Finding into death of Sharon Lee McDonald

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2011/3827

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: Sharon Lee McDonald

Delivered On: 5 December 2012

Delivered At: Level 11, 222 Exhibition Street Melbourne 3000

Hearing Dates: 5 December 2012

Findings of: PETER WHITE, CORONER

Police Coronial Support Unit Leading Senior Constable Tracey Ramsey

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I, PETER WHITE, Coroner having investigated the death of Sharon Lee McDonald

AND having held an inquest in relation to this death on 5 December 2012 at Melbourne find that the identity of the deceased was Sharon Lee McDonald born on 10 September1964 and the death occurred 9 October 2011 at Eastern Health — Angliss Hospital, Upper Ferntree Gully, Victoria from:

1 (a) LARGE INTESTINAL INFARCTION

1 (6) VOLVULUS

CONTRIBUTING FACTORS

’ DOWN SYNDROME

in the following circumstances:

1. On5 December 2012, I delivered my findings in relation to the death of Sharon Lee McDonald. I attach the transcript of the finding as delivered on 5 December 2012.

Pursuant to section 73(1) of the Coroners Act 2008, I order that the following not be published on the internet:

Form 37 and attached transcript with finding.

Signature: ee a rn

PETER WHITE

CORONER =a Date: 4 June 2014 pe

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FINDING:

THE CORONER: I find that the identity of the deceased was

Sharon Lee McDonald normally resident at 9 Reita Avenue, Wantirna South.

I am satisfied that Ms McDonald died of (1) A large intestinal infarction, 1(b) volvulus - to which a contributing factor was her Down Syndrome.

Ms McDonald was a 47 year old woman with Down Syndrome who died of complications of large intestinal infarction due to volvulus.

A review of the Eastern Health Angliss Hospital medical record reveals that she was admitted to that hospital on 6 October 2011 with bowel obstruction thought to be secondary to faecal loading.

She had ongoing problems with Megacolon which required a careful diet of minced food and regular use of Lacatose.

According to the Eastern Health Angliss Hospital records she was diagnosed with an arterial septal defect in 1990 at the Austin Hospital. There was no surgical intervention. She was in high level care and was mainly uncommunicative and was being looked after by several caregivers in the community.

Post-mortem examination revealed volvulus of the sigmoid and transverse colon with haemorrhagic infarction of the wall. Approximately 500 mls: of haemorrhagic fluid was found within the peritoneal cavity.

There was evidence of congenital heart disease with a patent arterial septal defect which measured three centimetres across. As a result, the right arterial

cavity was dilated and the right ventricle wall was

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thickened. Histological examination of the lung showed early aspiration pneumonia. There was evidence of severe pulmonary hypertension. There was no post-mortem evidence of injury to the upper airway or gullet which may have been caused by the introduction of the nasogastric tube.

Volvulus is the complete twisting of the loop bowel around its mesenteric base and produces intestinal obstruction and infarction of the bowel dying off of tissue due to lack of blood supply.

This lesion occurs most often in large loops of the sigmoid but can happen elsewhere in the bowel as well.

There was no evidence of adhesions at post-mortem. Due to the marked distension and infarction of the bowel the possibility of malrotation of the bowel cannot entirely be excluded. Volvulus of the bowel is often complicated by shock and vascular collapse.

These are my findings.

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