Finding into death of Kerran Lyn Hills

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2015 2435

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 KERRAN LYN HILLS without holding an inquest:

find that the identity of the deceased was KERRAN LYN HILLS

born on 18 May 1959

and the death occurred on 18 May 2015

at the Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria

from:

1(a) ASPIRATION PNEUMONIA COMPLICATING SEIZURE IN A WOMAN WITH

TRISOMY 21 AND ALZHEIMER’S DISEASE

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

1. Kerran Lyn Hills was a 59 year old lady who lived in a Department of Health and Human Services funded accommodation facility for people with disabilities in Glenroy. Ms Hills had lived in the Glenroy accommodation for 16 years. She had lived in care facilities for most of her life as she was born with Down Syndrome. Her father reported that she generally enjoyed good health and a happy lifestyle.

2. In 2012, Ms Hills started to show signs of dementia and she was diagnosed with Alzheimer’s disease. This subsequently affected her mobility. January 2015, she was assessed by an Occupational Therapist who recommended that she commence using a wheelchair. She also required a mobile electric full hoist and small sling along with an electric hospital bed. This was ordered by the facility.

3. On 9 May 2015, Ms Hills was being transferred by the sling from the bath to her bed. While in the sling staff observed her to be having seizures. Staff immediately called an ambulance and she was transferred to the Royal Melbourne Hospital. On arrival, a chest x-ray showed signs of an infection. The treating medical team formed the opinion that it was unlikely that Ms Hills would make a recovery. In consultation with her family, the decision was made to

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administer comfort care. Ms Hills’ condition deteriorated over the next week and she passed away on 18 May 2015.

Forensic Pathologist Dr Heinrich Bouwer of the Victorian Institute of Forensic Medicine performed a post mortem medical examination, Dr Bouwer provided me with a report of his findings at autopsy. He found evidence of bronchopneumonia consistent with aspiration of stomach contents. Neuropathological examination of the brain showed severe Alzheimer’s type changes and cortical atrophy without evidence of encephalitis or meningitis. C-reactive protein was markedly elevated consistent with chest infection. Dr Bouwer concluded that the cause of Ms Hills’ death was 1(a) aspiration pneumonia complicating seizure in a woman with trisomy 21 and Alzheimer’s disease. Dr Bouwer was of the opinion that her death was due to natural causes. ] adopt Dr Bouwer’s findings in relation to the cause of death.

. As Ms Hills was a resident of a DHHS facility and therefore considered to be ‘in care’, her death was reported to the Coroners Court of Victoria pursuant to section 4(2)(c) of the Coroners Act 2008 (Vic) (the Act). I was required to conduct an investigation in to Ms Hills’ death. The Coroner’s Investigator, Senior Constable Janine Watson, provided me with a coronial brief of evidence. That brief contained statements from Ms Hills’ father, a staff member of the DHHS run facility, Dr Andrea Benrups of the Royal Melbourne Hospital, attending police officers and Ms Hills’ medical records. I have relied on the totality of the material before me in setting out this finding.

As Dr Bouwer provided me with an opinion that Ms Hills’ death was due to natural causes, pursuant to section 52(3A) of the Act, I was not required to hold an inquest.

On the evidence before me, I find that Ms Hills died from aspiration pneumonia complicating seizures on the background of trisomy 21 and Alzheimer’s Disease, I am satisfied that the care she received at the DHHS facility was appropriate.

Pursuant to section 73(1B) of the Act I 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 Hills’ family

Senior Constable Janine Watson, Coroner’s Investigator

PETER WHITE CORONER Date: 25 November 2015