Finding into death of Patricia Faye Stone

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IN THE CORONERS COURT Court Reference: COR 2018 0896

OF VICTORIA

AT MELBOURNE

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 & 52(3A) of the Coroners Act 2008

Findings of: AUDREY JAMIESON, CORONER

Deceased: PATRICIA FAYE STONE

Date of birth: 21 August 1946

Date of death: 23 February 2018

Cause of death: COMPLICATIONS OF METASTATIC INTRA

ABDOMINAL MALIGNANCY (UNKNOWN PRIMARY)

Place of death: Austin Hospital - 145 Studley Road, Heidelberg, Victoria 3084

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Pursuant to section 67(1) and 52(3A) of the Coroners Act 2008, I make findings with respect to the following circumstances:

Patricia Faye Stone was 71 years of age at the time of death. She did not have a spouse nor children. Ms Stone had a mild intellectual disability. She resided in Department of Health and Human Services (DHHS) Disability Services Residential Accommodation in Reservoir along with five other residents. Ms Stone was a sociable and funny person; she

described herself as having many friends and the support of her family.

Ms Stone had non-insulin-dependent diabetes, mild hypertension and mild cataracts. She was fairly independent and was able to make decisions and choices in relation to activities of daily living. However, she had the support of her brother Brian Stone to

make more complex decisions and he consented to medical treatment on her behalf.

On 3 January 2018, Ms Stone was transported by ambulance to Austin Hospital as staff at the DHHS facility had become concerned about her physical wellbeing.

Austin Hospital medical practitioners identified that Ms Stone had cancerous masses on her liver which had metastasised into her lungs and bones. Although Ms Stone had experienced some symptoms of liver cancer, it was not necessary to establish the definitive origin of her cancer at that time. She was transported back to the DHHS accommodation to be cared for palliatively in her own home. Ms Stone’s palliative care needs were managed by Melbourne City Mission (MCM) palliative care nurses, who

were assisted by DHHS Staff.

On 13 February 2018, MCM palliative care nurses identified that Ms Stone’s care needs could no longer be met at home. Subsequently, she was admitted to the Olivia Newton John Palliative Care Unit of the Austin Hospital. During the early hours of 23 February 2018, Ms Stone died in the palliative care unit with her family at her side.

INVESTIGATIONS

Forensic pathology investigation

Dr Matthew Lynch, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM), performed an external examination upon the body of Patricia Faye Stone, reviewed a post mortem computed tomography (CT) scan and referred to the Victoria

Police Report of Death, Form 83. Dr Lynch reviewed the CT scan with radiologist Dr

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Chris O’Donnell. The scanning detected metal in Ms Stone’s right radius as well as metastatic malignancy with no clear primary malignancy. Toxicological analysis of post mortem blood identified drugs associated with hospital treatment. Dr Lynch ascribed the medical cause of Ms Stone’s death to complications of metastatic intra-abdominal

malignancy (unknown primary).

Disability Services Commissioner

6. On 26 February 2018, the Disability Services Commissioner (the Commissioner) commenced an investigation into the provision of disability services to Ms Stone, pursuant to section 1281 of the Disability Act 2006 (Vic) [the Disability Act].

On 13 November 2019, the Commissioner provided the Investigation Report to then Acting State Coroner English. The report did not identify any concerns in relation to the provision of services to Ms Stone. There was no evidence that DHHS staff’s provision of

care to Ms Stone was causally associated with her death.

Coronial Investigation

7. Mr Stone’s death was reportable pursuant to section 4 of the Coroners Act 2008 (Vic) (the Act) because she was a person placed in care at the time of his death. Section 3 of the Act states that a person placed in care includes a person who is under the control,

care or custody of DHHS.

8. Section 52(3A) of the Act provides, inter alia, that a Coroner is not required to hold an Inquest into the death of a person who was in custody or care immediately before their death, if the Coroner considers that their death was due to natural causes. Mrs Stone’s death falls under the auspices of this section of the Coronial legislation and, consequently, I have determined that it is appropriate to finalise my Investigation by way of a Form 38 Finding into a Death with Circumstances. Such a Finding must be

published, pursuant to section 73(1B) of the Act.

9. Ihave determined that the circumstances of Ms Stone’s death have been canvassed by the Commissioner’s investigation of DHHS’ provision of services to her as a Disability Services Residential Accommodation resident. There appear to be no outstanding issues in relation to the circumstances leading to her death and consequently no further

investigation of Ms Stone’s death is required. There are no death-prevention or public

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health and safety issues that would warrant further delineation in this document of the

circumstances of Ms Stone’s death.

FINDINGS

The investigation has identified that Ms Stone was in care pursuant to section 3 of the Coroners Act 2008 (Vic). I find that there is no evidence of a causal connection between the cause of death and the fact that Patricia Faye Stone was a person placed in care at the time of

her death.

I accept and adopt the medical cause of death ascribed by Dr Matthew Lynch and I find that Patricia Faye Stone died from complications of metastatic intra-abdominal malignancy, in

circumstances where her primary malignancy is not known.

I further find that Patricia Faye Stone died due to natural causes. Consequently, the Finding into the death of Patricia Faye Stone has been finalised without an Inquest, pursuant to

section 52(3A) of the Coroners Act 2008 (Vic).

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

published on the internet.

I direct that a copy of this finding be provided to the following: Brian Stone

Austin Health

The Department of Health and Human Services

The Disability Services Commissioner

Signature:

AUDREY JAMIES®O!

CORONER Date: 6 January 2020

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