Finding into death of Louise Ann Ryan

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2015 1689

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, PETER WHITE, Coroner having investigated the death of LOUISE ANN RYAN without holding an inquest:

find that the identity of the deceased was LOUISE ANN RYAN

born on 24 July 1971

and the death occurred on 8 April 2015

at 9 Leigh Court, Doveton, Victoria

from:

1 (a) HYPOSTATIC BRONCHOPNEUMONIA IN THE SETTING OF BIRTH

RELATED BRAIN INJURY

Pursuant to section 67(1) of the Coroners Act 2008 I make findings with respect to the following circumstances:

1. Louise Ann Ryan was a 43 year old lady who was in permanent Department of Human Services (DHS) care. Ms Ryan had cerebral palsy secondary to a birth related brain injury and needed constant care.

2. Ms Ryan’s carers reported that she had deteriorated over the four weeks prior to her death and they were preparing for palliative care. Ms Ryan’s general practitioner reported that prior to her death, she was experiencing recurrent chest infections and her condition had declined.

3. On8 April 2015, at approximately 6.10am, disability support worker Dieudonne Kabwe checked Ms Ryan and found her condition severely declined. Staff called an ambulance but Ms Ryan was not for resuscitation and she passed away.

4. Senior Forensic Pathologist Dr Matthew Lynch of the Victorian Institute of Forensic Medicine performed a post mortem medical inspection. The post mortem CT scan showed hydrocephalus and increased markings in the right lung base. Dr Lynch concluded that the cause of Ms Ryan’s death was 1(a) hypostatic bronchopneumonia in the setting of birth

related brain injury. Dr Lynch considered that her death was due to natural causes. I adopt Dr Lynch’s findings in relation to the medical cause of death.

5. As Ms Ryan was cared for in a DHS facility, I required the coroner’s investigator to prepare a coronial brief of evidence, that I have relied on in setting out the circumstances above. On the evidence available to me, I am satisfied that Ms Ryan received appropriate and reasonable care. I find that Ms Ryan died of natural causes.

Pursuant to section 73(1B) of the Coroners Act 2008, | order that this finding be published on the

internet in accordance with the rules.

I direct that a copy of this finding be provided to the following: Ms Ryan’s family

First Constable Richard Keesman, coroner’s investigator

PETER WHITE CORONER Date: 1 September 2015