Finding into death of Jane Laura Gooding

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE

Findings of:

Deceased:

Date of birth:

Date of death:

Cause of death:

Place of death:

Court Reference: COR 2017 978

FINDING INTO DEATH WITHOUT INQUEST

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

MR PHILLIP BYRNE, CORONER JANE LAURA GOODING

11 NOVEMBER 1977

27 FEBRUARY 2017

I (a) MULTIORGAN FAILURE

I (b) PROBABLE SEPSIS

CONTRIBUTING FACTORS

CEREBRAL PALSY, EPILEPSY

KNOX PRIVATE HOSPITAL, 262

MOUNTAIN HIGHWAY, WANTIRNA, VICTORIA 3152

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2017 978

FINDING INTO DEATH WITHOUT INQUEST

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

I, PHILLIP BYRNE, Coroner having investigated the death of JANE LAURA GOODING

without holding an inquest:

find that the identity of the deceased was JANE LAURA GOODING

bom on 11 November 1977

and the death occurred on 27 February 2017

at Knox Private Hospital, 262 Mountain Highway, Wantirna, Victoria 3152

from: 1(a) MULTIORGAN FAILURE 1(b) PROBABLE SEPSIS

CONTRIBUTING FACTORS

CEREBRAL PALSY, EPILEPSY

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

circumstances: Background

1. Ms Laura Jane Gooding was aged 39 years old at the time of her death. She resided in a Department of Health and Human Services residential care facility in Ringwood. She is

survived by her parents Mr Graham Gooding and Mrs Deborah Gooding.

2. Ms Gooding had a medical history of cerebral palsy, epilepsy, and blindness.

3. Ms Gooding’s death constituted a ‘reportable death’ under the Coroners Act 2008 (Vic), as immediately before death she was a person placed under the care of the secretary to the

Department of Health and Human Services (‘DHHS’).' Ordinarily, a coroner must hold an

! Section 4, definition of ‘Reportable death’, Coroners Act 2008; Section 4, definition of ‘Person placed in custody or care’, Coroners Act 2008.

inquest into a death if the death or cause of death occurred in Victoria and the deceased person was immediately before death a person placed in custody or care.? However, a coroner is not required to hold an inquest if the coroner considers that the death was due to

natural causes.?

Circumstances of the death

4,

On 23 February 2017 Ms Gooding was presented at the Knox Private hospital Emergency Department with increasing shortness of breath, fever, vomiting, abdominal pain and collapse. In the Emergency Department, Ms Gooding was hypotensive, tachypnoeic, and tachycardic. Blood pressure support was commenced with fluids and noradrenaline. Ms Gooding became increasingly more agitated, and needed sedation to the point of requiring intubation.

A Computed Tomography (CT) scan was performed, which revealed bilateral consolidation and a pericardial effusion, the significance of which was unclear at the - time. Ms Gooding was returned to the Intensive Care Unit (ICU) for ventilation, blood.

pressure support, and administration of antibiotics. Ms Gooding’s condition deteriorated, and an echocardiogram was undertaken which demonstrated features of tamponade. Ms Gooding was taken to an operating theatre where Thoracic Surgeon Mr Lubicz drained

the pericardial effusion.

Ms Gooding improved haemodynamically, but subsequently went into multiorgan dysfunction. Ms Gooding’s liver function deteriorated, and she suffered acute kidney injury with oliguria and the deterioration of her renal function left her likely requiring renal replacement therapy. Ms Gooding also had pneumonia requiring ventilation, and

experienced ongoing seizures.

Treating clinicians discussed Ms Gooding’s irretrievable condition with her family, advising that her pathway to recovery was likely going to be very difficult given Ms Gooding’s comorbidities and her inability to cope with foreign environments. Following discussions with Ms Gooding’s family, comfort measures were implemented. Following

extubation at midday, Ms Gooding was declared deceased at approximately 12:30p.m.

In first contact with the Court’s Coronial Admissions and Enquiries Office (CAE) Ms Gooding’s father, Mr Graham Gooding, stated that he was very happy with the care provided by Knox Private Hospital.

2 Section 52(2})(b) Coroners Act 2008.

3 Section 52(3A), Coroners Act 2008.

POST-MORTEM INSPECTION AND REPORT

9. The matter was appropriately referred to the Coroner. Having regard to the circumstances, Mr and Mrs Gooding’s strong objection to autopsy, and having conferred with a forensic pathologist, I directed an external-only post-mortem examination be conducted. A post-mortem examination was performed by Forensic Pathologist Dr Linda Iles of the Victorian Institute of Forensic Medicine. Dr lies formed the opinion that the immediate cause of Ms Gooding’s death was I (a) Multiorgan failure, 1(b) probable

sepsis with contributing factors of cerebral palsy and epilepsy.

FINDING

10.1 am satisfied, having considered all of the evidence before me, that no further

investigation is required.

11.1 formally find Ms Laura Jane Gooding died at Knox Private Hospital, Wantirna on 23 February 2017 as a result of multiorgan failure and probable sepsis, with contributing factors

of cerebral palsy and epilepsy. I am satisfied Ms Gooding died due to natural causes.

12. I direct that a copy of this finding be provided to the following: Mr Graham Gooding and Mrs Deborah Gooding, Senior Next of Kin; and Senior Constable Nicholas Licari, Reporting Member, Victoria Police.

13. Pursuant to section 73(1B) of the Coroners Act 2008, 1 also direct the finding be published on the Coroners Court of Victoria website in accordance with the rules of the

Coroners Court.

Signature:

PHILLIP BYRNE ~~ CORONER ©

Date: 19 May 2017