Deceased
Susanne Maree Deeker
Demographics
64y, female
Coroner
Coroner Audrey Jamieson
Date of death
2013-11-13
Finding date
2014-07-17
Cause of death
Aspiration pneumonia in the setting of Down Syndrome and recent seizures
AI-generated summary
Ms Susanne Maree Deeker, a 64-year-old woman with Down syndrome, epilepsy, dementia, and gastro-oesophageal reflux disease, died from aspiration pneumonia following recent seizures. She presented to hospital twice in November 2013 with seizure-related events and respiratory symptoms. Clinical lessons include recognising that patients with Down syndrome, dementia, and seizure disorders are at high risk of aspiration pneumonia; ensuring appropriate monitoring and preventive measures (such as swallowing assessment and dietary modification) in this vulnerable population; and considering whether earlier intervention or more intensive management during her second admission might have altered the outcome. The coroner found no evidence of preventable harm related to her placement in care.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Court Reference: COR 2013 5194
Form 37 Rule 60(1) Section 67 of the Coroners Act 2008
Inquest into the Death of: SUSANNE MAREE DEEKER
Delivered On: 17 July 2014 Delivered At: Coroners Court of Victoria Level 11, 222 Exhibition Street
Melbourne 3000
Hearing Date: 17 July 2014 Finding Of: AUDREY JAMIESON, CORONER
Police Coronial Support Unit Leading Senior Constable Stuart Hastings
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I, AUDREY JAMIESON, Coroner having investigated the death of SUSANNE MAREE
AND having held an inquest in relation to this death on 17 July 2014
at MELBOURNE
find that the identity of the deceased was SUSANNE MAREE DEEKER
born on 7 October 1949
and the death occurred on 13 November 2013
at Rosebud Hospital, 1527 Point Nepean Road, Rosebud 3939
from:
1 (a) ASPIRATION PNEUMONIA IN THE SETTING OF DOWN SYNDROME AND
in the following circumstances:
On 17 July 2014, a mandatory inquest under section 52(2)(b) of the Coroners Act 2008 (Vic) (the Act) was held into the death of Ms Susanne Maree Decker, becausc immediately before her death, Ms Dceker was “a person placed in..,.care” as it is defined in the Act. Ms Deeker had Down Syndrome and had been a client of the Department of Human Services
(DHS) prior to her death.
Ms Deeker was 64 years of age at the time of her death. She lived at a supported care facility operated by the DHS located at 242 Jetty Road, Rosebud (the residence). Ms Deeker had
lived at the residence for twelve ycars and previously with her parents.
Ms Deeker had a past medical history that included Down Syndrome, cpilepsy, hypothyroidism, anaemia, asthma, Alzheimer’s disease, and gastro ocsophageal reflux disease. She was diagnosed with dementia in 2011 after a progressive cognitive decline. Ms Deeker’s dementia rapidly deteriorated in the six months prior to her death. She expericnced hypotensive collapses and recurrent chest infections requiring hospitalisation. She developed.
blindness in her right eye following an infection that required surgical intervention on 21 October 2013, after which her health and cognitive status appeared to deteriorate.
Thereafter, she was unable to attend her day placement duc to increased confusion,
In August 2013, Ms Deeker experienced her first seizure and was treated at the Rosebud Hospital.
At approximately 7.50pm on 5 November 2013, Ms Deeker was taken by ambulance to Rosebud Hospital Emergency Department (ED) after another seizure event when she collapsed in the bathroom of her residence. She was observed in the ED and discharged back
to her residence at 1.45am.
At approximately 9.00pm on 7 November 2013, Ms Deeker was transported from her residence to the Rosebud Hospital ED with a cough and shortness of breath. It appears that she may have experienced another seizure event whilst in the ambulance. She was admitted to Rosebud Hospital with a diagnosis of aspiration pneumonia and treated with antibiotics.
On 13 November 2013, a medical emergency team (MET) call was made in response to her increasing respiratory distress. After discussions with Ms Deeker’s family, a decision was made not to provide resuscitative treatment to her in the ‘event of an artest. Ms Deeker died
at 11.03pm on 13 November 2013.
Dr Kate Strachan, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an external examination upon the body of Ms Deeker, reviewed a post mortem CT scan and reviewed the Victorian Police Report of Death, Form 83. Anatomical findings included cerebral atrophy, minor coronary artery calcification and increased lung markings particularly involving the right upper lobe and both lower lobes. Dr Strachan ascribed the cause’of Mr Deeker’s death toaspiration pneumonia ‘in the’setting of Down Syndrome-and
recent seizures,
The circumstances of Mr Decker’s death have been the subject of investigation by Victoria Police. Police obtained statements from Ms Deeker’s General Practitioner, Dr Mandar Gokhale, the Rosebud Hospital Patient Services Manager, and the DHS residence Acting
House Supervisor.
The evidence supports a conclusion that Ms Deeker died on 13 November 2013 and that the cause of her death was aspiration pneumonia in the setting of Down Syndrome and recent
seizures. The circumstances under which Ms Deeker died were, according to the forensic
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pathologist, consistent with Ms Deeker’s relevant past medical history. There was no
evidence to suggest any other cause or contribution to her death. Ms Deeker died from
natural causes related to her underlying seizure disorder and the development of aspiration
pneumonia.
Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected
with the death:
In all the circumstances, I am satisfied that there would be no benefit from conducting a full inquest into Ms Deeker’s death or obtaining any further medical or other evidence, as neither would assist me to further understand the medical issues before me or the cause of Ms Deeker’s death which resulted from natural causes in the context of her underlying seizure disorder and the development
of aspiration pneumonia.
I accept and adopt the medical cause of death as ascribed by Dr Kate Strachan and I find that Susanne Maree Deeker died from natural causes being aspiration pneumonia in the setting of Down
Syndrome and recent seizures.
AND I farther find that there is no relationship between the cause of Ms Deeker’s death and the fact
that she was “a person placed in care”.
Pursuant to section 73(1) of the Coroners Act 2008, I order that the following be published on the
internet.
I direct that a copy of this finding be provided to the following: Ms Janet Deeker
Dr Mandar Gokhale, South Coast Medical
Mr Dan McMahon, Patient Services Manager, Rosebud Hospital
Ms Robyn Reid, Acting House Supervisor, 242 Jetty Rd Group Home, Department of Human
Services
Leading Senior Constable D Riddle
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Signature:
AUDREY JAMIESON Date: 17 July 2014
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