Finding into death of Bevan John Stevens

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2018 2100

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2)

Section 67 of the Coroners Act 2008 (Amended pursuant to section 76 of the Coroners Act 2008 as at 2 April 2019)!

Findings of: PHILLIP BYRNE, CORONER Deceased: BEVAN JOHN STEVENS

Date of birth: 11 APRIL 1945

Date of death: 5 MAY 2018

Cause of death: I (a) ASPIRATION PNEUMONIA

COMPLICATING SIGMOID VOLVULUS IN A MAN WITH DOWN SYNDROME

Place of death: AUSTIN HOSPITAL, 145 STUDLEY ROAD,

HEIDELBERG, VICTORIA, 3084

1 Paragraph 11, line one, Northern deleted and replaced with Austin.

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2018 2100

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 BEVAN JOHN STEVENS without holding an inquest:

find that the identity of the deceased was BEVAN JOHN STEVENS

born on 11 April 1945

and the death occurred on 5 May 2018

at Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084

from: 1 (a) ASPIRATION PNEUMONIA COMPLICATING SIGMOID VOLVULUS IN A MAN WITH

DOWN SYNDROME

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

BACKGROUND

1. Bevan Stevens, 73 years of age at the time of his death, resided in a group home managed by the Department of Health and Human Services (DHHS), and, on that basis, I conclude he was “in care” within the meaning of the Coroners Act 2008.

2. Mr Stevens has a significant medical history, including dysphagia with recurrent aspiration

pneumonia and Down syndrome.

CIRCUMSTANCES SURROUNDING DEATH

3. On 1 May 2018, Mr Stevens was seen by a locum at the facility where he resided and was noted to be drowsy with shortness of breath. He was conveyed to the Austin Hospital where

‘x-rays demonstrated sigmoid volvulus and consolidation in the lower zone of the left lung.

4. Mr Stevens was admitted to the Austin Hospital on 1 May 2018 and commenced on

ceftriaxone. On 2 May 2018, a rigid sigmoidoscopy was performed.

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REPORT TO CORONER

5. Mr Stevens died at the Austin Hospital on 5 May 2018. His death was reported to the coroner as he was “in care” at the time of his death. I directed an external only post mortem

examination.

6. The examination was undertaken by Dr Gregory Young who advised Mr Stevens died due

to:

1 (a) aspiration pneumonia complicating sigmoid volvulus in a man with Down

syndrome.

7. Dr Young advised Mr Stevens’s death was due to natural causes. On that basis, I finalise my investigation by way of this short Finding Without Inquest. I am advised by Forensic Pathologist Dr Gregory Young that the conditions suffered by Mr Stevens “increase the risk

of aspiration”.

CONCLUSION

8. On the material available, I believe one could not reasonably conclude that the care/treatment of Mr Stevens was other than reasonable and appropriate.

COMMENT

9. Pursuant to section 67 (3) of the Coroners Act 2008, I make the following comments connected with the death.

10. In earlier correspondence, I advised the Senior Next of Kin I would leave my investigation in abeyance awaiting the outcome of a review by the office of the Disability Services Commissioner (DSC) in relation to the provision of services to Mr Stevens. Due to developments at the offices of the DSC, I now propose to proceed to finalisation of my

coronial investigation.

FINDING

11.1 formally find Bevan John Stevens, who had Down syndrome, died at the Austin Hospital on 12 August 2018 due to aspiration pneumonia complicating sigmoid volvulus in a man

with Down syndrome.

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

published on the Coroners Court of Victoria website.

DISTRIBUTION OF FINDING

13. I direct that a copy of this finding be provided to the following: Mr Graeme Stevens, Senior Next of Kin;

Ms Jacinda De Witts, Acting General Counsel and Chief Legal Officer, Legal Services, DHHS;

Ms Lynette Russell, Austin Health; and

First Constable Andrew Moharic, Reporting Officer, Victoria Police

Signature: