Finding into death of Gerald Quinane

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2014 1349

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: GERALD QUINANE

Delivered On: 20 November 2014 Delivered At: Coroners Court of Victoria

65 Kavanagh Street, Southbank

Melbourne 3006 Hearing Date: 20 November 2014 Finding Of: AUDREY JAMIESON, CORONER Counsel Assisting Ms Jodie Burns, Senior Legal Counsel

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I, AUDREY JAMIESON, Coroner having investigated the death of GERALD QUINANE

AND having held an inquest in relation to this death on 20 November 2014

at MELBOURNE

find that the identity of the deceased was GERALD QUINANE

born on 21 August 1931

and the death occurred on 11 March 2014

at Albury Wodonga Health, Wodonga Campus, 69 Vermont Street, Wodonga, 3690

from: l(a) BRONCHOPNEUMONIA

in the following circumstances:

1. On 20 November 2014, a mandatory inquest under section 52(2)(b) of the Coroners Act 2008 (Vic) (the Act) was held into the death of Mr Gerald Quinane, because immediately before his death, Mr Quinane was “a person placed in....care” as it is defined in the Act. Mr Quinane had an intellectual disability and had been a client of the Department of Human

Services (DHS) Disability Services for most of his life.

BACKGROUND AND CIRCUMSTANCES

2. Mr Gerald Quinane was 82 years of age at the time of his death. He lived at a DHS managed

residential service at 3 Dundee Drive, Wodonga (the residence) with five other residents.

3, Mr Quinane’s medical history included viral meningitis as an infant and subsequent acquired brain injury, visual and hearing impairment, aphasia and recurrent urinary tract infections (UTIs). Due to the frequency of Mr Quinane’s UTIs, residence staff were able to

test samples at the residence and obtain antibiotic prescriptions when required.

4. Mr Quinane had been cared for by his sister, Ms Teresa Fitzgerald until she was no longer able to care for her brother. He was then placed in State care, where he remained for over 50

years.

5. Mr Quinane had resided in a number of State care facilities in Beechworth and more

recently in Rutherglen until he moved to the residence in February 2012.

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6. In October 2013, Mr Quinane’s vision and hearing deteriorated to the extent that he was no longer able to carry out his personal activities of daily living without assistance. He underwent an aged ‘care assessment that determined he required high-level care and was

placed on a waitlist for a suitable facility.

7. His behaviour deteriorated to the extent that he required his General Practitioner (GP) from _ the Federation Clinic in Wodonga to conduct home visits, as staff feared his behaviour

would affect other patients should he attend the clinic.

8. Mr Quinane had an episode of ill health in late January 2014. His GP reviewed him in early February 2014 and did not identify a cause for his apparent decline.

9, Mr Quinane appeared well from 7 February until 1 March 2014, when he began refusing food, but continued accepting fluids. Residence staff noticed that he had developed a productive cough and called for an ambulance, which arrived at 1:30pm and transported him to the Wodonga Hospital. Mr Quinane was administered an initial dose of intravenous antibiotics under sedation, and later, oral antibiotics and was discharged to the residence at 8:00pm the same day. Paramedics advised residence staff that Mr Quinane had a UTI and to

provide him with analgesia, which he initially refused but eventually accepted.

10. | Mr Quinane’s condition had not improved on 2 March 2014 and by 3 March 2014, he refused all oral intake, Residence staff contacted his GP who attended and following an assessment, advised that Mr Quinane was to go to hospital. Mr Quinane was transported to Wodonga Hospital via ambulance two hours after it was called. He was admitted to Wodonga Hospital and assessed as ‘not for resuscitation’ on 6 March 2014, Mr Quinane developed an aspiration pneumonia on 7 March 2014 and refused medication, food and

‘observations.

11. | Wodonga Hospital staff attempted to discharge Mr Quinane back to the residence between 4 and 11 March 2014, however the residence supervisor would not accept Mr Quinane until his condition stabilised. The DHS sought accommodation for him commensurate with his care needs. A place was found for him at the Grange Nursing Home, however Mr Quinane died on 11 March 2014, prior to the commencement of this placement. Mr Quinane was in

receipt of palliative care at the time of his death.

FORENSIC PATHOLOGIST EXAMINATION AND EVIDENCE

12. Associate Professor David Ranson, Senior Forensic Pathologist at the Victorian Institute of

Forensic Medicine, performed an external examination upon the body of Mr Quinane,

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reviewed a post mortem CT scan and reviewed the Victorian Police Report of Death, Form

83. Associate Professor Ranson also had available to him the Wodonga Hospital medical records and the medical deposition. Anatomical findings included evidence of pleural

effusions together with patchy lung opacities, and a renal cyst.

13. Associate Professor Ranson ascribed the cause of Mr Quinane’s death to bronchopneumonia.

POLICE INVESTIGATION

14, The circumstances of Mr Quinane’s death have been the subject of investigation by Victoria

Police. Police obtained statements from GP Dr Phillip Steele of the Federation Clinic and

DHS residence House Supervisor Ms Rowena Murray.

FACTORS CAUSING OR CONTRIBUTING TO DEATH

The evidence supports a conclusion that Mr Quinane died on 11 March 2014 and that the cause of his death was bronchopneumonia. The circumstances under which Mr Quinane died were, according to the pathologist, consistent with Mr Quinane’s relevant medical history. There was no evidence to suggest any other cause or contribution to his death. Mr Quinane died from natural causes related to his underlying medical conditions and the

development of bronchopneumonia.

COMMENTS Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the death:

I acknowledge that the ambulance response time on 3 March 2014 was not ideal, nor was the apparent lack of clear communication between the Wodonga Hospital and the residence between 4 and 11 March 2014, however I do not find that either aspect of Mr Quinane’s care

was in any was causally connected to his death. .

In all the circumstances, I am satisfied that there would be no benefit from conducting a full inquest into Mr Quinane’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 Mr Quinane’s death which resulted from natural causes in the context of his underlying

medical conditions and development of bronchopneumonia.

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FINDING l accept and adopt the medical cause of death as ascribed by Associate Professor David Ranson and

I find that Gerald Quinane died from natural causes being bronchopneumonia

AND I further find that there is no relationship between the cause of Mr Quinane’s death and the

fact that he 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 Teresa Fitzgerald

Dr Phillip Steele, Federation Clinic, Wodonga

Albury Wodonga Health

Mr Shane Beaumont, Manager Complex Support and Systemic Improvement, Residential Services

& Complex Support, Service Implementation & Support, Department of Human Services Leading Senior Constable Brian R Tyler

Signature:

AUDREY JAMIESON CORONER Date: 20 Novembe

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