Finding into death of Wendy Maree Jones

IN THE CORONERS COURT

OF VICTORIA

AT MELBOURNE

Court Reference: COR 2015 4250

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 WENDY MAREE JONES

without holding an inquest:

find that the identity of the deceased was WENDY MAREE JONES born on 14 May 1964

and the death occurred on 21 August 2015

at Benalla Health, Coster Street Benalla Victoria 3672

from:

1(a) BRONCHOPNEUMONIA 1(b) CEREBRAL INFARCTION IN A WOMAN WITH CEREBRAL PALSY

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

lL.

Ms Wendy Jones was 51 years of age at the time of her death. She lived in a residential care

facility at 1 Olivers Road, Benalla.

Ms Jones had a history of cerebral palsy, epilepsy, and had a poor swallowing reflex and was

wheel chair bound.

On 10 July 2015, Ms Jones was found in her bed at her residential care facility with a right side facial droop and no movement on the right side of her body. Emergency services were called and she was transported to North East Health in Wangaratta. A number of tests were conducted to try and ascertain what had happened to Ms Jones, but the results were inconclusive. Ms Jones continued to have seizures, remained unresponsive and her health deteriorated over the

following weeks.

1 of 3

4. On 8 August 2015, after discussions with her parents, Ms Jones was transported to Benalla Health for palliative care. Ms Jones’ health continued to decline and at 10.00am on 21 August

2015 she died, surrounded by her family.

INVESTIGATIONS Forensic pathology investigation

5. Dr Michael Burke, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed a full post mortem examination on the body of Ms Jones, referred to medical records

and the Victoria Police Report of Death, Form 83.

6. Toxicological analysis of post mortem blood showed morphine', codeine’, midazolam’, 7-

aminoclonazepam a metabolite of clonazepam’.

7. Dr Burke stated that the post-mortem examination showed that Ms Jones had widespread bronchopneumonia in keeping with an individual who was undergoing palliative care. He stated that Ms Jones’ brain showed marked swelling to the left side with compression of the ventricles.

Dr Burke opined that Ms Jones had suffered a sudden “stroke” most probably thrombotic, then

she suffered secondary seizures and developed bronchopneumonia in palliative care.

8. On the evidence available to him, Dr Burke reported to the Coroner that the causes of Ms Jones’ death were bronchopneumonia and cerebral infarction in a woman with cerebral palsy. 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 Jones’ death was reportable pursuant to section 4 of the Coroners Act 2008 (Vic) (‘the Act’) because she 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). In these

' Morphine is a narcotic analgesic used to treat moderate to severe pain and is a metabolite of codeine.

• Codeine is an analgesic drug derived from morphine.

3 Midazolam is a short acting benzodiazepine used intravenously in intensive care patients.

• Clonazepam is a benzodiazepine possessing sedative and anticonvulsant properties.

2 of 3

circumstances, I have exercised my discretion pursuant to section 52(3A) not to hold an inquest

into Ms Jones’ death.

1. FINDINGS

On the evidence available to me, I find that Wendy Maree Jones died of natural causes.

I accept and adopt the medical cause of death as identified by Dr Michael Burke and find that

Wendy Maree Jones died of bronchopneumonia and cerebral infarction.

And I further find that there is no relationship between the cause of Ms Jones’ death and the fact she

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:

Mrs Bonnie Jones

Mr Alan Jones

Ms Janine Holland, Benalla Health

Ms Kym Peake, Department of Health and Human Services

Senior Constable Frances Gottschling

Signature:

AUDREY JAMIESON CORONER

Date: 14 June 2016

3 of 3