Finding into death of Jocelyn Riddiford

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2017 4162

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: Peter White, Coroner Deceased: Jocelyn Riddiford Date of birth: 14 March 1965 Date of death: 2] August 2017 Cause of death: Unascertained (natural causes)

Place of death: Colac

I, PETER WHITE, Coroner,

having investigated the death of JOCELYN RIDDIFORD

without holding an inquest:

find that the identity of the deceased was JOCELYN RIDDIFORD

born on 14 March 1965

and that the death occurred 21 August 2017

at the Colac Hospital, Colac Area Health, 2-28 Connor Street, Colac, Victoria 3250

from:

I(a) UNASCERTAINED (NATURAL CAUSES)

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

circumstances:

Ms Riddiford was a 52-year-old woman who resided in supported accommodation at the

Colanda Centre in Colac from 16 years of age.

Ms Riddiford was diagnosed with an intellectual disability with autism. She had poor verbal skills, but good receptive communication, communicating through the use of single words, Makaton signing! and gestures.

Ms Riddiford’s step-mother, Catherine Stoddart, regularly visited Ms Riddiford and has advised the Court that the level of care provided to Ms Riddiford by staff at the Colanda Centre was ‘outstanding’?

Ms Riddiford participated in a daily activity program through SkillsConnection. She enjoyed being active, participating in a range of activities including bushwalking, swimming and various social outings.

Approximately 18 months prior to Ms Riddford’s death, Heather Cardinal, Ms Riddiford’s

carer, observed that Ms Riddiford’s health was declining. She was experiencing swelling, stiff

joints, appeared to be gaining weight and had increased difficulties walking.

. In July 2016, Ms Riddiford underwent blood tests at the direction of her general practitioner Dr

Mohammad Gadi, which showed that Ms Riddiford’s iron levels were low.

' Makaton is a language program using signs and symbols to help people communicate.

? Coronial Brief, Statement of Catherine Stoddart, dated 4 October 2017, 1.

Dr Gadi noted that between December 2016 and April 2017 Ms Riddiford lost 11 kilograms and her iron levels continued to remain low. She had an increasingly poor appetite, vomiting, loose bowels and worsening mobility.

According to Ms Stoddart, as Ms Riddiford’s health deteriorated she became increasingly fatigued and stopped attending her activities program.

In February 2017, Ms Riddiford’s symptoms were fully investigated by the Gastroenterology Unit at Barwon Health. The Haematology Unit at the Andrew Love Cancer Centre provided

care and management recommendations for Ms Riddiford’s condition.

-In June 2017, Ms Riddiford underwent a colonoscopy and gastroscopy at Barwon Health in

Geelong. The gastroscopy showed mild gastritis and a normal duodenum with histology showing chronic gastritis? and normal duodenal* mucosa’. The colonoscopy showed mild telangiectasia® throughout the large bowel and a small rectal polyp was also removed. A bone marrow biopsy was also performed, which did not show any abnormalities other than low iron

stores.

Throughout July 2017, Ms Riddiford’s health continued to deteriorate.

On 16 August 2017, Ms Stoddart discussed Ms Riddiford’s advanced care plan with her general practitioner. Ms Riddiford was not considered suitable for invasive treatment and given her poor prognosis she was referred for palliative care. Ms Riddiford was moved from her home to Colac Hospital on 18 August 2017. Measures were taken for Ms Riddiford’s comfort and she was declared deceased on 21 August 2017.

Senior Forensic Pathologist Dr Malcolm Dodd of the Victorian Institute of Forensic Medicine reviewed the circumstances of the death as reported by police to the Coroner and performed an extemal examination. In spite of the external examination the cause of death remains

unascertained (natural causes).

Routine post-mortem toxicology detected acetone’, morphine’, diazepam’ and its metabolite

nordiazepam, midazolam'® and metoclopramide!! consistent with therapeutic use.

3 Inflammation of the stomach.

4 The first part of the small intestine, going from the stomach to the jejunum.

Mucous.

§ A condition in which the small blood vessels, especially in the face and thighs, are permanently dilated producing dark red blotches.

7 Acetone is an endogenous substance produced in humans.

3 Morphine is a narcotic analgesic used to treat moderate to severe pain. It is also a metabolite of codeine.

° Diazepam is a sedative/hypnotic drug of the benzodiazepines class.

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

15. The Coronial Brief on which this finding is largely based was prepared by Senior Constable Simon Redford of Victoria Police.

16. 1 find that Jocelyn Riddiford, late of Colac, died at the Colac Hospital, Colac Area Health, 2-28 Connor Street, Colac, Victoria 3250 on 21 August 2017, and that the cause of her death remains

unascertained (natural causes).

Pursuant to section 73(1B) of the Coroners Court Act 2008 (Vic), I order that this Finding be

published on the internet.

I direct that a copy of this finding be provided to the following: Ms Cathy Stoddart, Senior Next of Kin

Senior Constable Simon Redford, Coroner’s Investigator, Victoria Police

Signature:

p~ ats)

PETER WHITE .

CORONER

Date:

' Metoclopramide is an anti-cmetic drug used for the treatment of nausea and vomiting.