Finding into death of Robert Louis Gerrard

IN THE CORONERS COURT Court Reference: COR 2019 4930

OF VICTORIA

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

Findings of: Simon McGregor, Coroner Deceased: Robert Louis Gerrard Date of birth: 17 April 1963 Date of death: 11 September 2019 Cause of death: Unascertained (likely natural causes)

Place of death: 11 Simpson Place, Keilor East, Victoria

INTRODUCTION

1. Robert Louis Gerrard was a 56-year-old man who lived with in a supported residential care facility in Keilor East at the time of his death. He was found deceased in his room on 11

September 2019.

THE PURPOSE OF A CORONIAL INVESTIGATION

2. Mr Gerrard’s death was reported to the Coroner. Immediately before his death Mr Gerrard was a person in the care of the Department of Health and Human Services and so fell within

the definition of a reportable death in the Coroners Act 2008.

3. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame

or determine criminal or civil liability.

4. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death

under investigation.

5. Senior Constable Sime Marinovic of Victoria Police made a report of the death for the coroner. I have also obtained medical records and a report from a Forensic Pathologist at the

Victorian Institute of Forensic Medicine (VIFM).

6. After considering all the material obtained during the coronial investigation, I determined that I had sufficient information to complete my task as coroner and that further investigation was not required. Whilst I have reviewed all the material, [ will only refer to

that which is directly relevant. to my findings or necessary for narrative clarity.

7. | have based this finding on the evidence contained in the coronial brief. In the coronial

jurisdiction facts must be established on the balance of probabilities.!

1 This is subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

In considering the issues associated with this finding, I have been mindful of Mr Gerrard’s basic human rights to dignity and wellbeing, as espoused in the Charter of Human Rights and Responsibilities Act 2006, in particular sections 8, 9 and 10.

CIRCUMSTANCES IN WHICH THE DEATH OCCURRED

Mr Gerrard had a long medical history extending back to his childhood including muscular dystrophy, osteoporosis and scoliosis. He also suffered gastro-oesophageal reflux disease

and respiratory issues.

These conditions caused numerous bone fractures and difficulty walking. Mr Gerrard obtained a wheelchair around the age of eighteen. Towards the end of his life he was unable

to weight bear but was independent in most transfers.

On 6 September 2019 Mr Gerrard told staff at his facility that he felt sick to his stomach. He still felt sick the next day so a locum doctor was called. The doctor stated that Mr Gerrard

might have a viral infection and provided medication.

Mr Gerrard continued to feel sick for the next several days.

At around 1.10am on 11 September 2019 Mr Gerrard rang his bell for staff attendance. He asked for Gastrolyte as it helped him sleep.

He rang his bell again at 3.05am and asked if it was time to get up. Staff informed him it

was not and so he remained in bed,

At around 5.50am staff entered his room to wake him and found him unresponsive. They

contacted emergency services and began CPR but Mr Gerrard could not be revived.

IDENTITY AND CAUSE OF DEATH

Mr Gerrard’s body was visually identified by Disability Support Worker Mark Jewel.

Identity is not in dispute and requires no further investigation.

On 20 September 2019, Dr Heinrich Bouwer, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an external examination of Mr Gerrard’s body and reviewed a post mortem computed tomography (CT) scan and the Police Report of Death for the Coroner. No autopsy was performed.

18. Dr Bouwer recommended that a full post mortem examination be performed in order to ascertain the precise morphological cause of death. However, based on the information available to him, Dr Bouwer was able to form the opinion that the death was due to natural causes.

19. Dr Bouwer provided a written report, dated 20 September 2019, in which he formulated the cause of death as ‘/(a) Unascertained (likely natural causes)’.

20. I accept Dr Bouwer’s opinion as to cause of death. I do not consider it necessary to conduct any further examinations.

FINDINGS AND CONCLUSION

21. lexpress my sincere condolences to Mr Gerrard’s family for their loss.

22. Aslam satisfied by Dr Bouwer’s report that Mr Gerrard’s death was due to natural causes, | am not required to hold an inquest into his death.

23. Having investigated the death, without holding an inquest, I make the following findings pursuant to section 67(1) of the Coroners Act 2008:

(a) The identity of the deceased was Robert Louis Gerrard, born 17 April 1963;

(b) The death occurred on 11 September 2019 at 11 Simpson Place, Keilor East, Victoria from unascertained causes which were likely natural; and (c} The death occurred in the circumstances described above.

24, Pursuant to section 73(1B) of the Act, I direct that this finding be published on the Internet.

25. IJ direct that a copy of this finding be provided to the following:

(a) Mr Alexander Gerrard and Mrs Helen Gerrard, senior next of kin; and

(b) Senior Constable Sime Marinovic, Victoria Police.

Signature:

LOW

SIMON McGREGOR

CORONER Date: 2 March 2020