Finding into death of Alison Margaret Stamp

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2011 2263

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: ALISON MARGARET STAMP

Delivered On:

Delivered At:

Hearing Dates:

Findings of:

Representation:

Police Coronial Support Unit

15 June 2012

Level 11, 222 Exhibition Street Melbourne 3000

29 May 2012

AUDREY JAMIESON, CORONER Ms Sue Ellen on behalf of Eastern Health

Leading Senior Constable Amanda Maybury

1, AUDREY JAMIESON, Coroner having investigated the death of ‘ALISON STAMP

AND having held an inquest in solation to this death on 29 May 2012 at MELBOURNE .

find that the identity of the deceased was ¢ ALISON MARGARET STAMP, born on 14 September 1956 and the death ocoutred on 22 June 2011 at Wantirna Health, Mountain Highway, Wantirna South 3152 from:

1(a) INFECTIVE EXACERBATION OF AST. HMA WITH CONGESTIVE CARDIAC

FAILURE

2, DOWN SYNDROME in the following circumstances:

1. Ms Alison Margaret Stamp was 54 years of age at fhe time of her death, She suffered from Down syndrome, dementia and asthma and had lived in tegidential care wnits all of her life.

At the time of her death,,.Ms Stamp was residing at a Department of Human Services, Community Residential Unit located at 44 Crusoe Drive, Lysterfield, She was a high-care patient who was confined fo a wheelchair and suffered chronic chest infections on a regular

basis.

2, On9 June 2011, Ms Stamp was admitted to the William Angliss Hospital and was diagnosed.

with pneumonia and infective exacerbation of asthma. During the course of her admission, 4 medical decision was made not to initiate cardiopulmonary resuscitation in the evont of a cardiac arrest, On 17 June 2011, Ms Stamp was transforred to Wantirna Palliative Care. She was visited by her father, Mr Henry Stamp, on the same day who considered his daughter to

be in her usual state.

3. On 19 June 2011, when Mr Stamp revisited his daughter, her condition had noticeably ‘ deteriorated. On 21 June 2011, after sudden clinical deterioration in her condition, she was exatnined by the palliative care physician She’ was noted to be in respiratory failure.

Palliative care continued.

4, - On22 June 2011 at 1025 hours Ms Stamp was declared deceased.

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5,

Ms Stamp’s death was reportable as defined within section 4 of the Coroners Act 2008 as

immediately before her death, she was a person placed in custody or care as it defined within

• the Aot.!

Investigations

6,

Dr Paul Bedford, Forensic Pathologist at the Victorian Institute of Forensic Medicine,

performed an external exatnihation on the body of Ms Stamp. He also teviewed a post

mortem CT scan and reviewed Ms Stamp’s clinical records before reporting to the coroner that a reasonable cause of death in the cireumstances could be attributed to infective exacerbation of asthma with congestive cardiac failure. Contributing to death was her Down

syndrome.

The police investigation did: not-identify -any-suspicious. circumstances and no issues have atisen in relation to the care Ms Stamp received at her resideritial care unit or following her

‘admission to hospital.

An inquest was held in accordance with Section 52(2)(b) as immediately before her death Ms

Stamp was a person placed in custody or care. ,

Finding

I accept and adopt the medical cause of death as identified by Dr Bedfoid.and find that Alison

Margaret Stamp died from infective exacerbation of asthma with congestive cardiac failure.

Contributing to her death but not directly related to the cause was her underlying condition of Down

syndrome.

AND | find no relationship between the cause of Ms Stamp’s death and the fact that she was’ a

-person placed in custody or care.

' Person placed in oustody or care "person held in care” means—

(a) ‘a person under the control, care or custody of the Seoretary to the Department of Human Services; or the - Secretary of the Department of Health’

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

Mr Arthur Stamp, Senior Next of Kin

Senior Constable Suzanne Brendel, Knox Police Station, Investigating Member Dr Yvette Kozielski, Eastern Health ‘

Signature:,

AUDREYVAMIESON CORONER

Dater TS June 2012

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