Finding into death of Elizabeth Joy Whelan

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR. 2016 2216

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 ELIZABETH JOY WHELAN

without holding an inquest:

find that the identity of the deceased was ELIZABETH JOY WHELAN born on 26 April 1953

and the death occurred on 18 May 2016

at 155 Mansfield Strect, Berwick, Victoria

from:

1 (a) CARDIOMEGALY IN A WOMAN WITH AORTIC STENOSIS!

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:

Elizabeth Joy Whelan was 63 years of age at the time of her death. She resided in a Department of Health and Human Services (“DHHS”) group home in Berwick, Victoria.

Ms Whelan had a past medical history of antenatal rubella infection with developmental delay, anxiety disorder, left perforated eardrum, infrapateilar bursitis, ulcerative oesophagitis, constipation, bilateral hip dysplasia, vitamin D deficiency, calluses on the feet, visual and hearing impairment, iron deficiency anaemia, and urinary tract infection.

Ms Whelan had traits of autistic-like preoccupation with chewing soft objects and rocking behaviour. At times she had episodes of high anxiety which resulted in her pinching staff, screaming and scratching herself; causing large infected grazes. Other times, she had severe depression with tearfulness, withdrawal, and appetite and slecp disturbance. Ms Whelan was able to ambulate short distances independently within the DHHS group home, however, required supervision outside the home.

Tn 1954, Ms Whelan’s mother left the family home. She, and her siblings were cared for by their grandparents thereafter.

‘ Cardiomegaly is enlargement of the heart, not in keeping with normal physiological change in an individual. Itis commonly associated with valvular heart disease such as aortic stenosis.

5. Ms Whelan’s sister, Anne Ilumphery, assisted their grandmother in caring for Ms Whelan.

She continued to do this beyond her marriage, and until their grandmother was unable to do so,

6. In 1989, with the assistance of DHHS, Ms Whelan was placed in a nursing home in Seaford, Victoria.

7. Some years later, Ms Whelan was transferred to the DHHS group home in Berwick, Victoria.

8. Whilst under the care of her General Practitioner, Dr Mark Robinson, Ms Whelan was reviewed by Cardiologist, Dr John Counsell. The purpose of the assessment was to identify whether there was a possibility of Ms Whelan suffering from aortic stenosis. Dr Counsell’s advice was that as Ms Whelan had no ongoing symptoms, no further action needed to be taken, unless she became short of breath or syncopal.* Neither of these symptoms occurred.

9. In or around 5 May 2016, Ms Whelan developed an upper respiratory tract infection.? She was reviewed and prescribed Roxithromycin 300mg for five days.

10. On 10 May 2016, upon assessment, it was established that Ms Whelan had not improved and had developed evidence of bronchitis.> She was prescribed Augmentin Duo Forte twice a day for five days.®

11. On 16 May 2016, it was noted that Ms Whelan’s condition had improved, however, she was not her normal self, and had a residual cough. Another five-day course of Augmentin Duo Forte was prescribed.

12, On 18 May 2016, at approximatcly 8:30am, Ms Whelan left the group home to.attend an Outlook One day program.’ She had been well throughout the day; returning to the group home around 3:10pm. Ms Whelan was provided with afternoon tea and then retreated to her room for an afternoon nap, as per her usual routine. .

13. A short time later, Ms Whelan ate her dinner in the dining room before returning to her room.

14. At approximately 6:20pm, Ms Whelan walked into the lounge room where three group home staff members were taking their meal break. Ms Whelan approached one of the staff members and stamped her feet. At the time it was noted that she was gasping and appeared

2 Syncope is also referred to as fainting. It is a short loss of consciousness and muscle strength characterised by a fast onset, short duration, and spontancous recovery. It is caused by a decrease in blood flow to the brain, usually from low blood pressure.

3 An acute upper respiratory infection (URD) is a contagious infection of your upper respiratory tract. Your upper respiratory tract includes the nose, throat, pharynx, larynx, and bronchi, The most well-known URI is the common cold.

4 Roxithromycin is an antibiotic that is used to treat upper respiratory tract, urinary and soft tissue infections (eg. acute bronchitis and pharyngitis, tonsillitis, and worsening of chronic bronchitis).

5 Bronchitis is the inflammation of the larger airways of your lungs. It is caused by a viral infection and causes an ongoing cough.

© Augmentin Duo Forte is an antibiotic that is used to treat bacterial infections.

7 The Department of Health and Human Services’ Outlook One program provides a range of tailored supports to the unique needs of the individual. It provides a blend of community activities, personal support, training and employment based on individual’s needs, goals and lifestyle choices.

to be having trouble breathing. The staff member directed one of her colleagues to call “000’,

15. At 6:22pm, emergency services were calicd. At the same time Ms Whelan grabbed one of the staff members on her leg. She then slumped to her knees and rolled over onto her side.

She began to turn blue. Upon advice from the emergency services operator, the staff members immediately commenced cardiopulmonary resuscitation (“CPR”).

16, At 6:38pm, members from Ambulance Victoria arrived at the scene. They found Ms Whelan to be in cardiac arrest with asystole.® They continued with CPR, without success.

17. At 7:05pm, Ms Whelan was declared deceased.

18. Forensic Pathologist Dr Gregory Young of the Victorian Institute of Forensic Medicine, performed a post mortem autopsy. Dr Young provided me with a report of his findings. The post mortem autopsy examination revealed an enlarged heart with left ventricular hypertrophy,’ and myocardial fibrosis.!° The aortic valve was calcified and stenotic." Signs of heart failure included pleural effusions and a pericardial effusion.”

19. Ante mortem toxicology studies were also performed. Testing revealed the presence of fluvoxamine,'? risperidone and metabolite hydroxyrisperidone."4

20. As part of my investigation, First Constable Aaron Trinder provided me with a coronial brief of evidence (“the brief’). The brief contains statements from Ms Whelan’s sister, general practitioner, a Department of Health and Human Services worker, and the police member who attended the scene.

21. On the evidence before me, I am satisfied that Elizabeth Joy Whelan died from natural

causes by way of l(a) Cardiomegaly in a woman with aortic stenosis, whilst residing in the care of a Department of Health and Human Services group home.

5 Asystole is a cardiac arrest rhythm in which there is no discernible electrical activity on the electrocardiogram (ECG) monitor, Asystole is sometimes referred to as “flat line”. It is the most serious and irreversible form of cardiac arrest.

9 Left ventricular hypertrophy (I, VH) is a condition in which the muscle wall of the heart’s left pumping chamber (ventricle) becomes thickened (hypertrophy). Other conditions, such as heart attack, valve disease and dilated cardiomyopathy, can cause the heart (or the heart cavity) to get bigger.

‘© Myocardial fibrosis is a condition in which the heart’s muscle cells are impaired.

" The aortic valve is a valve in the human heart between the left ventricle and the aorta. It is one of the two scmilunar vales of the heart, the other being the pulmonary heart. The heart has four valves and the other two are the mitral and the tricuspid valves. Calcified or calcification occurs when calcium builds up in body tissue, blood vessels, or organs, This build up can harden and disrupt your body’s normal processes. Stenotic refers to the abnormal narrowing in a blood vessel or other tubular organ or structure. [t is also sometimes called a stricture.

'2 A pleural effusion refers to an unusual amount of fluid around the lung. A pericardial effusion refers to an abnormal accumulation of fluid in the pericardial cavity of the heart. Because of the limited amount of space in the pericardial cavity, fluid accumulation leads to an increased intrapericardial pressure which can negatively affect heart function.

3 Tuvoxamine is an antidepressant.

‘4 Risperidone is an atypical antipsychotic. It is prescribed for schizophrenia and some behavioural disorders (delusions, aggression).

I direct that a copy of this finding be provided to the following: Elizabeth Whelan’s family

First Constable Aaron Trinder, Coroner’s Investigator

Department of Health and Human Services

Signature:

PETER WHITE CORONER ° Date: 20 June 2016