Deceased
William Allistair Hughston Heale
Demographics
67y, male
Coroner
Coroner Heather Spooner
Date of death
2011-02-10
Finding date
2012-12-12
Cause of death
Acute on chronic renal failure with pyelonephritis
AI-generated summary
William Heale, a 67-year-old man with Down syndrome and chronic renal failure, died from acute-on-chronic renal failure complicated by pyelonephritis. He was initially managed in the community with support from the Department of Human Services, then hospitalised in January 2011 with haematuria and renal obstruction. He was transferred to palliative care on 2 February 2011 with a Not For Resuscitation order and died 8 days later. The coroner found he received appropriate care despite multiple complex comorbidities. Post-mortem findings confirmed pyelonephritis with Pseudomonas aeruginosa infection. No errors or preventability issues were identified by the coroner.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
Court Reference: COR 2011 525
Form 37 Rule 60(1)
Section 67 of the Coroners Act 2008
Inquest into the Death of: WILLIAM HEALE
Delivered On:
Delivered At:
Hearing Dates:
Findings of:
Police Coronial Support Unit:
12 December 2012
Coroners Court of Victoria Level 11, 222 Exhibition Street, Melbourne
12 December 2012
Leading Senior Constable King Taylor
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I, HEATHER SPOONER, Coroner having investigated the death of WILLIAM HEALE
AND having held an inquest in relation to this death on 12 December 2012
at MELBOURNE ,
find that the identity of the deceased was WILLIAM ALLISTAIR HUGHSTON HEALE born on 6 June 1943
and the death occurred on 10 February 2011
at Wantirna Health Palliative Care, 251 Mountain Highway, Wantirna 3152
from:
1 (a) ACUTE ON CHRONIC RENAL FAILURE 1(b) PYELONEPHRITIS
in the following circumstances:
Mr Heale was aged 67 when he died. He resided in a Department of Human Services (DHS) community house situated at 34 Douglas Street, Ashwood. Mr Heale had a past medical history that included Down’s syndrome, chronic renal failure, atonic bladder, left eye
enucleation and spondylolistheses at the levels of L4-L5 and L5-S1.
Mr Healy was ‘a person in care’ of the DHS due to the level of his disability and pursuant to Sections 3(1) and 52(2)(b) Coroners Act 2008 an inquest was mandatory.
A police investigation was conducted and fhe investigators summary was read to the court. It
stated in part:
“On 2 February 2011 William Heale was transferred from Box Hill hospital to Wantirna | Health for end of life care. Mr Heale was in Box Hill Hospital due to Chronic Renal Failure
and as such it was determined that he spend the remainder of his time at a Palliative Care Unit.
William had family but was under the care of the Department of Human Services. William also suffered from Down’s syndrome, atonic bladder, left eye enucleation and
spondylolistheses.
On admission to Wantirna Health a ‘Not for Resuscitation’ order was completed for Mr Heale.
This decision was based on overwhelming co-morbidities and a poor prognosis.
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Over the next week Mr Heale’s condition deteriorated to a point where that on the 8 February, é
as detailed by Mr Heale’s doctor, he was unable to swallow food or consciousness.
On 10 February 2011 at 0115 hours, Mr Heale passed away in his bed, located in the East .Ward of the Wantirna Health Palliative Care Unit. Police were notified of his death and required to attend as Mr Heale was ‘in care’ and as such it was a reportable death to the
Coroner.” The Coroner requested DHS to provide a report on Mr Heale which stated in part:
“Mr Heale was a 67 year old man with Down Syndrome, intellectual and physica! disabilities, who lived at 34 Douglas Street, Ashwood. Mr Heale required active night support as he was reliant on staff for all his support requirements including assistance with meals, personal
hygiene, mobility and continence care needs.
Mr Heale’s health needs were managed by his General Practitioner, Dr J.B. Boylan and Dr Rajakumar, Renal Specialist at Box Hill Hospital. The House Supervisor consulted with Dr “Boylan to develop specific health management plans for asthma, pain management and mealtime guidelines. A Comprehensive Health Assessment was completed by Dr Marcia
Smart on 16 September 2010.
Mr Heale had a renal operation in 2008, a hip replacement, was blind in one eye and hearing
impaired.
On 15 January 2011 after supporting Mr Heale with his personal needs staff noticed there was blood in his urine and they contacted a locum. The locum prescribed antibiotics for a suspected urinary tract infection and advised staff to monitor Mr Heale and to call an
ambulance if he had a high fever or the amount of blood in the urine increased.
On 17 January 2011 Mr Heale refused to eat his breakfast, and did not want to move. Staff notice that Mr Heale had blood in his urine and called an ambulance to transport him to Box Hill Hospital. The House Supervisor informed Mr Heale’s brother, Dr Walther Heale, of his
admission to hospital.
On 18 January 2011 the House Supervisor was advised by the doctor at the hospital Mr Heale would remain in the Renal Department. The House Supervisor was told a meeting would be
arranged by the hospital to meet with Dr Heale, house staff and the treating doctors to
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determine Mr Heale’s treatment on 19 January 2011. Operational Manager was advised by the Nurse Unit Manager Mr Heale had been diagnosed to have renal failure with urinary.
blockage. The Renal and Urology Units were discussing treatment options.
On 19 January 2011 the House Supervisor attended a meeting at the hospital with Dr Heale and the treating doctor to discuss treatment options. House Supervisor and staff visited Mr Heale at Box Hill Hospital where he was receiving intravenous fluids and antibiotics and
refusing all food and drink.
On 21 January 2011 house staff supported Mr Heale to eat a small amount of food and noticed he ate very slowly and was not very responsive. The House Supervisor, Dr Heale, treating doctor and the social worker from the hospital met and decided a nursing home would provide the best care for Mr Heale. Group home staff would continue to support Mr Heale with
personal care and meals.
Group home staff continued to visit and support Mr Heale with his personal needs and meals.
On the 27 January 2011 staff visited Mr Heale and supported him to eat some food. Hospital staff advised they needed group home staff to support Mr Heale as he was aggressive toward hospital staff attempts to support him. Staff supporting Mr Heale noted he took some time
before he recognised them and was able to be supported to eat some food.
On 28 January 2011 the House Supervisor visited Mr Heale and supported him with personal care and to eat breakfast. Dr Heale visited staff at Douglas Street group home and advised staff Mr Heale would not be returning to Douglas Street group home and he was looking for
an appropriate nursing home to care for Mr Heale.
On 2 February 2011 Mr Heale was transferred to Wantirna Palliative Care,
On 3 February 2011 the House Supervisor visited Mr Heale and gave Wantirna Palliative Care staff Mr Heale’s transition plan and health documents. Group home staff continued to visit Mr Heale each day.
On 10 February 2011 Dr Heale telephoned staff at Douglas Street group home to inform them Mr Heale had died peacefully in his sleep early in the morning,”
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An Autopsy was performed by Dr Malcolm Dodd, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM). He formulated the cause of death and in his report he
made the following comments:
“The cause of death in this case is primarily one of acute on chronic renal failure in a man
with pyelonephritis, marked distension of the ureters and pus within the pelvicalyceal system.
The summary of circumstances report indicates that the deceased was admitted to Wantirna
The post mortem examination disclosed dilated and floppy kidneys with marked dilatation of
the pelvicalyceal systems and ureters.
There was marked cortical thinning and presence of frank pus within the pelvicalyceal lumens
and ureters.
The bladder contained pus and urine.
Biochemical analysis disclosed mixed flora within the kidneys but in particular, Pseudomonas
aeruginosa was grown in large numbers.
Right bronchial secretions disclosed Staph aureus.
Toxicological analysis of body fluids was noncontributory. ~
Biochemistry disclosed a state of renal failure with elevated creatinine and urea levels.
As far as can be ascertained, there is no evidence to suggest that this death was due to
anything other than natural causes.”
It is apparent that Mr Heale suffered from multiple complex and significant co-morbidities, Despite receiving appropriate care he has unfortunately succumbed to renal failure in a
palliative setting.
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I direct that a copy of this finding be provided to the following:
Dr Walter Heale
Senior Constable Dane Harris, Lilydale Police Station, Investigating Member Signature:
CONE AT HEATHER SPOONER CORONER Date: 12 December 2012
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