Finding into death of Andrew Wilson

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2012 1050

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: ANDREW WILSON

Delivered On: a) / o/ 20/8

Delivered At: Level 11, 222 Exhibition Street | Melbourne 3000

Hearing Dates: 19 December 2012

Findings of: - JOHN OLLE, CORONER

Police Coronial Support Unit Leading Senior Constable Tracey Ramsey

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• J, JOHN OLLE, Coroner having investigated the death of ANDREW. WILSON

AND having held an inquest in relation to this death on 19 December 2012 at Level 11, 222 Exhibition Street, Melbourne 3000

find that the identity of the deceased was ANDEW WILSON

born on 28 March 1967

and the death occurred on 21 March 2012

at 12 Dredge Street, Reservoir 3073

from:

1 (a) ASPIRATION AND INTELLECTUAL DISABILITY

in the following circumstances:

1, Andrew Wilson was aged 44 years at the time of his death. He lived in care! at a Department of Human Services, Community Residential Unit (CRU) situated at 12 Dredge Street,

Reservoir.

2. The coronial brief has fully addressed the circumstances of Andrew’s death.”

3. Atinquest, Leading Senior Constable Ramsey” read a summary of evidence, Circumstances

4, At about 5.45am on 21 March 2012, Andrew was observed in his bed by CRU overnight staff

member, Mr Ciccosillo. Andrew was breathing rapidly with shallow breaths.

5. Over the following ten minutes Andrew’s breaths slowed and deepened. CPR was commenced and emergency services called. Sadly, ambulance personnel were unable to revive

Andrew.

' Deaths in care necessitate a mandatory inquest 2 A copy of the brief will remain on the court file

3 : Coroner’s Assistant

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Background

6. Andrew had resided at the CRU since 2006. He was unable to speak and had little movement.

His mobility was limited to a wheel chair and Andrew required constant care. In addition to his intellectual disability, Andrew suffered epilepsy, asthma, swallowing difficulties and

severe scoliosis, Post mortem medical examination

7. On 27 March 2012 Dr Michael Burke, forensic pathologist at the Victorian Institute of

Forensic Medicine performed an autopsy on the body of Andrew Wilson.

8. Dr Burke found the cause of death to be aspiration and intellectual disability. Dr Burke

commented:

“Mr Andrew Wilson was a 44 year old man with intellectual disability, epilepsy, asthma, severe: scoliosis, and spastic quadriplegia. He is a client of DHS. Mr Wilson was unable

to speak and required complete care.

Mr Wilson had positive faecal occult blood tests and was referred to Northern Hospital for colonoscopy. On the 10" day of March 2012, a colonoscopy was reported as normal.

On the 19" day of March 2012, a colonoscopy was reported as normal. On the 19" day of March 2012, Mr Wilson had not used his bowels and was prescribed a laxative and then an enema. Two days later he opened his bowels three times but vomited twice. He

developed shallow, rapid breaths. An ambulance was called, however he passed away.

The postmortem examination showed marked faecal loading, There was no evidence of bowel ischaemic or dilatation. There was no suggestion of bowel perforation or

peritonitis.

The postmortem examination showed widespread aspiration pneumonia.

The toxicological examination showed the anti-convulsant medications Lamotrigine and

Valproic acid. There was evidence of mild renal impairment.

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On the basis of the information available to me at this time, I am of the opinion that this —

death is due to natural causes."

9. [find the cause of death of Andrew Wilson to be aspiration and intellectually disability

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

eservoir Police Station, Investigating Member

Senior Constable Steve Suttor

Signature:

JOHN OLLE CORONER Date:

4 Dr Burkes post-mortem report.

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