Finding into death of Lee Isabell Mills

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 002122

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: LEE ISABELL MILLS

Delivered On: 27 MARCH 2014

Delivered At: MELBOURNE

Hearing Dates: 27 MARCH 2014

Findings of: CORONER ROSEMARY CARLIN

Place of death/Suspected death: ROYAL MELBOURNE HOSPITAL, VICTORIA: Counsel Assisting LEADING SENIOR CONSTABLE ANDREA HIBBINS

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I, ROSEMARY CARLIN, Coroner

having investigated the death of LEE ISABELL MILLS

AND having held an inquest in relation to this death on 27 MARCH 2014 at MELBOURNE

find that the identity of the deceased was LEE ISABELL MILLS

born on 14 NOVEMBER 1960

and the death occurred on 16 MAY 2013

at ROYAL MELBOURNE HOSPITAL, VICTORIA

from:

l(a) RENAL FAILURE COMPLICATING UROSEPSIS IN A WOMAN WITH DOWN

SYNDROME (PALLIATED)

in the following circumstances:

A summary inquest was held in relation to the circumstances of the death of Ms Mills in circumstances where she was in the care of the Department of Human Services (DHS). The

inquest is a mandatory inquest.

Ms Mills was born on 14 November 1960 and was 55 years of age at the time of her death.

She resided at a group home, 131 Primrose Street in Essendon, a supported accommodation home run by DHS, which had been her home since 1995. Ms Mills remained at this residence until the time of her death. She also attended the Macey Heights day care service run by YMCA five days a week.

. Ms Mills suffered from an intellectual disability and was diagnosed with early onset

dementia, epilepsy and hyperthyroidism. She also required a permanent catheter for her chronic bladder retention and chronic renal failure. An incontinence nurse from the Royal District Nursing Service attended to Ms Mills’ catheter care on a weekly basis and would

conduct a full catheter change every six weeks.

On 5 May 2012, Ms Mills complained of back pain and was administered paracetamol by staff. She was distressed throughout the night and the following day was given further

paracetamol as she had a sore back, neck, legs and ears. On 7 May, she woke around 3.00

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a.m. and again complained of a sore back for which she was administered further paracetamol. She was also taken to her GP, Dr Andrew Brodsky for a scheduled Vitamin B

injection.

On 8 May at approximately 3.00 am., Ms Mills woke and advised staff that she was suffering pain and had a temperature. A locum doctor was called to assess her condition and

she was administered antibiotics for a suspected urinary tract infection.

On 9 May, Ms Mills continued to present with pain and refused to eat or drink. A locum doctor attended at around 9.00 p.m. and diagnosed her with oral thrush and low blood pressure. Staff were advised to take Ms Mills’ blood pressure in the morning and if it was

still low, to transport her to hospital.

The following morning, at around 8.00 a.m., the house supervisor observed Ms Mills’ blood pressure to be extremely low and she was consequently transported to the Royal Melbourne Hospital where she was admitted to the emergency department at approximately 2.00 p.m.

On admission, she was recorded as presenting with a five day history of abdominal and back pain, shakes and chills, one day of poor oral intake, confusion and agitation and with a past

history of recurrent urinary tract infection.

On 11 May, Ms Mills was admitted to a ward. She was diagnosed with E. coli urosepsis, acute on chronic renal failure and delirium. An infection had entered her blood stream resulting in septicaemia. Over the next two days, her treating clinicians advised DHS that her prognosis was poor and her organs were failing. She was treated with intravenous

antibiotics and intravenous hydration.

On 14 May, it was reported that Ms Mills was no longer responding to treatment despite active ward management. Following discussions with her family, a decision was made to cease active therapy and to institute comfort measures. Ms Mills’ condition deteriorated and

she died on 16 May 2013.

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10. Dr Heinrich Bouwer, forensic pathologist with the Victorian Institute of Forensic Medicine, reported that the cause of the death was 1(a) Renal Failure Complicating Urosepsis in a Woman with Down Syndrome (Palliated). The post mortem CT scan showed bilateral pleural fusions and a small scar at the kidney and an external examination of the body.

There were no issues in relation to toxicology.

11. There were no suspicious circumstances reported by Victoria Police upon their attendance. I am satisfied that there were no issues in relation to the care or management of Ms Mills

during the course of her residence at 131 Primrose Street or during her clinical course.

12. In those circumstances I find that Lee Mills died as a result of natural causes including

Renal Failure Complicating Urosepsis in a Woman with Down Syndrome (Palliated).

13.1 direct that a copy of these findings be provided to the family of Ms Lee Mills, the Interested Parties and to the Investigating Police Officer.

Signature:

ROSEMARY CARLIN CORONER

27 MARCH 2014

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