Finding into death of Jennifer Joyce Coomber

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2018 3559

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Jacqui Hawkins Deceased: Jennifer Joyce Coomber Date of birth: 16 June 1952 Date of death: 22 July 2018 Cause of death: I(a) Ischaemic heart disease Place of death: 3 Henderson Court, Bundoora, Victoria, 3083 1 of 4

BACKGROUND

1. Jennifer Joyce Coomber was 66 years old at the time of her death. Ms Coomber lived in group home managed by the Department of Health and Human Services (DHHS) as she had a moderate intellectual disability.

2. Ms Coomber made decisions about her daily activities, and her sister made decisions about her health and finances. DHHS staff provided day to day supports to Ms Coomber including with personal hygiene, dressing and toileting, and assistance with domestic tasks and community engagement. Ms Coomber was a social person and enjoyed spending time with others reciting poems, singing, and dancing.

3. Ms Coomber’s medical history included hypertension, hypothyroidism, and osteoporosis.

4. On 22 July 2018, Ms Coomber went into cardiac arrest and could not be revived.

5. Ms Coomber’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008.

6. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death and with some exceptions, surrounding circumstances.

Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The law is clear that coroners establish facts; they do not lay blame or determine criminal or civil liability.1

7. In writing this Finding, I do not purport to summarise all the evidence but refer to it only in such detail as appears warranted by its forensic significance and the interests of narrative clarity.

IDENTITY OF THE DECEASED

8. Ms Coomber was visually identified by her carer, Kylie Martin, on 22 July 2018. Identity was not in issue and required no further investigation.

MEDICAL CAUSE OF DEATH

9. On 24 July 2018, Dr Matthew Lynch, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an autopsy on the body of Ms Coomber and reviewed the Form 1 In the coronial jurisdiction facts must be established on the balance of probabilities 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.

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83 Victoria Police Report of Death, medical records from Bundoora Family Clinic, and the post mortem computed tomography (CT) scan.

10. At autopsy, a number of significant natural disease processes were identified. There was evidence of a 95% occlusion of the left anterior descending coronary artery with patchy myocardial fibrosis (scarring of the heart muscle). There were changes in the brain and kidney in keeping with chronic hypertension. The lungs showed evidence of oedema and chronic bronchitis but there was no evidence of acute pneumonic change. There was also evidence of obesity (BMI of 46). This degree of obesity is associated with significant cardiovascular morbidity and mortality.

11. Toxicological analysis of post mortem blood detected the presence of valproic acid.2

12. Post mortem biochemistry disclosed an elevated C-reactive protein suggestive of inflammation/sepsis. No specific inflammatory focus was identified at autopsy. Serum tryptase (a marker of anaphylaxis) was not elevated.

13. Post mortem biochemistry grew streptococcus salivarius and sanguinis from enrichment culture. Dr Lynch explained that these organisms colonise the oropharynx and gastrointestinal tract thus their identification in post mortem blood culture was of uncertain significance. They are described as causing bacterium intravitam.

14. Dr Lynch commented that the most likely mechanism of Ms Coomber’s death was cardiac arrythmia, which is the most common form of ‘heart attack’, whereby narrowing of the coronary arteries results in insufficient oxygenated blood being delivered to the heart muscle.

15. Dr Lynch commented that on the information available to him, there was no evidence to suggest Ms Coomber’s death was due to anything other than natural causes.

16. Dr Lynch provided an opinion that the medical cause of death was 1(a) Ischaemic heart disease. I accept and adopt this cause of death.

CIRCUMSTANCES IN WHICH THE DEATH OCCURRED

17. On the morning of 22 July 2018, carers at Ms Coomber’s group home noticed that she appeared dazed was not responding to staff, and needed assistance getting out of bed. She was also observed having some difficulty standing and had a chesty cough. An ambulance was requested.

2 Valproic acid is used therapeutically as an anticonvulsant, treatment for manic depression or in some instances for neurogenic pain.

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18. Ambulance Victoria Paramedics attended and found that Ms Coomber’s vital signs and mobility were normal and advised staff to request a locum doctor.

19. A doctor attended and diagnosed Ms Coomber with a chest infection and prescribed antibiotics. Staff continued to monitor Ms Coomber at 10-minute intervals throughout the day.

20. At about midnight, Ms Coomber started having difficulty breathing and subsequently stopped breathing. Staff commenced cardiopulmonary resuscitation (CPR) and requested an ambulance. Paramedics continued resuscitation efforts, however, Ms Coomber could not be resuscitated.

21. Having considered the evidence I am satisfied that no further investigation is required.

FINDINGS

22. Pursuant to section 67(1) of the Coroners Act 2008, I make the following findings connected with the death:

(a) the identity of the deceased was Jennifer Joyce Coomber born 16 June 1952; and

(b) Ms Coomber died on 22 July 2018 from 1(a) Ischaemic heart disease;

(c) in the circumstances described above.

23. I wish to express my sincere condolences to Ms Coomber’s family. I acknowledge the grief and devastation that you have endured as a result of your loss.

24. I order pursuant to section 73(1B) of the Coroners Act 2008, that this finding be published on the Coroners Court of Victoria Website.

I direct that a copy of this finding be provided to the following: The family of Ms Coomber; Information recipients; and Coroner’s Investigator, Victoria Police Signature: ___________________________________

JACQUI HAWKINS Coroner Date: 30 September 2020 4 of 4