Finding into death of C E

IN THE CORONERS COURT COR 2024 004763 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Judge John Cain, State Coroner Deceased: CE Date of birth: 19 June 1973 Date of death: 28 February 2024 Cause of death: 1(a) Advanced Parkinson's disease Place of death: Austin Health, 147 Studley Road, Heidelberg Victoria 3084 Keywords: Specialist Disability Accommodation resident, supported independent living, disability support, reportable deaths, natural causes

INTRODUCTION

1. On 28 February 2024, CE was 50 years old when he passed away at the Austin Hospital.

2. At the time of his death, CE was a National Disability Insurance Scheme (NDIS) participant.

He received funding to reside in a Specialist Disability Accommodation (SDA) enrolled dwelling1 provided by the then-Department of Health and Human Services. CE was receiving these supports due to severe early onset Parksinson’s disease. He also experienced regular seizures, elements of paranoia and hallucinations, and difficulties swallowing and communicating.

3. CE is survived by his parents, his wife, SE, and their two adult children. He enjoyed going for outings with his support workers to do some shopping or for a walk and liked to keep his mind active with computer games. He regularly visited his family, or they visited him at his SDA.

THE CORONIAL INVESTIGATION

1. CE’s death fell within the definition of a reportable death in the Coroners Act 2008 (the Act) as he was a ‘person placed in custody or care’ within the meaning of the Act, as a person receiving funding for Supported Independent Living (SIL) and residing in an SDA enrolled dwelling immediately prior to his death. This category of death is reportable to ensure independent scrutiny of the circumstances leading to death given the vulnerability of this cohort and the level of power and control exercised by those who care for them. The coroner is required to investigate the death, and publish their findings, even if the death has occurred as a result of natural causes.

2. 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.

1 SDA enrolled dwelling is defined under the Residential Tenancies Act 1997 (Vic). The definition, as applicable at the time of CE’s death, is a permanent dwelling that provides long-term accommodation for one or more SDA residents, that is enrolled as an SDA dwelling under relevant NDIS (Specialist Disability Accommodation) Rules in force at the relevant time. An SDA resident means a person who is an NDIS participant funded to reside in an SDA enrolled dwelling, or who receives continuity of supports under the Commonwealth Continuity of Support Program in respect of specialist disability services for older people (from 1 July 2021, the Disability Support for Older Australians program). The definition of SDA resident was amended on 1 July 2024 pursuant to the Disability and Social Services Regulation Amendment Act 2023 to extend to include persons who are residing, or propose to reside, in an SDA dwelling under an SDA residency agreement or residential rental agreement.

3. 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.

4. This finding draws on the totality of the coronial investigation into the death of CE including information from the National Disability Insurance Agency (NDIA) and the NDIS Quality and Safety Commission, as well as a Medical Certificate Cause of Death (MCCD) completed by a medical practitioner at the Austin Hospital. 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.2

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

5. CE presented to the Austin Hospital on 20 February 2024 following several weeks of progressive fatigue, reduced oral intake, pain (secondary to dystonias/rigidity) and ongoing seizures. In the days prior to his presentation, CE experienced an escalation in his symptoms and his wife and mother were in agreement that his care could no longer be managed at his

SDA.

6. Following agreement between CE’s wife and parents, he was admitted to the Austin Hospital for palliative care. His complex symptoms were managed, and he passed away peacefully on the evening of 28 February 2024 in the presence of his family.

Identity of the deceased

7. On 28 February 2024, CE, born 19 June 1973, was identified by medical practitioner Dr Jessica Jones via a review of medical records and visual identification.

8. Identity is not in dispute and requires no further investigation.

2 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.

Medical cause of death

9. On 28 February 2024, medical practitioner Dr Jessica Jones reviewed CE’s complete medical history and completed a MCCD. Dr Jones provided an opinion that the medical cause of death was advanced Parkinson’s disease.

10. On 17 August 2024, a Medical Liaison Nurse (MLN) at the Victorian Institute of Forensic Medicine, reviewed the MCCD at my direction and confirmed that the cause of death was due to natural causes.

11. I accept Dr Jones’ opinion and am satisfied that the death was due to natural causes.

FINDINGS AND CONCLUSION

12. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was CE, born 19 June 1973; b) the death occurred on 28 February 2024 at Austin Health, 147 Studley Road, Heidelberg, Victoria 3084, from advanced Parkinson's disease; and c) the death occurred in the circumstances described above.

13. The available evidence does not support a finding that there was any want of clinical management or care on the part of the SIL provider, or clinical staff at the Austin Hospital, that caused or contributed to CE’s death.

14. Having considered all the available evidence, I find that CE’s death was from natural causes and that no further investigation is required. As such, I have exercised my discretion under section 52(3A) of the Act not to hold an inquest into his death and to finalise the investigation of CE’s death in chambers.

I convey my sincere condolences to CE’s family, friends and carers for their loss, and acknowledge the distress caused by the delay in the reporting and investigation of CE’s death.

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: SE, Senior Next of Kin Arete Care Austin Health Signature: ___________________________________ Date: 27 November 2024 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.