Finding into death of SMW

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2020 3566

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Deceased: SMW1 Findings of: CORONER DARREN J. BRACKEN Date of Birth: 4 December 1971 Date of Death: 17 March 2020 Cause of Death: Aspiration Pneumonia in the setting of Fahr’s Disease Place of death: Box Hill Hospital, 8 Arnold Street Box Hill Victoria 1 A pseudonym.

CIRCUMSTANCES

1. At the time of his death SMW was 48 years old and lived in a group home at Ashwood, Victoria. SMW had Fahr’s disease,2 a moderate disability, psychosis, impaired speech and suffered from constipation, epilepsy, overheating, extreme sweating, skin rashes and dysphagia. The Victorian Department of Health and Human Services had provided disability services to SMW until 31 March 2019 when the operation of the group house in Ashwood was taken over by ‘Life Without Barriers’, an organisation that provided disability services. At the time of his death SMW had been receiving disability services for some time.

2. On 23 March 2020 the Disability Services Commissioner (“the Commissioner”) commenced an investigation into SMW’s death which was concluded some time prior to 22 January 2021. By letter to the court dated 22 January 2021 the Commissioner described the investigation, what had been ascertained and the various sources of information which had been relied upon (“the Commissioner’s Letter”).

3. The Commissioner’s Letter set-out SMW’s personal and medical history, described his health management at the Group Home and set out the circumstances of his death.

The Commissioner’s letter described;

• SMW becoming unwell on 17 March 2020 and having some difficulty swallowing his medication.

• His condition improving and then deteriorating

• Him being taken to the Box Hill Hospital by ambulance and a doctor at the hospital tell SMW’s father that SMW was very unwell and may die within hours. The doctor telling SMW’s father that the hospital would make SMW comfortable.

• SMW dying at 10.54pm.

2 A neurodegenerative condition associated with abnormal calcium deposition.

• Life Without Barriers conducting a Service Review of the disability services it had provided to SMW before his death which identified one issue relating to the services provided to SMW.

Issue Identified by Life Without Barriers Service Review

4. Life Without Barriers identified that: “…the final treatment sheet was not signed in relation to [SMW] prescribing doctor was due to prescribing doctor’s limitation, this was an anomaly relating to specific circumstances of the prescribing doctor.”

5. There is no evidence that the ‘anomaly’ referred to in the Life Without Barriers’ Service Review contributed to the cause of SMW’s death.

6. The Coroners Act (2008) requires me to liaise with other investigative authorities, official bodies or statutory officers to avoid unnecessary duplication of inquiries and investigations and to expedite the investigation of deaths and fires.3

CONCLUSION

7. The Commissioner’s Letter explicitly refers to the Commissioner having concluded the Investigation, made no findings and did not identify any service improvements that Life Without Barriers should be required to make.

8. As at March 2020 SMW had laboured under significant disabilities and conditions for a long time as a result of which he suffered ongoing serious debilitating illness.

MATTERS IN RELATION TO WHICH FINDINGS MUST, IF POSSIBLE, BE MADE PURSUANT TO SECTION 67 CORONERS ACT (2008)

9. Having investigated SMW’s death and pursuant to 67(1) of the Coroners Act (2008), I find that:

• The identity of the deceased is SMW born 4 December 1971.

• SMW’s death occurred: 3 Coroners Act (2008) s.7.

• On 17 March 2020 at the Box Hill Hospital, 8 Arnold Street Box Hill Victoria.

• as a result of Aspiration Pneumonia in the setting of Fahr’s Disease and

• in the circumstances set-out above.

PUBLICATION Pursuant to section 73(1B) of the Act, I order that this Finding (in a redacted format) be published on the Coroners Court of Victoria website in accordance with the rules.

DISTRIBUTION I direct that a copy of this finding be provided to the following: SMW’s, Senior Next of Kin; Victorian Disability Services Commissioner; The Proper Officer, Life Without Barriers; and The Proper Officer, Box Hill Hospital Signature: ______________________________________

DARREN J BRACKEN CORONER Date: 10 March 2022