Finding into death of Adrian Peter Carlin

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: 2013 / 0663

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: Adrian Carlin

Delivered On: 7 October 2014 Delivered At: Coroners Court of Victoria

65 Kavanagh Street, Southbank Hearing Date: 7 October 2014 Findings of: Caitlin English, Coroner Representation:

Police Coronial Support Unit: | Sergeant Greig McFarlane

I, Caitlin English, Coroner, having investigated the death of Adrian Carlin

AND having held an inquest in relation to this death on 7 October 2014 at Melbourne

find that the identity of the deceased was Adrian Peter Carlin

born on 26 May 1946

and the death occurred on 14 February 2013

at St Vincent’s Hospital, Melbourne

from: 1 (a) BRONCHOPNEUMONIA

in the following circumstances:

Introduction

1, Adrian Carlin was 66 years old when he died. Mr Carlin had Down syndrome as well as a motor disorder and late onset epilepsy. Just prior to his death he was residing at a group

home managed by the Department of Human Services at 7 Stainer Street, Kew.

2. Due to Mr Carlin residing at premises managed by the Department of Human Services (DHS), he is a person ‘in care’ pursuant to section 3 Coroners Act 2008. This means his death is a reportable death to the coroner (s 11 Coroners Act). Further, his ‘in care’ status

mandates the coroner to hold an inquest into his death (s 52 (2)(b) Coroners Act).

Background

3. Mr Carlin was the youngest child of ten children and was born in Yarrawonga. At the time

of his death, he was single and had no children.

4. Mr Carlin’s older brother, Vincent Carlin and his wife Teresa, were his main carers. Vincent

Carlin would see Mr Carlin frequently:

My wife and I would see a lot of Adrian, we knew everybody that had anything to do with Adrian, all the nurses and staff: Adrian lived there for 50 years. If I was anywhere near Kew, I'd see Adrian and was always there for birthdays and things and meetings. I was the

only one staff could call on.’

Vincent Carlin described Mr Carlin as unable to talk. ‘He knew what was going on but he

couldn’t communicate.’ Regarding Mr Carlin’s quality of life, Vincent Carlin stated:

‘...he was the best brother anyone could have...Considering his condition, he lived a wonderful life. Kew Cottages were great to Adrian, couldn’t do enough for him, they liked him and you could tell that he liked them. He got a lot of enjoyment out of the staff.’

Disability services

Ts

In 1957, at the age of 11 years, Mr Carlin went to live at Kew Residential Services,

previously known as Kew Cottages.

As well as having Down syndrome, Mr Carlin’s motor disorder meant he had a mild paraplegia and malformation of both feet. He had difficulties walking and used a

wheelchair.

Health issues

11,

12,

Mr Carlin’s treating medical practitioner was Dr Hiran Edirisinghe from Templestowe

District Medical Centre.

Dr Edirisinghe described Mr Carlin as having ‘multiple and complex medical problems incuding Down syndrome, dementia, epilepsy, pressure ulcers, suprapubic catheter for an

atonic bladder and a number of behavioural and psychiatric issues.’

Mr Carlin also suffered from dysphasia and required full staff support at meal times. A meal time profile was created and Mr Carlin ate a modified diet following an assessment by a

speech pathologist.

In early 2012, Dr Wendyl Dsouza, Neurology Consultant at St Vincent’s Hospital, diagnosed Mr Carlin with ‘likely early dementia.’

Events prior to death

In the 12 months prior to his death, Mr Carlin was admitted to hospital 13 times for chest

infections and urinary tract infections.

Vincent Carlin stated:

Prior to Adrian passing away he was suffering from seizures. In one year he would’ve had

close to 12 seizures where he would stop breathing and he would go to hospital. I have kept

a record at home of each occasion I received a phone call because Adrian was on his last.

.. think in the end that Adrian was just exhausted. In the last 6 months of his life he was

losing weight and looked terrible. He’d lost his spark.’

. In Jate 2012, Mr Carlin’s health was deteriorating and his support needs were exceeding

beyond that capable of being provided in a group home setting. He had recurrent respiratory and urological infections in the background of progressive and expected physical and

functional decline,

Mr Carlin was reviewed by an aged care assessment team at St Vincent’s Hospital. At a meeting on 19 January 2013, with Mr Carlin’s family members, doctor and DHS staff, this resulted in an agreement that his health and medical support needs would be better met at an

aged care facility due to his rapidly deteriorating health.

. It was also determined that a palliative approach be taken in caring for Mr Carlin due to his

significant health issues associated with ageing, repeated bouts of pneumonia and the potential risk of infection as a result of frequent hospital admissions. He was to remain in

the group home at Stainer Street whilst a hospice bed was sought.

On 13 February 2013, Mr Carlin was admitted to St Vincent’s Hospital, after two days of decreased oral intake and assessment as non-responsive. He was diagnosed with pneumonia in the right middle lobe because of aspiration. He was recommended for the palliative care ward after consultation with his family and doctor’s advice that medical

treatment was futile.

. Mr Carlin was given palliative care to ensure he was comfortable from pain, breathlessness

and agitation. His medication regime of morphine, midazolam and haloperidol remained

unchanged from his admission to the palliative care unit until his death.

Mr Carlin died at 5.50pm on 14 February 2013. Acting Operations Manager Neil Gumley and Disability Accommodation Services Manager Megan Kearney were with Mr Carlin

when he passed away.

Post mortem investigation

Pal

Dr Yeliena Baber, Forensic Pathologist from the Victorian Institute of Forensic Medecine performed a post mortem Inspection and Report on the body of Mr Carlin on 18 February

2013. She formulated the cause of death. I accept her opinion. She stated:

‘External examination of the body showed findings consistent with the clinical history and

no significant trauma was identified.’ Further investigation

22. The Coroner referred the circumstances of Mr Carlin’s end of life care to the Coroners

Prevention Unit! (CPU) for review.

23. The CPU review of Mr Carlin’s care and treatment at St Vincent’s Hospital from the medical records found the care was appropriate and there were no medical concerns regarding treatment.

Finding

I find Adrian Carlin died from bronchopneumonia.

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

Mr Vincent Carlin

Secretary, Department of Human Services

Signature:

CAITLIN ENGLISH vA

‘CORONER Date: 7 October 2014

''The Coroners Prevention Unit is a specialist service for Coroners created to strengthen their prevention role and provide them with professional assistance on issues pertaining t public health and safety.