Finding into death of Vanessa Jenner

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference; COR 2011 0545

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: VANESSA JENNER Delivered On: 15 August 2012 Delivered At: Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne 3000 Hearing Dates: 15 August 2012

Findings of: JOHN OLLE, CORONER

Police Coronial Support Unit Leading Senior Constable Amanda Maybury

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1, JOHN OLLE, Coroner having investigated the death of VANESSA JENNER

AND having held an inquest in relation to this death on 15 August 2012

at MELBOURNE

find that the identity of the deceased was VANESSA THERESE JENNER born on 31 October 1972

and the death occurred 11 February 2011

at Royal Melbourne Hospital, Grattan Street, Parkville 3052

from: l(a) SEPTICAEMIA 1(b) UROSEPSIS 1(c) LENNOX GASTAUT SYNDROME

in the following circumstances:

1. Vanessa Jenner lived in the care of the Department of Human Services’,

2, .The coronial brief has fully addressed the circumstances of Vanessa’s death. Further, my investigation has received the full co-operation of the Department of Human Services.” Vanessa had an intellectual disability, cerebral palsy, an acquired brain injury and Lennox’ Gastaut epilepsy. She lived at 15 John Street, Altona North? She received accommodation support since moving into the home in April 1987, Prior to moving into the home, she lived with her family. The reports of DHS staffhave fully set out the care received by Vanessa over

’ the years, Inquest brief and statements will remain on the court file.

3. A mandatory inquest has been conducted this day.

' Pursuant to Section 52 (2b) of the Coroners Act 2008 an inquest into.the death must be conducted.

2 Detailed statements of residential staff.

3 A disability accommodation services (DAS) residence,

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Circumstances leading to Vanessa’s hospital admission

On 6 February 2011, Vanessa’s disability support officer observed bruising to Vanessa’s right thigh groin and hip. An ambulance was called and attended, however, serious injuries were not identified and hospital admission was not considered warranted. The following morning, staff had difficulty rousing Vanessa. She subsequently refused her breakfast and had difficulty taking her moming medication. An ambulance was called and Vanessa was

transported to the Royal Melbourne Hospital.

Di Kieron Gorman, Consultant Intensivist at the Royal Melbourne Hospital, has provided a

detailed report. Dr Gorman explained:

“Vanessa was admitted from a nursing home. She required full nursing care after brain surgery at age of 12 and a subsequent seizure disorder (Lennox Gastaut Syndrome), Vanessa had an intellectual disability as well as cerebral palsy, she had difficult to control seizures, Her admission on 7 February 2011 was for a probable urinary tract infection and an obvious bleed into her right thigh requiring both a blood transfusion. .

with a fresh frozen plasma Iransfusion and possibly a platelet iransfusion,

On the 8 February 2011 Vanessa’s situation has deteriorated requiring an admission to the Intensive Care Departmeni. A computer tomography of her right thigh showed a large collection consistent with an infected haematoma on appearance, Vanessa was hypotensive and hypoxic, The computer tomography showed bilateral consolidation of the lung bases - a chest x-ray on the 8 February 2011 showed extensive hing consolidation, Treatment for all of the above would require intubation and mechanical ventilation, an operation to drain the infected haematoma in the right thigh, aggressive

drug therapy for her sepsis and continued intravenous antibiotics.

This was considered not in Vanessa's best interest given her severe co-morbidities and poor premorbid function. After a family discussion on the 9 February 2011 a decision was made not to continue active treatment. Vanessa was discharged to a ward with a

palliative care plan in place. Vanessa died at 1630 hours on LI February 2011,"

My investigation has been greatly assisted by Dr Gorman’s report.

• Report Dr Gorman

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Post Mortem Medical Examination

7. On the 14 February 2011, Dr Michael Burke, Forensic Pathologist at the Victorian Institute of

Forensic Medicine, conducted an external examination only on the body of Vanessa Jenner,

8. Dr Burke found the cause of death to be septicacmia, urosepsis and Lennox Gastaut

syndrome.

Finding

I find the cause of death to be septicaemia, urosepsis and Lennox Gastaut syndrome.

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

Mrs Diane Wilkinson Senior Constable Justin Embleton-Smith, Investigating Member

Interested Parties

Signature: Ny ee, OC fa

JOHN OLLE A CORONER | Date: 15 August J D

OF Vj ra cto} th he wea

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