Finding into death of Stephen Robert Blom

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2014 2638

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 I, CAITLIN ENGLISH, Coroner having investigated the death of Stephen Robert Blom

without holding an inquest:

find that the identity of the deceased was Stephen Robert Blom born on 18 June 1968

and the death occurred on 22 May 2014

at the Austin

from:

Hospital, 145 Studley Road, Heidelberg 3084

ACUTE RENAL FAILURE IN THE SETTING OF UROSEPSIS AND SAN

FILIPPO SYNDROME

Pursuant to section 67(2) of the Coroners Act 2008, J make findings with respect to the following circumstances:

1. Mr Stephen Blom was 45 years of age at the time of his death. He resided in a community

residential unit, managed by the Department of Human Services (DHS), at 15 Park Avenue,

Kew.

2, At the time of his death, Mr Blom was ‘in care’ pursuant to s 3 Coroners Act 2008 (the Act).

He had resided in the community residential unit for approximately eight years.

3. A coroner must hold an inquest if the deccased was, immediatcly. before death, a person

placed in care, in accordance with section 52(2)(b) of the Act.

4: Pursu

ant to section 52(3A) of the Act, I am not required to hold an inquest in these

circumstances, if I consider that the death was due to ‘natural causes’.

5. In accordance with section 53(3B) of the Act, a death may be considered to be due to

‘natural causes’ if the coroner has received a report from a medical investigator, in

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accordance with the rules, that includes an opinion that the death was due to ‘natural

causes’.

I have received a report in this case. I also note that no issues have been identified or concerns raised regarding Mr Blom’s health management. Therefore, I make my findings with respect to the circumstances and exercise my discretion not to hold a public hearing

through an inquest.

A police investigation was conducted into the circumstances of Mr Blom’s death. A brief prepared by Victoria Police for the coroner includes statements obtained from Mr Blom’s uncle, Mr James Browne, DHS house supervisor, Mr Henry Lim, general practitioner Dr Stephen Bennie and the coroner’s investigator.

1 and as a result, he was severely

Mr Blom suffered from San Filippo Syndrome intellectually disabled. Mr Browne, Mr Blom’s appointed legal guardian, reported Mr Blom had onset of early dementia at age 34. He further reported that the staff at Park Avenue,

Kew looked after Mr Blom very well.”

On 5 May 2014, Mr Blom was taken to see Dr Bennie as he was confused and unsteady on

his feet. Dr Bennie prescribed antibiotics for a urinary tract infection.

Dr Bennie next saw Mr Blom on 12 May 2014. Mr Blom was lethargic, constipated, had reduced urinary output and had been vomiting once or twice a day. Dr Bennie changed Mr

Blom’s antibiotics and ordered an abdominal x-ray to exclude a large bowel obstruction.

Mr Blom’s abdominal x-ray showed severe constipation. On 13 May 2014, Dr Bennie prescribed medication for rehydration and suppositories for constipation. Dr Bennie reported

that Mr Blom’s listlessness may have been related to his constipation?

On 14 May 2014, Mr Blom again saw Dr Bennie, who thought Mr Blom was improving, although he was still listless. Mr Blom’s abdomen was lax and not tender. Dr Bennie

ordered further suppositories to be administered.

On 15 May 2014, Dr Bennie noted Mr Blom was lethargic, was not walking and not eating.

He made the decision to transfer Mr Blom to the Austin Hospital for further investigation.“

' A rare neurodegencrative disorder.

? Coronial Brief, page 2.

3 Coronial Brief, page 6.

4 Ibid.

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14. On admission, Mr Blom was diagnosed with a pre-renal acute kidney injury. The decision

was made to trial intravenous therapy, antibiotics and diuresis. This was unsuccessful.

15. A meeting was held between Mr Blom’s family and medical staff. A decision was made for

Mr Blom to be palliated and to be made as comfortable as possible.

16. Mr Blom passed away peacefully on 22 May 2014 at 9.30pm.

Post Mortem Examination

17. A post mortem inspection and report was completed by Forensic Pathologist Dr Matthew Lynch at the Victorian Institute of Forensic Medicine on 26 May 2014. Dr Lynch formulated the causc of death. I accept his opinion. Dr Lynch noted;

“on the basis of all the information available to me at this time, I am of the opinion that this

death was due to natural causes.” Finding I find that Stephen Blom died from acute renal failure in the setting of urosepsis and San Filippo

syndrome,

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

Mr James Browne

Constable Steven Gegson, Victoria Police

Pursuant to section 73(1B) of the Coroners Act 2008, I direct that a copy of this finding be published on the internet.

Signature:

CAITLIN ENGLISH .

CORONER Date: 22 June 2015

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