Finding into death of Jennifer Anne Capes

IN THE CORONERS COURT OF VICTORIA.

AT MELBOURNE

Court Reference: COR 2011 1069

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: JENNIFER CAPES

Nelivered On: 2 July 2012

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

Hearing Dates: 2 July 2012

Findings of: PETER WHITE, CORONER |

Police Coronial Support Unit — Sergeant David Dimsey, assisting the coroner

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1, PETER WHITE, Coroner having investigated the death of JENNIFER CAPES

AND having held an inguest in relation to this death on 2 July 2012 at MELBOURNE

find that the identity of the deceased was JENNIFER ANNE CAPES born on 25 September 1960 : and the death oceurred on 23 March 2011

at Norfolk Terrace Community Care Unit in Travencore Crescent, Flemington

from:

1 (a) UNASCERTAINED

CONTRIBUTING FACTORS

2. METASTATIC OVARIAN CANCER

in the following circumstances:

At approximately 6,00am on the 23rd of March, Jennifer Capes was located by the night mursing staff in her unit when she appeared to be not breathing, Ambulance Victoria was

called and staff commenced CPR until the ambulance officers attived and took over.

Ms Capes was found to be in cardio respiratory arrest with asystole and ambulance officers continued for approximately four minutes, but were unable to resuscitate her. She was

pronounced deceased at approximately 7.45am on that morning by her attending doctor.

Background

Jennifer Capes was residing in Unit 1 of Norfolk Terrace Community Care Unit, | Travencore Crescent, Travencore. Norfolk Terrace is a facility which is oversecn by the North West Mental Health and Inner West Area Mental Health Service. It is a 24-hour nursing staff

facility and accommodates people with mental health issues.

Jennifer Capes was being treated at Norfolk Terrace and had been living independently in a Ministry of Housing property whilst on a Disability Pension and had a financial administrator

through the State Trustees Office, She was also on a community treatment order due to her

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history of poor compliance and poor attendance and engagement with mental health services.

This included numerous admissions to the John Cade Acute Inpatient Unit at the Royal

Melbourne Hospital.

In October 2010, she was diagnosed with metastatic ovarian endomeirial cancer, On the 31 January 2011, she was referred to the Inner West CCU as she was experiencing difficulty in living independently in the community and had a significant decline in her functioning, secondary to her poor physical health. A decision was made to house her at Norfolk Terrace

where she could live and be continuously monitored,

On the last review of Jennifer Capes, it was noted that she had metastatic cancer Stage 4 and that she was receiving palliative chemotherapy. Her last chemotherapy was on the 16 March

2011, one week prior to her death.

I also note that she was suffering from chronic obstructive airways disease with Type 2 respiratory failure and congestive cardiac failure. She had been treated for this at the Royal Melbourne Hospital fom 23 February 2011 until 1 March 2011, and that intervention had not

been successful,

For the last 24 houts prior to her death she had been noted to have shortness of breath in

keeping with her presentations over the previous few months.

At approximately 3.00am on 23 March nursing staff at Norfolk Terrace observed that she was

sleeping and breathing during their nightly.checks,

On the check which took place at 6.00am on 23 March she was located in her bed and apparently was not breathing, The nurse contacted and asked for an ambulance to attend and the ambulance officors arrived and took over CPR until her death was finally called later that

morning (indistinct).

Following an autopsy at the Victorian Institute of Forensic Medicine, Dr Malcolm Dodd, Forensic Pathologist, found that the cause of death was wnascertained and that a contributing

factor was metastatic ovarian cancer.

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Finding Tam satisfied on the evidence that Jonnifor Capes suffered from a great number of illnesses and

contributing diseases and that the cause of death was natural and a combination of those various

illnesses and diseases,

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

Ms Rae Oates, noxt of kin Senior Constable Michael Gifford, Moonee Ponds Police Station, Investigating Member Dr Ruth Vine, Chief Psychiatrist

Interested Parties

PETER WHITE CORONER Date: 2 July 2012

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