Deceased
Trevor James Bayldon
Demographics
55y, male
Coroner
Coroner Catherine Fitzgerald
Date of death
2022-12-28
Finding date
2023-10-02
Cause of death
Bronchopneumonia in a man with functional decline and trisomy 21
AI-generated summary
Trevor Bayldon, a 55-year-old man with Down syndrome, dementia, and epilepsy, died from bronchopneumonia at St Vincent's Hospital. He presented with respiratory distress and altered consciousness after functional decline over the preceding 12 months. Hospital staff provided high-flow oxygen, IV fluids, and antibiotics, but his condition deteriorated despite maximal support. After discussion with carers acknowledging his poor functional baseline and progressive frailty, ICU admission was deemed not in his best interests. He received palliative care and died the following day. The death was due to natural causes. No clinical errors, system failures, or preventable factors were identified in this case of expected mortality in a severely disabled man with advancing age-related decline.
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Specialties
IN THE CORONERS COURT COR 2022 007435 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Catherine Fitzgerald Deceased: Trevor James Bayldon Date of birth: 11 April 1967 Date of death: 28 December 2022 Cause of death: 1(a) Bronchopneumonia in a man with functional decline and trisomy 21 Place of death: St. Vincent's Public Hospital Melbourne, 41 Victoria Parade, Fitzroy, Victoria, 3065 Keywords: In care, natural causes, bronchopneumonia
On 28 December 2022, Trevor James Bayldon was 55 years old when he passed away at St Vincent’s Hospital, Melbourne (SVHM). At the time of his death, Mr Bayldon resided at 1/10 Lisson Grove, Hawthorn, a staff supported disability service operated by Scope. He had been living at that address for 21 years.
Mr Bayldon was diagnosed with down syndrome at birth and was removed from the care of his mother and placed in the care of the state. He resided in state run care facilities throughout his life. However, service provision for the residence where he lived was transferred from the Department of Health and Human Services to Home@Scope on 21 July 2019. At the time of his death, Mr Bayldon’s accommodation and care needs were funded by the National Disability Insurance Scheme (NDIS).
Mr Bayldon had multiple complex health issues. His medical history included dementia and epilepsy. In the 12 months prior to his passing, Mr Bayldon’s physical condition deteriorated significantly, and he required the use of a wheelchair to mobilise. He had limited verbal skills and was only able to communicate via gestures, signs, pictures, and sounds.
Mr Bayldon reconnected with his sister Carleen Bayldon later in life. His sister noted that Mr Bayldon was well-cared for and loved at his residence in Lisson Grove, and he had many friends there. She believed that her brother “had the best ‘family’ and care growing up” and that he did not want for anything.
1 Section 4(1), (2)(c) of the Act.
2 Pursuant to Reg 7(1)(d) of the Coroners Regulations 2019, a “prescribed person or a prescribed class of person” includes a person in Victoria who is an “SDA resident residing in an SDA enrolled dwelling”, as defined in Reg 5.
The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and the circumstances in which the death occurred. The 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.
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.
Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Mr Bayldon’s death. The Coroner’s Investigator conducted inquiries on my behalf and submitted a coronial brief of evidence.
This finding draws on the totality of the coronial investigation into the death of Trevor James Bayldon including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.3
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred
On the morning of 27 December 2022, Mr Bayldon was observed by his carer with an altered conscious state, increased work of breathing and breathlessness. His carers called 000 and requested an ambulance. On arrival, paramedics noted that Mr Bayldon was struggling to breathe, was grey in colour and was diaphoretic.
Mr Bayldon was transported by ambulance to SVHM, where he was assessed in the emergency department (ED). ED staff found he was non-communicative, tachycardic, hypotensive and tachypnoeic. His breathing was shallow with audible upper respiratory tract secretions and scattered crackles.
3 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.
Staff commenced Mr Bayldon on high flow nasal prong oxygen, intravenous fluid resuscitation and intravenous antibiotics. Blood tests revealed an elevated white cell count and c-reactive protein, hypernatremia, and a mild kidney injury.
Despite maximal active supports, Mr Bayldon’s condition continued to deteriorate, and he required very high oxygen supports. Clinicians spoke with Mr Bayldon’s carers, and it was agreed that due to his poor functional baseline and progressive frailty, that an admission to the intensive care unit (ICU) was not in his best interests. Mr Bayldon was assessed by the Palliative Care Team, and he was provided with end-of-life comfort care. He passed away at 1.08pm on 28 December 2022.
Identity of the deceased
Medical cause of death
Examination of the post-mortem CT scan showed bilateral lung consolidation with air bronchograms, a large, distended bladder, fatty liver, and cerebral atrophy.
Toxicological analysis of post-mortem samples was not indicated and was therefore not performed.
Dr Bouwer provided an opinion that the medical cause of death was “1 (a) Bronchopneumonia in a man with functional decline and trisomy 21”. Dr Bouwer also provided an opinion that the death was due to natural causes.
I accept Dr Bouwer’s opinion.4 4 Pursuant to s 52(3A) of the Act, a coroner is not required to hold an inquest where the deceased was, immediately before death, a person placed in custody or care, if the coroner considers that the death was due to natural causes.
I convey my condolences to Mr Bayldon’s family for their loss.
Pursuant to section 73(1B) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.
I direct that a copy of this finding be provided to the following: Gloria Bayldon, Senior Next of Kin St Vincent’s Hospital Melbourne First Constable Alex Kimberley (VP45975), Victoria Police, Coroner’s Investigator Signature: ___________________________________ Coroner Catherine Fitzgerald Date : 02 October 2023 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after
the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
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