to stand trial in the Supreme Court on the charge of murder and on the same day, was found not guilty on the grounds of mental impairment. Prior to her admission, Ms Berg was unemployed and lived alone in a flat in Port Melbourne.

2. Ms Berg had a long history of mental illness dating back to 1977 and remained psychotic despite treatment with a range of antipsychotic medications. She was the mother of four children, all of whom were removed from her custody and with whom, she had very little contact. In early September 2010, Ms Berg presented to the Oncology Department of the Austin Hospital with a lump in her neck, that was subsequently biopsied and confirmed to be a high grade carcinoma, Further investigations diagnosed advanced lung cancer and advice from the Oncologist, was that the toxicities and logistics of chemotherapy would far outweigh any potential benefits that may arise. Ms Berg was assessed as being competent to consent to, or refuse medical treatment and to understand the nature of her medical situation, to evaluate treatment options open to her and to make choices with respect to them. Ms Berg indicated that she was reluctant to have any further intervention, On 23 September 2010 Ms Berg signed a Schedule 1, Refusal of Treatment Certificate, under the Medical Treatment Act 1988, indicating her refusal for cardio pulmonary resuscitation to be administered, in the event of her death.

Ms Berg indicated that she would like to die in the Barossa Unit at the Thomas Embling Centre, rather than being transferred to an inpatient palliative care unit at the Austin Hospital.

3. Palliative care was provided to Ms Berg at Thomas Embling and as she continued to smoke cigarettes during her illness, by November 2010 she required the assistance of an oxygen cylinder 24 hours a day, in order to breathe, On 8 November, there was a rapid decline in Ms Berg's health and consequently she was in the company of nursing staff at all times to assist her with her needs. Ms Berg became bedridden in the last 48 hours of her life and died at 1.25pm on 13 November 2010.

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4, No autopsy was performed in this case as the coroner, on advice from Dr Michael Burke, Senior Pathologist with the Victorian Institute of Forensic Medicine, directed that no autopsy was required. Dr Burke performed an external examination of Ms Berg at the mortuary, reviewed the circumstances of her death, the medical deposition and clinical notes, the post mortem CT scan and provided a written report of his findings. Dr Burke reported that in all the circumstances a reasonable cause of death appeared to be metastatic lung cancer,

5. I find that Rosemary Berg died from natural causes with the cause of death being metastatic lung cancer and I further find that her management was within the normal parameters of reasonable health care practice,

Signature:

IAIN WEST ~| DEPUTY STATE CORONER

23 January 2012

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