Finding into death of Alan James Drake

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2015 3604

FINDING INTO DEATH WITHOUT INQUEST

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

I, AUDREY JAMIESON, Coroner having investigated the death of ALAN JAMES DRAKE without holding an inquest:

find that the identity of the deceased was ALAN JAMES DRAKE

born on 24 October 1956

and the death occurred on 20 July 2015

at Ballarat Base Hospital, North Ballarat Victoria 3350

from:

l(a) PNEUMONIA AND UROSEPSIS IN A MAN WITH MULTIPLE

COMORBIDITIES INCLUDING DOWN SYNDROME

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

1, Mr Alan Drake was 58 years of age at the time of his death. He lived in a residential care

facility at 53 McGibbony Street, Ararat.

2. Mr Drake had a history of Down syndrome, intellectual disability, coeliac disease, hypothyroidism, haemochromatosis, gastro-oesophical reflux disease, aspiration pnuemonia and

osteoarthritis.

3. On 16 July 2015, Mr Drake appeared unwell and was examined by his General Practitioner Dr Alan Huynh. He was diagnosed with a urinary tract infection and prescribed oral antibiotics, however Mr Drake’s health deteriorated and he was admitted to the East Grampians Health Service (EGHS) in Ararat on 17 July. At EGHS, he was diagnosed with bilateral pneumonia

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and commenced on intravenous antibiotics. Within hours of admission, Mr Drake experienced

progressive respiratory distress and hypotension and was transferred to Ballarat Base Hospital.

At Ballarat Base Hospital, a number of invasive procedures were undertaken which Mr Drake found very distressing. After consultation with Mr Drake’s brother, the decision was made to provide supportive medical treatment that did not distress Mr Drake any further. Over the following three days, Mr Drake’s health continued to deteriorate and medical staff kept him comfortable and minimized his pain. Mr Drake died on 20 July 2015 and was declared deceased at 1.25pm.

INVESTIGATIONS

Forensic pathology investigation

Dr Gregory Young, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an external examination on the body of Mr Drake, referred to medical records and the Victoria Police Report of Death, Form 83. Dr Young noted that there were signs of medical

intervention and no unexpected signs of trauma.

On the evidence available to him, Dr Young reported to the Coroner that the cause of Mr Drake’s death was pneumonia and urosepsis in a man with multiple comorbidities including

Down syndrome. He was of the opinion that the death was due to natural causes.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected with

the death:

1. Mr Drake’s death was reportable pursuant to section 4 of the Coroners Act 2008 (Vic) (‘the Act’) because he was immediately before death a person placed in care, as defined by section 3 of the Act. Section 52 of the Act mandates the holding of an Inquest, save for circumstances where the person is deemed to have died from natural causes, pursuant to section 52(3A). I have exercised my discretion pursuant to section 52(3A) not to hold an

inquest into Mr Drake’s death.

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FINDINGS

On the evidence available to me, I find that Alan James Drake died of natural causes.

T accept and adopt the medical cause of death as identified by Dr Gregory Young and find that Alan

James Drake died of pneumonia and urosepsis.

And I further find that there is no relationship between the cause of Mr Drake’s death and the fact

he was a person placed in care.

Pursuant to section 73(1B) of the Coroners Act 2008, I order that this Finding be published on the internet.

I direct that a copy of this finding be provided to the following:

Mr David Drake

Dr Allan Huynh

Ballarat Base Hospital

Ms Mary McGorry, Department of Health and Human Services

Ms Kym Peake, Department of Health and Human Services

Leading Senior Constable Eleanor Bergheim

Signature:

AUDREYJAMIESON CORONER ——— |

Date: 14 June 2016

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