Finding into death of Miriam Ralph

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2014 2362

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 MIRIAM RALPH

without holding an inquest:

find that the identity of the deceased was Miriam Ralph

born on 5 July 1965

and the death occurred on 9 May 2014

at McCallum Disability Services, Leopold Street, Ballarat, Victoria

from: 1 (a) UNASCERTAINED (NATURAL)

Pursuant to section 67(1) of the Coroners Act 2008, there is a public interest to be served in making

findings with respect to the following circumstances:

1. Miriam Ralph was 49 years of age at the time of her death. For approximately six years prior to her death, Ms Ralph lived in a community residential unit at Redan. The residential unit is operated by the Department of Health and Human Services’ Disability Services at Ballarat.

Ms Ralph is survived by her two sisters and extended family.

2. As Ms Ralph was in the care of the State at the time of her death, Ms Ralph’s death was reportable under the Coroners Act 2008 and Victoria Police conducted an investigation into

the circumstances of her death.

3. Although Ms Ralph was in care at the time of her death, as her death was from natural causes, this is not a case where an Inquest is mandatory (section 52(3A) Coroners Act

2008).

The Coroner’s Investigator prepared a coronial brief, which includes statements obtained from Ms Ralph’s sister and Disability Support Workers, her General Practitioner, Victoria Police investigators and the forensic pathologist who examined Ms Ralph. I have drawn on

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

Health History

Ms Ralph had a history of intellectual and psychiatric problems. She had an intellectual disability and suffered from bipolar disorder, Parkinson’s Disease and mild asthma.

Ms Ralph was on prescription medications including Benztrop, Carbamazepine, Levodopa, Risperidone, Ventolin inhaler and oxycodone for pain relief. The McCallum services had in place an asthma plan, dated 12 August 2013, which included administering a Ventolin

inhaler and spacer when required and refers to administering nebuliser if required.

Following a car accident on 28 March 2014, in which she sustained serious injuries including fractured ribs, pneumothorax and a fiactured pelvis, Ms Ralph spent approximately two weeks in the Royal Melbourne Hospital before being transferred to the Ballarat Base Hospital. While in hospital Ms Ralph underwent rehabilitation and physiotherapy. Ms Ralph was released from hospital on 23 April 2014 and returned to the community residential unit at Redan. During her hospitalisation, Ms Ralph suffered from

breathing difficulties and shortness of breath.

Events Proximate to Death

On 9 May 2014, Ms Ralph was transported by bus to the McCallum Services on Leopold Street, Ballarat, Ms Ralph prescnted well to Disability Support Workers and they had no concerns regarding her health. At approximately 10.30am, Ms Ralph was given a cup of Milo, a kiwi fruit and a sandwich, which she had brought with her, for morning tea.

Ms Ralph had a small bite of her sandwich and shortly thereafter began coughing and told a

staff member that she was having difficulty breathing and requested her Ventolin inhaler,

Four staff members attended to Ms Ralph and attempted to give her First Aid treatment, including fetching her Ventolin inhaler, calling an ambulance and commencing CPR when she stopped breathing. Ms Ralph was not administered her Ventolin inhaler as she was no

longer breathing when the staff member returned after collecting it from another room.

Shortly after 11.20am, paramedics arrived and took over CPR on Ms Ralph. Unfortunately,

all resuscitation attempts were unsuccessful and Ms Ralph died at approximately 11,35am.

Post Mortem Examination

Dr Michacl Burke, Forensic Pathologist at the Victorian Institute of Forensic Medicine, : conducted a post mortem examination on 15 May 2014. Dr Burke initially concluded that Ms Ralph’s medical cause of death was ‘Acute asthma’. However, following further review of Ms Ralph’s case, including her medical history, Dr Burke completed a report, dated 15 September 2015, in which he formulated the cause of death as ‘Unascertained (natural)’.

L accept Dr Burke’s opinion as to the medical cause of death.

Toxicological analysis showed a slightly raised tryptase and IgE level and identified

medications consistent with prescribed medications.

Finding

T find that:

1,

The identity of the deccased was Miriam Ralph, born on 5 July 1965; and

Ms Ralph died on 9 May 2014 at McCallum Disability Services, Leopold Street, Ballarat,

Victoria, from unascertained natural causes.

I convey my sincere condolences to Ms Ralph’s family.

I direct that a copy of this finding be provided to the following: Ms Leonie McGuirk, Senior Next of Kin

S/C Lynctte O’Donohue, Coroner’s Investigator, Victoria Police

Victorian Department of Health and Human Services

Signature:

CAITLIN ENGLISH CORONER

Date:

14 April 2016