Deceased
Diane Maree Wilson
Demographics
49y, female
Coroner
Deputy State Coroner Iain West
Date of death
2013-09-17
Finding date
2014-11-24
Cause of death
lobar pneumonia in the setting of Down's syndrome and progressive dementia
AI-generated summary
Diane Wilson, aged 49 years with Down's syndrome and progressive dementia, died of lobar pneumonia following gradual physical deterioration from March to September 2013. She presented to hospital with seizures secondary to dehydration and poor oral intake, which had persisted for months. After failing to respond to active therapy including intravenous fluids, the family and clinical team decided against parenteral feeding. She was transferred to palliative care where comfort-focused management was implemented. The coroner found that care provided by the Department of Human Services and Eastern Health was within reasonable standards, with no preventable factors identified. Clinical lesson: early recognition of deteriorating oral intake in vulnerable populations with cognitive impairment and multidisciplinary planning for nutritional and hydration support is important, though this case did not reveal any failure in care.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
Court Reference: 2013 / 4160
Form 37 Rule 60(1) Section 67 of the Coroners Act 2008
Inquest into the Death of: DIANE MAREE WILSON
Delivered On: 24 NOVEMBER 2014
Delivered At: MELBOURNE
Hearing Dates: 24 NOVEMBER 2014
Findings of: IAIN WEST, DEPUTY STATE CORONER Representation: [list representation]
Police Coronial Support Unit INSPECTOR PAUL HAYES
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I, IAIN WEST, Deputy State Coroner having investigated the death of Diane Maree Wilson
AND having held an inquest in relation to this death on 24 November 2014
at Melbourne
find that the identity of the deceased was Diane Maree Wilson born on 16 June 1964
and the death occurred on 17 September 2013
at Wantirna Health Palliative Care Unit, 251 Mountain Highway, Wantirna 3152, Victoria
from:
1 (a) LOBAR PNEUMONIA IN THE SETTING OF DOWN’S SYNDROME AND
in the following circumstances:
Ms Diane Wilson, aged 49 years, was a client of the Department of Human Services and since November 2012, resided in supported accommodation at 24 Canara St, Doncaster East. Her “in care” status was due to her suffering Down’s syndrome. In addition, Ms Wilson had a past medical history of atrial septal defect repair, hepatitis B, hypothyroidism, mild hearing loss, progressive dementia since 2009 and in 2011, she suffered episodes of loss of consciousness. Froin March 2013 to June 2013 there was a marked deterioration in Ms Wilson’s physical condition, with her becoming non verbal from May 2013 and no longer being able to stand, walk or feed herself.
Prior to her physical deterioration, Ms Wilson worked at an Australian Disability Enterprise facility and was quite active and social, enjoying going out with friends and playing basketball. Following her deterioration she experienced bouts of anxiety, confusion and distress and subsequently, required physical support in all facets of her personal care.
On the 24 August 2013, Ms Wilson was admitted to Box Hill Hospital from her accommodation facility with two episodes of seizure like activity, deemed secondary to hypovolaemia and poor oral intake. She was also suffering a urinary tract infection of a weeks duration for which she had been on antibiotics. Ms Wilson was found to be dehydrated and it was noted that her oral intake had been deteriorating for 3-4 months prior to her admission due to food and fluid refusal. She was medicated on anticonvulsants, sodiuin valproate and clonazepam and her management focus was to support her with rehydration and to exclude any reversible causes for her deterioration. Ms Wilson failed to respond to active therapy, including intravenous fluids and her oral intake remained poor with small amounts of pureed diet.
In consultation with family the decision was made not to proceed to parenteral feeding of nutrients. Following a number of reviews by the palliative care team the decision was made on the 9 September 2013 to transfer Ms Wilson to Wantirna for end of life care. Whilst at Wantirna she underwent a speech pathology assessment which confirmed she was only able to tolerate mildly thickened fluids and that she was unable to take oral medication.
Accordingly Ms Wilson was placed on a mildly thickened fluid diet and later, subcutaneous infusion of clonazepam of 3 mg daily.
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Ms Wilson’s management became more and more focused on her comfort. Her condition continued to deteriorate and on the 16 September, family were advised to make prompt arrangements to visit. On the 17 September Ms Wilson remained unresponsive throughout the day and her breathing became progressively more laboured. In the presence of family and friends, Ms Wilson subsequently died at approximately 8.40 pm.
I formally find that Ms Diane Wilson died of lobar pneumonia in the setting of Down’s syndrome and progressive dementia. The evidence satisfies me that the care she received whilst a client of the Department of Human Services and as a patient of Eastern Heath, was within the parameters of reasonable health care practice.
I direct that a copy of this finding be provided to the following: Ms Lee-Ann Wilson
Mr Peter Wilson
Medico-Legal Officer Eastern Health
Department of Human Services
Signature:
TAIN WEST DEPUTY STATE CORONER Date: 24 November 2014
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