Finding into death of Richard Alan Jones

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 2018 6510

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

PHILLIP BYRNE, CORONER RICHARD ALAN JONES 12 MARCH 1950 27 DECEMBER 2018 I (a) EXACERBATION OF CONGESTIVE

CARDIAC FAILURE AND ASPIRATION PNEUMONIA ON A BACKGROUND OF

CEREBRAL PALSY

AUSTIN HOSPITAL, 145 STUDLEY ROAD, HEIDELBERG, VICTORIA, 3084

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2018°6510

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 ROBERT ALAN JONES without holding an inquest:

find that the identity of the deceased was ROBERT ALAN JONES

born on 12 March 1950

and the death occurred on 27 December 2018

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

from:

1 (a) EXACERBATION OF CONGESTIVE CARDIAC FAILURE AND ASPIRATION

PNEUMONIA ON A BACKGROUND OF CEREBRAL PALSY

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

circumstances:

BACKGROUND

1. Richard Alan Jones, 68 years of age at the time of his death, resided in a Department of Health and Human Services (DHHS) managed group home at 10 Botanic Drive, Kew. Mr Jones’s, who suffered from cerebral palsy, was severely physically and intellectually disabled. Mr Jones’s past medical history also included epilepsy, hypertension, hypothyroidism and

gastroesophageal reflux disease.

CIRCUMSTANCES SURROUNDING DEATH

2. Mr Jones’s was conveyed by ambulance to the Austin Hospital on the moming of 27 December 2018 in respiratory failure secondary to an exacerbation of previously diagnosed

congestive cardiac failure and aspiration pneumonia.

3. Upon admission, Mr Jones was given intravenous antibiotic therapy for infection and

morphine for agitation; Mr Jones had become quite agitated when non-invasive intubation was

introduced.

Mr Jones’s Senior Next of Kin (SNOW), his cousin, Ms Heather Dalgleish, in consultation with senior clinicians, decided ward based management for palliative care was appropriate. Mr

Jones was admitted to the ward and later that same evening he died.

REPORT TO THE CORONER

Mr Jones’s death was reported to the. coroner. Having considered the circumstances and having conferred with the forensic pathologist, I directed an external only post mortem examination. The examination was undertaken at the Victorian Institute of Forensic Medicine by Forensic pathologist Dr Yeliena Baber who subsequently advised Mr Jones’s death was due

to:

1 (a) exacerbation of congestive cardiac failure and aspiration pneumonia on a

background of cerebral palsy.

Dr Baber advised Mr Jones’s death was due to natural causes. In light of that advice, considering the available material (including the e-Medical Deposition provided by the Austin Hospital) I have concluded no further investigation is warranted and finalise my

investigation by Finding Without Inquest.

COMMENT

Pursuant to section 67 (3) of the Coroners Act 2008, I make the following comments

connected with the death.

I note that this death is subject to a Disability Services Commissioner (DSC) review in relation to the provision of services to Mr Jones. However, I now propose to proceed to finalisation of

my coronial investigation. —

FINDING

I formally find Richard Alan Jones died at the Austin Hospital on the evening of 27 December 2018 due to exacerbation of congestive cardiac failure and. aspiration pneumonia on a background of cerebral palsy.

Pursuant to section 73 (1) (B) of the Coroners Act 2008, J 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: Ms Heather Dalgliesh, Senior Next of Kin,

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

Ms Lynette Russell, Austin Health; and Senior Constable De Felice, Reporting Officer, Victoria Police

Signature: ws,

PHILLIP BYRNE CORON:

Date: 5 April 2019