Coronial
VIChospital

Finding into death of Phyllis Franke

Deceased

PHYLLIS FRANKE

Demographics

74y, female

Coroner

Coroner Phillip Byrne

Date of death

2017-09-09

Finding date

2019-02-08

Cause of death

complications of metastatic intra abdominal malignancy (unknown primary)

AI-generated summary

A 74-year-old woman in residential disability care presented with non-specific illness in late August 2017. Following GP consultation, she was admitted to Beechworth Health Service then transferred to Wangaratta Hospital where CT imaging revealed advanced metastatic intra-abdominal malignancy of unknown primary. She was returned for palliative care and died on 9 September 2017. The Disability Services Commissioner investigated separately and concluded several aspects of her management were sub-optimal, though the coroner does not specify these details in this finding. The case highlights the importance of timely investigation of deterioration in care-dependent persons and ensures appropriate communication between investigative bodies.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practiceoncologypalliative care

Error types

diagnosticdelay

Contributing factors

  • delayed diagnosis of metastatic cancer
  • sub-optimal management aspects identified by Disability Services Commissioner
Full text

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IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2017 4540

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: PHILLIP BYRNE, CORONER Deceased: PHYLLIS FRANKE Date of birth: 14 JUNE 1943 Date of death: 9 SEPTEMBER 2017 Cause of death: I (a) COMPLICATIONS OF METASTATIC

INTRA ABDOMINAL MALIGNANCY (UNKNOWN PRIMARY) Place of death: BEECHWORTH HEALTH SERVICE, 52

SYDNEY ROAD, BEECHWORTH, VIC, 3747

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2017 4540

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 PHYLLIS FRANKE without holding an inquest:

find that the identity of the deceased was PHYLLIS FRANKE

born on 14 June 1943

and the death occurred on 9 September 2017

at Beechworth Health Service, 52 Sydney Road, Beechworth, VIC, 3747

from:

1 (a) COMPLICATIONS OF METASTATIC INTRA ABDOMINAL MALIGNANCY

(UNKNOWN PRIMARY)

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

circumstances:

BACKGROUND

  1. Phyllis Franke, 74 years of age at the time of her death, resided in a Department of Health and Human Services (DHHS) group facility home at 8 McHarg Place, Beechworth. Ms Franke had resided at the facility since 1993. Ms Franke had an extensive past medical

history.

CIRCUMSTANCES SURROUNDING DEATH

  1. Late in August 2017, Ms Franke had been feeling unwell. After consulting her general practitioner (GP), Ms Franke was admitted to Beechworth Health Service before being transferred to the Wangaratta Hospital. Ms Franke was then returned to Beechworth Health Service for palliation. A computed tomography (CT) taken at Wangaratta Hospital demonstrated Ms Franke had advanced metastatic cancer. The cancer was considered

untreatable. Ms Franke was palliated, and she passed away on 9 September 2017.

Page |

REPORT TO THE CORONER

  1. As Ms Franke was “in care” within the meaning of the Coroners Act 2008 her death was

reported to the coroner.

  1. Having considered the circumstances, and having conferred with a forensic pathologist, I

directed an external only post mortem examination.

  1. I subsequently received an Inspection and Report under the hand of Senior Forensic

Pathologist Dr Matthew Lynch who advised Ms Franke’s death was due to: 1 (a) complications of metastatic intra abdominal malignancy (unknown primary).

FURTHER INVESTIGATION

  1. Even though Ms Franke died due to natural causes, the Disability Services Commissioner (DSC) undertook an investigation into her death. I left my investigation in abeyance while

the DSC undertook its review.

  1. Inearly January this year, 2019, I was provided with a copy of the DSC investigation report,

which was provided with the usual caveat as to the use of the information contained therein.

  1. The DSC investigation concluded that several aspects of Ms Franke’s management were

considered to be sub-optimal.

CONCLUSION

  1. Section 7 of the Coroners Act 2008 provides that a coroner should liaise with other investigative statutory officers to avoid unnecessary duplication of investigations. Based on the thorough investigation undertaken by the DSC, in accordance with section 7 I propose

no further investigations and finalise my investigation by way of Finding Without Inquest.

FINDING

10.1 formally find Phyllis Franke died at Beechworth Health Service, 52 Sydney Road, Beechworth, Victoria, on 9 September 2017 due to complications of metastatic intra

abdominal malignancy (unknown primary). Ms Franke’s death was due to natural causes.

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

published on the Coroners Court of Victoria website.

DISTRIBUTION OF FINDING

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

e Mr Anthony Kolmus, Deputy Commissioner, Disability Services Commissioner; and e Constable Andrew Deegan, Reporting Officer, Victoria Police

Signature:

CORONER Date: 8 February 2019

Official source Archived copy

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