Finding into death of Stewart Neil Padgham

IN TH

E CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2014 4878

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 I, JOHN OLLE, Coroner having investigated the death of STEWART NEIL PADGHAM

without holding an inquest:

find that the identity of the deceased was STEWART NEIL PADGHAM born on 15 May 1957

and the death occurred on 22 September 2014

at Au

from:

stin Hospital, 145 Studley Road, Heidelberg VIC 3084

l(a) ASPIRATION PNEUMONIA IN AN INTELLECTUALLY DISABLED MAN

Pursuant to Section 67(1) of the Coroners Act 2008, 1 make these findings with respect to the

ollowing circumstances:

Stewart Padgham was born on 15 May 1957 and was 57 years old at the time of his death. Mr Padgham had a medical history of severe intellectual disability, epilepsy, cystine storage disease, ocsophageal ulcers, gastritis, helicobacter, anaemia, self-abusive behaviour, osteomyclitis, reflux, amputation of left index finger, hiatus hernia, ulcer of the left third finger and shingles.’ Due to Mr Padgham’s severe intellectual disability, he was only able to speak a few unclear monosyllabic words and was always very physically resistive if medical care was attempted.’ Mr Padgham was, immediately before death, a person placed under the care of the secretary to the Department of Human Services DHS’). He resided in DHS

supported accommodation in Watsonia as a high level care patient.

' Statement of Dr Katrina Philip, Gencral Practitioncr, Coronial brief.

Thid.

1 0f3

Mr Padgham’s house manager, Lindy Beattie, reported that on 14 September 2014 Mr Padgham became very unwell and weak, and was consequently taken to Austin Hospital. He had been vomiting. since 8pm the previous night, was not tolerating oral intake and was coughing and dry retching, Upon admission he was hypoxic and hypotensive with aspiration pneumonia. He required IV fluids, antibiotics and high flow oxygen. Mr Padgham had difficulty swallowing, and was reviewed by Speech Pathologists and Dieticians who advised thickened fluids and vitamised foods. During admission Mr Padgham refused examination and taking oral medications, and took only minimal fluids and food. He was extremely cachectic.

Following discussions between treating clinicians, Mr Padgham’s family and Ms Beattie it was agreed that palliative care, with comfort measures/symptom relief implemented and no further investigations, IV fluids or antibiotics, was the most appropriate management of Mr

Padgham.*

Mr Padgham was discharged from Austin Hospital at approximately 3.00pm on 20 September 2014, however approximately 30 minutes after returning home an ambulance was called due to Mr Padgham’s coughing, laboured and rapid respiration and cyanosis. He was re-admitted to Austin Hospital and a provisional diagnosis of repeat aspiration and subscquent pneumonia was made. Palliative measures were undertaken, Mr Padgham received subcutaneous

morphine for distress and agitation and he passed away on 22 September 201 4/4

POST-MORTEM INSPECTION

A post-mortem inspection and report was undertaken by Dr Joanna Glengarry, Forensic Pathologist at the Victorian Institute of Forensic Medicine. Dr Glengarry reported that examination of the post-mortem CT scan showed right lower lobe consolidation and

pulmonary changes of bronchiectasis. The external examination showed a frail man with a

BMI of 13.85. External examination of the body does not show evidence of an injury of a type

likely to have caused or contributed to death,

Dr Glengarry reported that the death is due to natural causes and that the cause of death is

aspiration pneumonia in an intellectually disabled man.

3 Statement of Associate Professor Richard O*Brien, Austin Health, dated 7 November 2014.

• Ibid.

2 of 3

FINDING

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

required. I am satisfied that there are no suspicious circumstances,

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

involved.

8. The statement of clinical course satisfies me that Mr Padgham’s care and management at his DHS supported accommodation in Watsonia was reasonable and appropriate, and that all

transfers to hospital occurred within a reasonable time frame.

9. I find that the death was duc to natural causes.

10. I find that Stewart Padgham died on 22 September 2014 and that the cause of his death is aspiration pneumonia in an intellectually disabled man.

11. I direct that a copy of this finding be provided to the following: The family of Stewart Padgham; Investigating Member, Victoria Police; and

Interested parties. <

Signature:

JOHN OLL CORONER 11 May 201

30f3