Finding into death of Zeina Taouk

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2014 578

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: ZEINA TAOUK

Delivered On: 19 January 2015

Delivered At: Coroners Court of Victoria

65 Kavanagh Street Southbank, VIC 3006

Hearing Dates: 19 January 2015 Findings of: JOHN OLLE, CORONER Coronet’s Solicitor Kate Hamilton

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I, JOHN OLLE, Coroner having investigated the death of ZEINA TAOUK

AND having held an inquest in relation to this death on 19 January 2015 at Melbourne

find that the identity of the deceased was ZEINA TAOUK

born on 14 August 1979

and the death occurred on 27 January 2014

at Austin Hospital, 145 Studley Rd, Heidelberg VIC 3084

from:

l(a) ASPIRATION PNEUMONIA IN THE SETTING OF PSEUDO-OBSTRUCTION

OF THE LARGE BOWEL

in the following circumstances:

1. Zeina Taouk was born on 14 August 1979 and was 34 years old at the time of her death.

She is survived by her immediate and extended family, with whom she maintained very

close and loving relationships.

2. A coronial brief was provided by Victoria Police to this Court, comprising statements obtained from the Department of Human Services, treating clinicians and investigating officers. It has wholly addressed the circumstances surrounding Ms Taouk’s death. I have

drawn on all of this material as to the factual matters in this finding.

SUMMARY INQUEST

3. At Inquest, a summary was read into evidence by Coroner’s solicitor, Kate Hamilton. I am

satisfied that the summary accurately reflects the evidence.

4. Ms Taouk was, immediately before death, a person under the control, care or custody of the Secretary to the Department of Human Services (‘DHS’). Consequently, this matter is a mandatory inquest.' Ms Taouk had been in permanent full time DHS residential care since she was approximately 14 years old, and most recently resided at a purpose built Community Residential Unit (‘CRU’) in Reservoir, catering for residents with complex high support needs. Ms Taouk required 24-hour support and assistance with all activities of

daily living and personal care requirements. She moved into the complex in 2010 and lived

" See Coroners Act 2008 (Vic) s 52(2)(b); Coroners Act 2008 (Vic) s 3(d), definition of ‘person placed in custody of care’,

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with four other residents.? The CRU is staffed full-time and has a high staff to client ratio

due to the high support needs of the clients residing there.

5. Ms Taouk had a medical history of cerebral palsy, developmental delay, Lennox-Gastaut Syndrome,’ spastic quadriparesis, chronic bowel issues including pseudo-obstruction of the bowel, recurring urinary tract infections, aspiration pneumonia and swallowing difficulties with gastronomy tube feeding. At the time of her death she could not weight bear, had very limited mobility, required a wheelchair for all mobility requirements, and was non-verbal

in her communication. *

6. Approximately two years prior to her death, Ms Taouk was diagnosed with pseudoobstruction of the large bowel for which she required hospitalisation on several occasions.

Bowel management care was provided by trained DHS staff daily. She required hospitalisation and medical treatment over the years, predominantly due to urinary tract infections, chest infections including pneumonia, bowel obstruction or increase in seizure activity. Over the last year of Ms Taouk’s life she had increasing episodes of being unwell, often due to pseudo-bowel obstructions and associated complications, leading to increased

hospitalisations.

7. On 19 January 2014 Ms Taouk was admitted to the Austin Hospital via ambulance after staff members observed her to be unwell and rang Nurse-On-Call for advice.> She presented to hospital with a decreased level of consciousness and was found to have pseudo-obstruction of the large bowel. She was reviewed in the emergency department and

a rectal tube was inserted for relief of her pseudo-obstruction.®

8. Ms Taouk was admitted under the general medical team for ongoing management. She experienced an aspiration episode when re-commenced on feed via PEG tube on 21 January 2014 and was commenced on IV ceftriazone to cover aspiration pneumonia. Antiepileptics were converted to IV administration. Ms Taouk experienced a seizure on 22 January 2014 and had an ongoing decreased Glasgow Coma Scale of 3-4, with an inability to clear secretions. She was reviewed by palliative care on 24 January 2014 and comfort

measures were implemented. Ms Taouk was commenced on a syringe driver with 10mg

2 Statement of Kylie Hudson, Department of Human Services, Undated, Coronial brief, 11.

3 A severe form of epilepsy. , 4 Statement of Kylie Hudson, above n 2, 11-12.

*Thid 13.

§ ¢- Medical Deposition Form, dated 28 January 2014, Court reference 578/14.

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morphine and 60mg hyoscine for management of respiratory distress and secretions and

passed away at 1.15am on 27 January 2014.

POST-MORTEM INSPECTION AND REPORT

A post-mortem inspection and report was undertaken by Dr Sarah Parsons, Forensic Pathologist at the Victorian Institute of Forensic Medicine. Dr Parsons reported that the post-mortem CT scan shows a full bladder, bilateral pleural effusions, right lower lobe and

left lung pneumonia and dilated cerebral ventricles.

Dr Parsons determined that the cause of death is aspiration pneumonia in the setting of

pseudo-obstruction of the large bowel.

FINDING

Lam satisfied, having considered all of the evidence before me, that no further investigation is required.

The progress notes and statement of clinical course provided by the Department of Health satisfy me that Ms Taouk’s care and management at the DHS Community Residential Unit, was reasonable and appropriate and that transfer to hospital occurred within a reasonable

time frame.

The evidence satisfies me that the medical management and care provided by the Austin Hospital was reasonable and appropriate in the circumstances, having regard to the

complexities involved.

I find that Zeina Taouk died on 27 January 2014 and that the cause of her death is

aspiration pneumonia in the setting of pseudo-obstruction of the large bowel.

I direct that a copy of this finding be provided to the following:

Signature:

The family of Zeina Taouk; Investigating Member, Victoria Police; and

Interested parties

JOHN @LLE CORONER Date:

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