Finding into death of John Harwood

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: 897 / 2011

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1)

Section 67 of the Coroners Act 2008 |

Inquest into the Death of: JOHN HARWOOD

Delivered On:

Delivered At:

Hearing Dates:

Findings of:

Police Coronial Support Unit

7 May, 2012

Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne 3000

7 May, 2012

JOHN OLLE, CORONER

Sergeant Tracy Weir

Lof4

I, JOHN OLLE, Coroner having investigated the death of JOHN HARWOOD AND having held an inquest in relation to this death on 7 May, 2012

at MELBOURNE

find that the identity of the deceased was JOHN HARWOOD

born on 15" March 1945

and the death occurred on 9 May 2011

at Austin Hospital, 145 Studley Road, Heidelberg 3084

from: la. PNEUMONIA 1b. ASPIRATION

in the following circumstances:

1. John Harwood was aged 65 years at the time of his death. He lived in. a Community

Residential Unit, Department of Human Services at 50/52 Crispe Street, Reservoir.

2. The coronial brief has fully addressed the circumstances of death.’ At inquest, Sergeant Weir read a summary of evidence which accurately sets out the circumstances of Mr Harwocd’s

death.

3. The Health Medical Investigation Team (EIMIT)* has reviewed the medical management of

Mr Harwood.

Summary of Medical Issues:

4. Mr Harwood was a 65yo man with a history of Downs syndrome. lollowing a hip

replacement at the John Fawkner Hospital in 2005, Mr Harwood had ongoing problems with

‘ “The coronial brief will remain on the court file.

2 The role of the Iealth and Medical Investigation Team (EIMIT) is to assist the Coroner's investigation into the nature and extent of deaths, which occurred during the provision of healthcare and identify potential system factors in healthcare related deaths. HMIT personnel comprise of practising Physicians aud Clinical Research Nurses who draw oun their medical, nursing and research experiences, skills and knowledge, to independently evaluate clinical evidence for the investigation of reportable healthcare deaths and to assist in identifying remediable factors that may assist in prevention and risk management in health services settings.

20f4

infection of the right hip around prosthesis. After operations in February 2011 to remove the prosthesis and clear the infection, there were many difficulties with feeding, necessitating nasogastric feeding which proved unsuccessful, culminating in a decision not to institute more

invasive feeding measures.

5. During this period Mr Harwood suffered many episodes of aspiration of gastric contents, ultimately leading the aspiration pneumonia. This in combination with the prolonged _ difficulty in feeding led to palliative care referral. He was kept comfortable and died from his respiratory condition. Medical management was of a high standard throughout, and difficult

ethical decisions were confronted transparently and with appropriate consultation.

6. HMIT indentified no issues of concern in the medical management of Mr Harwood.

Post Mortem Medical Examination

7. On 16 March 2011 Dr Michael Burke, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an autopsy on the body of John Harwood. Dr Burke found the

cause of death to be pneumonia and aspiration.

8. Dr Burke made the following comments:

“Mr John Harwood was a 65 year old man with a history of Down syndrome. Mr Harwood had been in palliative care since the 8" day of March 2011, He had an episode of aspiration

with associated aspiration pneumonia.

The post mortem examination showed no evidence of any injury that would have contributed

to or led to death.

The pos! mortem examination showed pneumonia with consolidation of the left lower lobe.

?

There is no evidence to suggest that death was due to anything other than natural causes,’

Finding

I find the cause of death of John Harwood to be pneumonia and aspiration.

3 of 4

I direct that a copy of this finding be provided to the following: _ Senior Next of Kin Constable Paul Butcher, Heidelberg Police Station, Investigating Member

Department of Human Services

Signature:

JOHN NE ee

Date: ‘iM 7

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