Finding into death of Gladys Yvonne Melhuish

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2015 1799

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

Findings of: CAITLIN ENGLISH, CORONER

Deceased: Gladys Yvonne Melhuish

Date of birth: 3 September 1945

Date of death: 13 April 2015

Cause of death: 1(a) Complications of a probable bowel malignancy

Place of death: Olivia Newton-John Cancer and Wellness Centre

145 Studley Road, Heidelberg, Victoria

Background

Gladys Yvonne Melhuish was born on 3 September 1945. She was 69 years old and lived in a Department of Human Services, disability supported accommodation, at 25 Hyde Street,

Hadfield, Victoria.

In 1945, as a new born baby, Ms Melhuish was left at the St Joseph’s Foundling home by her mother. Her sister Marie Dean was then four years old. Many years later Marie Dean had eventually managed to track down her sister’s whereabouts and the two reunited in

1994. Ms Melhuish had been residing at Plenty Hospital and had been under the guardianship of the Department of Human Services. She had resided in various different care facilities over the years and had moved to Hadfield some three years prior to her death.

Marie Dean had kept in contact with Ms Melhuish from 1994 onwards, eventually became Ms Melhuish’s next of kin.

Ms Melhuish had been diagnosed with schizophrenia, depression and an intellectual disability. Her medical history included hypertension, chronic hydronephrosis, recurrent urinary tract infections, recurrent haematuria, dyslipidaemia, chronic constipation, aortic aneurysm, fractured left neck of femur and insertion of a gamma nail in 2014 and a left clavicular fracture treated medically. She was treated for her mental health with clonazapine and was taking other medications including amisulpride, cephelexin, colecaciferol, coloxyl,

midazolam, morphine, oxycodone, pantoprazole and paracetamol.

The coronial investigation

Ms Melhuish death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008.

The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame

or determine criminal or civil liability .

A coronial brief has been prepared by the Coroner’s Investigator who is a member of Victoria Police. The brief includes statements from Ms Melhuish’s treating clinicians as well

as the forensic pathologist who examined Ms Melhuish.

the Ms Melhuish was ‘in care’ at the time of her death, in accordance with section 3(d) of the Coroners Act 2008 (Vic) (the Act). This provision covers the death of a person who was in the care of the Secretary to the Department of Human Services in relation to services

administered by the Department under the Disability Act 2006.

8. Due to Ms Melhuish’s ‘in care’ status, her death is a reportable death to the coroner.!

Further, her i care’ status mandates a coroner to hold an inquest into her death. However, a coroner is not required to hold an inquest in relation to a death occurring in care if the coroner considers that the death was due to natural causes.? A death may be considered to be due to natural causes if the coroner has received a report from a medical investigator that

includes an opinion that the death was due to natural causes.*

9. I have received a report from Dr Sarah Parsons, forensic pathologist, who has included in

her opinion Ms Melhuish’s death was due to natural causes.

10. I have based this finding on the evidence contained in the coronial brief. In the coronial jurisdiction facts must be established to the standard of proof which is the balance of

probabilities. ° Circumstances in which the death occurred

11. In October 2014, Ms Melhuish was diagnosed with regional lymphadenopathy and bowel thickening and treated by Dr Ragni Joseph at the Austin Hospital. Dr Joseph reportedly advised undergoing a colonoscopy would be distressing for Ms Melhuish, was unlikely to change her outcome and would involve taking her off some of her medications, potentially destabilising her medical management. Ms Melhuish did not therefore undergo further

investigation of her bowel disorder at that time.

12. On Tuesday 31 March 2015, Ms Melhuish was transported to the Austin Hospital Emergency Department for investigation of abdominal pain. Marie Dean and her husband, Graeme also attended the hospital. Ms Melhuish underwent an abdominal scan which

revealed a mass identified within the caecum and ascending colon which had the appearance

1 Coroners Act 2008 (Vic) s 11(1).

2 Coroners Act 2008 (Vic) s 52(2)(b) 3 Coroners Act 2008 (Vic) s 52(3A).

4 Coroners Act 2008 (Vic) s 52(3B)

2 This is subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

of a bowel carcinoma. Ms Melhuish and her sister were advised a colonoscopy was required to definitively diagnose the bowel mass as cancer. Ms Melhuish and Marie Dean both indicated Ms Melhuish did not wish to have further treatment. As a result of this decision, Ms Melhuish was transferred to a general medical ward for palliation and treated

with morphine and midazolam for pain relief via an abdominal intravenous line.

In view of Ms Melhuish’s deteriorating condition, the Hadfield facility informed the Marie Dean that Ms Melhuish was unable to return to their facility. A palliative care bed was then

found for Ms Melhuish at the Olivia Newton-John Cancer and Wellness Centre.

On 3 April 2015, Ms Melhuish was transferred to the ONJCWC under the care of Dr Radcliff. Over the following ten days Ms Melhuish continued to refuse to have any active management to treat the bowel obstruction. According to Marie Dean, Ms Melhuish continued to receive high quality palliative care from all her treating practitioners during this

time.

Ms Melhuish passed away peacefully on 13 April 2015.

Post mortem examination

On 17 April 2015, Dr Sarah Parsons, Forensic Pathologist at the Victorian Institute of Forensic Medicine, conducted a post mortem inspection on Ms Melhuish’s body. Dr Parsons completed a report on 22 April 2015 in which she formulated the cause of death as complications of a probable bowel malignancy. I accept Dr Parson’s opinion as to the medical cause of death. Dr Parsons performed an external examination and reviewed the post mortem whole body computed tomography scan, medical deposition and Ms Mehuish’s

medical records.

® Medical records of Gladys Melhuish from the Austin Hospital Heidelberg dated 31 March 2015.

Finding

17. I find that Gladys Yvonne Melhuish died on 13 April 2015 from the natural causes of complications of a probable bowel malignancy at the Olivia Newton-John Cancer and

Wellness Centre, 145 Studley Road, Heidelberg, Victoria

I direct that a copy of this finding be provided to the following: Mrs Marie Dean, Senior Next of Kin

First Constable Jamie Panagiotaros, Coroner’s Investigator, Victoria Police

Signature:

CAITLIN ENGLISH CORONER Date: 25 October 2016