Finding into death of Kerri Michelle Moore

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2018 3992

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: PHILLIP BYRNE, CORONER Deceased: KERRI MICHELLE MOORE Date of birth: 2 DECEMBER 1962 Date of death: 12 AUGUST 2018 Cause of death: I (a) ASPIRATION PNEUMONIA IN A

WOMAN WITH EPILESY AND INTELLECTUAL DISABILITY Place of death: NORTHERN HOSPITAL, 185 COOPER

STREET, EPPING, VICTORIA, 3076

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2018 3992

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 KERRI MICHELLE MOORE without holding an inquest:

find that the identity of the deceased was KERRI MICHELLE MOORE

born on 2 December 1962

and the death occurred on 12 August 2018

at Northern Hospital, 185 Cooper Street, Epping, Victoria, 3076

from:

1 (a) ASPIRATION PNEUMONIA IN A WOMAN WITH EPILESY AND INTELLECTUAL

DISABILITY :

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

circumstances:

BACKGROUND

1. Kerri Michelle Moore, 55 years of age at the time of her death, resided at a group home

managed by the Department of Health and Human Services (DHHS). Ms Moore suffered an

intellectual disability, progressive neurological deficit and epilepsy.

CIRCUMSTANCES SURROUNDING DEATH

2. Ms Moore was admitted to the Northern Hospital on 4 August 2018 with status epilepticus.

She was commenced on antibiotic therapy for aspiration pneumonia, intubated and transferred to the Intensive Care Unit (ICU) for seizure control. She was extubated on 8 August 2018 but had worsening infective markers with ongoing fevers. In consultation, a

decision was taken to provide palliative care. Ms Moore died in hospital on 12 August 2018.

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REPORT TO THE CORONER

3. Ms Moore’s death was reported to the coroner. Having conferred with a forensic pathologist, having considered the circumstances, and noting the Senior Next of Kin’s strong objection to autopsy, I directed an external only post mortem examination. The examination was undertaken at the Victorian Institute of Forensic Medicine by Forensic

Pathologist Dr Gregory Young who advised Ms Moore’s death was due to: 1 (a) aspiration pneumonia in a woman with epilepsy and intellectual disability.

CONCLUSION/FINALISATION

4. As 1am advised Ms Moore was “in care” within the meaning of the Coroners Act 2008 at the time of her death, and, as further advised, her death was due to natural causes, I can finalise my coronial investigation by way of Finding Without Inquest.

5. I note on the Coronial Admissions and Enquiries (CA&E) log that Mrs Mary Moore, the mother of Ms Moore, advised she was “very happy with the care at both the home and the hospital and does not have any issues that she would like investigated”. On the material available, I believe one could not reasonably conclude that the care/treatment of Ms Moore

was other than reasonable and appropriate.

COMMENT

6. Pursuant section 67 (3) of the Coroners Act 2008, 1 make the following comments

connected with the death.

7. 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 Ms Moore. However, I now

propose to proceed to finalisation of my coronial investigation.

FINDING

8. I formally find Kerri Michelle Moore died at the Northern Hospital on 12 August 2018 due

to aspiration pneumonia in a woman with epilepsy and intellectual disability.

9. 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

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

Mrs Mary Moore, Senior Next of Kin;

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

Ms Jackie Petrov, Legal Co-ordinator, The Northern Hospital; and

First Constable R Hughes, Reporting Officer, Victoria Police

Signature:

Date: 28 March 2019