Finding into death of Angela Therese Thompson

IN THE CORONERS COURT OF VICTORIA MELBOURNE

.Court Reference: COR 2012 0865

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: ANGELA THERESE THOMPSON

Delivered On: 20 May 2014

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

Hearing Date: 20 May 2014

Findings of: CAITLIN C ENGLISH, CORONER

Police Coronial Support Unit Scrgeant Greig McFarlane

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I, CAITLIN CREED ENGLISH, Coroner having investigated the death of ANGELA.THOMPSON

AND having held an inquest in relation to this death on 20 May 2014

at Melbourne

find that the identity of the deceased was ANGELA THERESE THOMPSON born on 31 July 1960

and the death occurred on 8 March 2012

at Royal Melbourne Hospital, 300 Grattan Street, Parkville 3050

from: l(a) ASPIRATION PNEUMONIA IN A WOMAN WITH DOWN SYNDROME AND

ALZHEIMER’S DEMENTIA

in the following circumstances:

Introduction

1. Angela Thompson was 51 years old when she died. Ms Thompson was born with Downs Syndrome and was a registered client with the Department of Human Services (the Department).

2, From 1992, Ms Thompson resided at 131 Primrose street, Essendon, (Primrose Street) a Disability Accommodation Service managed by the Department. Prior to that, she had resided at Janeficld in Bundoora since early childhood.

3. Because of Ms Thompson’s status as a person in the control, care or custody to the Secretary to the Department, her death was reportable to the Coroner (section 11 Coreners Act 2008 (Vic)). Pursuant to section 52 (2)(b), it is mandated that an inquest be held into Ms Thompson’s death.

4. To assist with the coronial investigation into Ms Thompson’s death, the investigating member

from Victoria Police has prepared an inquest brief.

Life at Primrose street

5. Primrose Street provided supported accommodation and Ms Thompson lived with four other women who had intellectual disabilities and a range of complex needs. Staff provided support with the activities of daily life including personal care, meal preparation, household duties,

facilitating activities, health care management and administering medicine.

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6. Her sister, Maureen Thompson, described Ms Thompson adjusting to life at Primrose Street

with her four co-residents and ‘quickly becoming a ‘family”’

She stated:

‘Angela attended Macy Heights YMCA five days a week where she partook in a variety of activities (referred to as her work) such as craft, art, gardening and cooking. On week ends they had the use of a small bus which allowed them to engage in a wide variety of additional pursuits which she and her ‘sisters’ really enjoyed.

Angela also holidayed with the family in Queensland and Victoria and did many overseas trips. There is no doubt that the move back into the community following institutionalisation resulted in a great improvement in her quality of life. Angela

enjoyed this new found independence for over a decade. A Ms Thompson’s deteriorating health 2008-2009

7, Tn 2008-9 Ms Thompson’s health began to deteriorate. Maureen Thompson refers to her losing some of her agility, vibrancy and ability to travel independently. She became more stubbom and started exhibiting irrational behaviour, which was often anti-social. She exhibited behavioural issues at Macey Heights and stopped attending the program there in 2010,

8, She refused to sleep in the house at Primrose street and moved into the garage for a number of months. When she returned to the house, she slept variously on the laundry floor, in the carers

sleepover room, outside the staff room and on the floor in the communal living room.

9. During 2011, Ms Thompson was diagnosed with early on-set dementia. Statements from her carers refer to her challenging behaviour, including episodes of compromised functioning, episodic incontinence, delirium and refusal to sleep in her bed.” ‘There is further commentary regarding Ms Thompson’s reduced. personal hygiene, aggression and agitation, disrupted day/night clock, habit of wandering away from the house, and increasing difficulties in getting

her to attend medical appointments.

' Statement of Maureen Thompson , 9 July 2012, page | 2 Statement of Natasha Williams, 19 August 2013, page 2

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Ms Maureen Thompson stated: ‘Angela was eventually diagnosed with depression but there was great difficulty treating her adequately as she would frequently refuse to attend doctor’s appointments, It was also extremely difficult to get a doctor to come to the home.

Staff would frequently have to rely on locums which meant the medical care was

fragmented.

Angela was becoming unsteady on her feet, refusing walking aids or assistance from | staff, She was experiencing frequent falls and we were extremely concerned that she would sustain a serious injury. On one of many occasions following a trip to hospital

following a fall (whereby she had injured her arm), Angela refused to wear a splint

or sling.”

10. Despite the difficulties in getting Ms Thompson to attend medical appointments, it appears during 2010 — 2011 she was cared for at various times by the following health care

professionals:

• Behavioural Intervention Support Tcam e St Vincent’s Hospital Victoria Dual Disability Health Centre e Centre for Developmental Disability Health (Dr Jenny Torr and Dr Burbridge) e GP’s Dr Barson and Dr Caitlin Tran e Psychiatrist Dr Alan Wragg (home visits to Primrose Street)

11. By July 2010, staff support for Ms Thompson at Primrose House had: increased to individualised support throughout the day and active night monitoring overnight.

12. Ms Maureen Thompson observed:

ct was clear that her needs were becoming highly complex and that transfer to a

high care facility such as a nursing home was inevitable. “

13. Ms Thompson's medical care was greatly complicated by the difficulties she had with the

medical environment.

3 Statement of Maureen Thompson, 9 July 2012, page 3

• Statement of Maureen Thompson, 9 July 2012, page 4.

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Ms Maureen Thompson stated:

‘Angela was distraught when taken to hospital and hated the clinical environment.

She was totally non-compliant and required a minimum of two carers to be with her the entire time she was away from home. She also refused investigative procedures and was terrified of X-ray machines, CT scans and MRI's, On many occasions tests had to be delayed or cancelled, resulting in further jeopardisation of her health

status.”

Events preceding Ms Thompson’s death

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On 25 December 2011 staff of Primrose Street took Ms Thompson to the Royal Melbourne Lospital (RMH) as she had not been eating, was unsteady on her feet and she had had a few falls, She was admitted and brain scans revealed changes linked to the dementia process and

she was discharged the next day.

On 1 January 2012, Ms Thomson was observed by staff to fall off the bed. She did not seem to have sustained an injury, although she complained of right shoulder pain that afternoon. She was taken to RMEJ and after x-ray diagnosed with a broken right shoulder. The x-ray also

highlighted an earlier fracture in her right shoulder estimated to be 18 months old.

Accommodation records of Primrose street were checked but no relevant event was identified

in the records.°

After this a number of recommendations and actions were implemented by staff at Primrose

Street to ensure appropriate support and care was provided to Ms Thompson including: e Arequest for an occupational therapist assessment.

« Additional staff resources at Primrose Street for night monitoring. This meant that in addition to the staff member on sleep over duty, there was a staff member actively

monitoring Ms Thompson overnight.

e In January 2012, Occupational Therapist, Belinda Collins from SCOPE completed a manual handling assessment for Ms Thompson and provided initial advice to the

staff on 2 February 2012 at the Primrose Street team Meeting.

5 Statement of Maureen Thompson, 9 July 2012, page 3.

® Statement of Natasha Williams, 19 August 2013, page 3.

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• On 4 January 2012, a medication review by a pharmacist was undertaken after becoming aware of the recent medication change instigated by the RMI resulted ina

potential contraindication with her usual medications Escitalopram and Olanzapine.

e On 5 January 2012, Dr Wragg (treating psychiatrist) attended Primrose Strect and

made the necessary changes to Ms Thompson’s medication.

e On 7 January 2012, Dr Tran (GP) reviewed Ms Thompson’s pain management

medication, No change was made.

• Ms Thompson suffered from constipation and was managed with analgesic medication that was prescribed by her GP and administered by Primrose staff in

accordance with her treatment sheet.

e The management and medical review of swollen ankle, due to an unknown cause.

® It is reported an application was submitted to the Victorian Civil and Administrative

Tribunal (‘VCAT”) for a health guardian by Ms Thompson’s sister Maurecn Burns.

• Ateview of Ms Thompson’s residential accommodation including exploration of an

Aged Care Assessment was anticipated to commence; however, did not proceed,’

19. Ms Maureen Thompson stated:

‘her injured shoulder had not been picked up earlier as Angela frequently refused investigations and could only be assessed under general anaesthesia. Sometimes there was considerable delay and (frequently) postponement of anaesthesia due to lack of availability of skilled specialists or the fact that some anaesthetists refused to treat Angela, not being familiar with Down syndrome patients and the associated

cardiac complications which may arise during anaesthesia. ’

20. Ms T hompson was taken to RMH twice on 14 January 2012. On the first occasion it was for knocking her left shoulder: The ED Medical e- notes stated:

‘Angela was here on 1” of January after a fall and sustained a fracture of the

greater tuberosity of the humerus. She presents today after a fall onto this shoulder.

7 Statement of Natasha Williams, 13 August 2013 page 3 8 Statement of Maureen Thompson, 9 July 2012, page 4.

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On exam there was no obvious deformity and a repeat X-ray showed the fracture unchanged from before. This should be treated conservatively with a sling if

tolerated and analgesia’.

21. Ms Thompson was non-compliant and/ or not able to tolerate treatment such as a sling.

22. Ms Thompson returned to RMH the same evening after she hit her head ‘whilst walking back down the drive to the house at 9.30pm’.” She was discharged the same evening with head injury advice.

23. During this time living options were discussed for Ms Thompson and alternative options considered including an appropriate nursing home for dementia patients. At a VCAT hearing in February 2012, Ms Maureen Thompson was appointed Ms Thompson’s advocate. It appears that no beds were available for Ms Thompson at a higher care facility,

24. Ms Thompson had a further fall and attended RMH for treatment on 25 February 2012.

25. On 6 March 2012 Ms Thompson was taken to RMH by ambulance. T he Ambulance Victoria electronic Patient Care Report stated:

«During the night she is very unsettled, tonight pt got up took a few steps then was witnessed to fall to her hands and hit her head on the carpeted floor...’ .

26. The RMH emergency record diagnosis stated: ‘Fracture of shoulder, (closed) Acute behavioural disturbance’

27. Ms Thompson was admitted and was awaiting surgery on her shoulder. It appears from the

hospital notes at times Ms Thompson slept on a mattress on the floor. On 8 March 2012 Ms Thompson developed aspiration pneumonia, She died at 12:27 pm prior to surgery after

palliative measures were put in place.

Health and Medical Investigation

28,

The matter was referred to the health & medical investigators’ of the Coroners Prevention Unit, on 26 March 2014 for discussion about the comments in the statement of her sister and

advocate, Maureen Thompson:

° Statement of Laurel Bartkowioz , 29 July 2012, page 5

1° The role of the health and medical investigators 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, Personnel comprise of practising Physicians and Clinical Research Nurses draw on their medical, nursing and research experiences, skills and knowledge to independently evaluate clinical evidence for the investigation of

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29,

The I 30.

‘We were well aware that in order to prevent a crisis from occurring she needed a more efficient and interventionist approach to her medical care. It was agreed by staff and family that a specialist to oversee and liaise with the GP, hospital and

other specialists would greatly improve outcomes for Angela.

Unfortunately we could find no such person. According to medical advice at the time Angela was exhibiting behaviour and symptoms of an ‘elderly person with dementia’, even though she was only 51 years of age when she passed away. It was clear that her needs were becoming highly complex and transfer to a high care

facility such as a nursing home was inevitable. a

The advice from health and medical investigators was that the co-ordination of medical care to someone like Ms Thompson (who had multiple disabilities, including Downs Syndrome and Alzheimer’s dementia) was extremely difficult and there were no easy answers. They acknowledged the problems in finding appropriately qualified medical personal.

nspection Report

Forensic Pathologist Dr Melissa Baker from the Victorian Institute of Forensic Medicine conducted an inspection of Ms Thompson after her death on 9 March 2012. In her comments,

Dr Baker stated:

‘Materials available to me at the time of compiling this report included the Victoria Police Report of Death Form No. 83, medical records and a medical deposition from Royal Melbourne Hospital, a medical certificate of cause of death, a post mortem CT

scan and the body of the deceased.

The deceased was a 51 year old woman who lived in a DHS Care Facility. Her past history included Down syndrome and Alzheimer's dementia which was progressively worsening to the point that DHS staff could not cope with her functional decline. In January 2012 the deceased had a fall and suffered a fracture to her right shoulder.

She had been non-compliant with management of the injury resulting in further decline. On 6m March, 2012 she was taken to Royal Melbourne Hospital as staff were

unable to cope with her, and she was admitted. On a chest x-ray it was noted that she

reportable healthcare deaths and to assist in identifying remediable factors that may assist in prevention and risk management in health services settings.

1 Statement of Maureen Thompson, 9 July 2012, page 4.

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had gross dislocation of her right humeral head with multiple avulsed bony fragments and the plan was for surgery at some stage during the admission. On 8th March at approximately 0130 hours a MET Call was made as the deceased was hypotensive, hypoxic, febrile, tachycardic and had a decreased conscious state, Vomitus was noted in her mouth and the impression was that she had aspiration pneumonia, She was treated with high flow oxygen, intravenous fluid and antibiotics. A chest x-ray showed extensive opacification throughout the right lung. The deceased’s condition was discussed with her sister who requested comfort measures and a palliative approach,

The deceased died peacefully at 1227 hours on 8m March, 2012.

According to the medical deposition from Royal Melbourne Hospital a possible cause of death was given as ‘aspiration pneumonia.’ There were no issues to be addressed by the forensic pathologist as the death was expected, Post mortem CT scan showed consolidation of the left and right lung bases and a left pleural effusion. There was cerebral atrophy but no evidence of acute intracerebral pathology.’

31, Dr Baker concluded her report that a reasonable cause of death would appear to be aspiration

pneumonia in a woman with down syndrome and Alzheimer’s dementia. In all the

circumstances, I accept that as the cause of Ms Thompson’s death.

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

Ms Maureen Thompson

Ms Natasha Williams DHS

Constable Matt Wilmot, Investigating Member, Victoria Police Dr Caitlin Tran

Dr Alan Wragg, Psychiatrist

Signature: a,

CAITLIN ENGLISH CORONER Date: 20 May 2014

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