Deceased
David Liam Goold
Demographics
22y, male
Coroner
Deputy State Coroner Iain West
Date of death
2013-09-29
Finding date
2014-11-24
Cause of death
ischaemic bowel
AI-generated summary
David Goold, aged 22 years with spastic quadriplegia and cerebral palsy, was a Department of Human Services client in supported accommodation. On 28 September 2013, care facility staff recognised acute illness and he was transported to Northern Hospital. He presented with acute abdominal symptoms requiring urgent investigation. Surgery revealed extensive non-viable ischaemic bowel affecting small and large bowel. He was admitted to ICU for palliative care and died within hours. The coroner found his management both in DHS care and at the hospital was within reasonable health care practice parameters. The underlying cause of mesenteric ischaemia could not be determined as the family declined autopsy. No clinical errors or preventable failures were identified.
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Specialties
Court Reference: 2013 / 4376
Form 37 Rule 60(1) Section 67 of the Coroners Act 2008
Inquest into the Death of: DAVID LIAM GOOLD
Delivered On: 24 November 2014
Delivered At: MELBOURNE
Hearing Dates: 24 November 2014
Findings of: IAIN WEST, DEPUTY STATE CORONER
Police Coronial Support Unit INSPECTOR PAUL HAYES
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I, IAIN WEST, Deputy State Coroner having investigated the death of David Liam Goold
AND having held an inquest in relation to this death on 24 November 2014
at Melbourne
find that the identity of the deceased was David Liam Goold born on 6 July 1991 and the death occurred on 29 September 2013
at Northern Hospital 185 Cooper Street, Epping 3076, Victoria
from:
1 (a) ISCHAEMIC BOWEL
in the following circumstances:
David Goold, aged 22 years, was a client of the Department of Human Services and resided in supported accommodation at 43 Winn Grove, Fawkner. He moved into the care facility in November 2011 and returned home to his family two nights a week. David’s “in care” status was due to him suffering spastic quadriplegia and cerebral palsy. In addition, David had a past medical history that included spinal fusion performed at the Alfred Hospital and epilepsy.
On the 28 September 2013, David was transported to the Northern Hospital after staff noticed he looked unwell. He presented with an acute abdominal condition and was assessed for urgent laparotomy which was arranged at 11.30pm. David was found to have extensive non-viable ischaemic small and large bowel and was subsequently adinitted to the Intensive Care Department for palliation. David’s condition continued to deteriorate and he died at 4,30 am on the 29 September 2013.
David underwent a preliminary examination at the Victorian Institute of Forensic Medicine by Forensic Pathologist, Dr Sarah Parsons. Dr Parsons recommended an autopsy examination as she believed it may assist in determining the cause of the ischaemia. The family objected on the basis that David had suffered enough, with the objection being upheld by the coroner. :
I find that David Goold died from ischaemic bowel and that his management whilst in the care of the Department of Human Services and as a patient at Northern Hospital, was within the parameters of reasonable health care practice.
I direct that a copy of this finding be provided to the following:
Ms Jane Lucas, mother of David Goold
Constable Christian Briant, Coroner’s Investigator
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Signature:
JAIN WEST DEPUTY STATE CORONER Date: 24 November 2014
3 of 3
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