Finding into death of Robert Djurovich

IN THE CORONERS COURT COR 2024 004840 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: Robert Djurovich Date of birth: 11 October 1964 Date of death: 1 January 2023 Cause of death: 1(a) Aspiration Pneumonia 2 Dementia with Down Syndrome, Epilepsy, Osteoparosis and Gastro-Oesophageal Refulx Disease.

Place of death: Maroondah Hospital, 1-15 Davey Drive, Ringwood East, Victoria, 3135 Keywords: Specialist Disability Accommodation resident, supported independent living, disability support, reportable deaths, natural causes

INTRODUCTION

1. On 1 January 2023, Robert Djurovich (Mr Djurovich) was 58 years old when he died at Maroondah Hospital, Ringwood East, Victoria, 3135, from aspiration pneumonia.

2. At the time of his death, Mr Djurovich was a National Disability Insurance Scheme (NDIS) participant. He received funding to reside in a Specialist Disability Accommodation (SDA) enrolled dwelling1 at a facility situated at 27 Morokai Grove, Lilydale, Victoria, 3140. Mr Djurovich was receiving these supports due to his intellectual disability and epilepsy. He had also been diagnosed with dementia and osteoporosis approximately 10 years prior to his death.

3. Mr Djurovich had been living in SDA group accommodation for many years. In the last six years of his life, his support needs had changed due to the progression of his dementia-related symptoms. Historically, Mr Djurovich had lived a busy life and enjoyed the support of his brothers and their wives and families who were very supportive and had regular contact with him.

THE CORONIAL INVESTIGATION

4. Mr Djurovich’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.

5. 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 1 SDA enrolled dwelling is defined under the Residential Tenancies Act 1997 (Vic). The definition, as applicable at the time of Mr Djurovich’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.

purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

6. 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.

7. This finding draws on the totality of the coronial investigation into the death of Robert Djurovich, including information from the National Disability Insurance Agency (NDIA) and the NDIS Quality and Safeguards Commission, as well as a Medical Certificate Cause of Death (MCCD) completed by a medical practitioner at Maroondah 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

8. Mr Djurovich’s health began to decline approximately six years prior to his death. His NDIS plan notes that his support needs changed due to the progression of his Alzheimer’s Disease.

9. On 1 November 2022, Mr Djurovich was admitted to Maroondah Hospital due to his declining health in the setting of respiratory discomfort following an aspiration event. Aspiration occurs when food, liquid, or other material enters a person’s airway and eventually the lungs by accident. It can happen when a person has trouble swallowing normally and can lead to serious health issues such as pneumonia. People with intellectual disability are at a higher risk of aspiration.3

10. Despite treatment, Mr Djurovich’s condition continued to deteriorate, and he passed away on 1 January 2023.

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.

3 NDIS Quality and Safeguards Commission, Practice Alert: Prevention of Respiratory Infections dated May 2022, p 3.

Identity of the deceased

11. On 1 January 2023, Robert Djurovich, born 11 October 1964, was identified by Medical Practitioner Dr Rhys Rumley via review of the medical records and visual identification.

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

Medical cause of death

13. On 1 January 2023, Medical Practitioner Dr Rhys Rumley reviewed Mr Djurovich’s complete medical history, conducted an external examination upon the body of Robert Djurovich and completed an MCCD dated 17 January 2023. Dr Rumley provided an opinion that the medical cause of death was aspiration pneumonia, with other significant contributing conditions of dementia with down syndrome, epilepsy, osteoporosis and gastro-oesophageal reflux disease.

14. On 18 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.

15. I accept Dr Rumley’s opinion, and I am satisfied that the death was due to natural causes.

FINDINGS AND CONCLUSION

1. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Robert Djurovich, born 11 October 1964 b) the death occurred on 1 January 2023 at Maroondah Hospital , 1-15 Davey Drive, Ringwood East, Victoria, 3135, Victoria from an aspiration pneumonia in the setting of dementia with down syndrome, epilepsy, osteoporosis and gastro-oesophageal reflux disease.

2. 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 Maroondah Hospital, that caused or contributed to Robert Djurovich’s death.

3. Having considered all the available evidence, I find that Robert Djurovich’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 Robert Djurovich’s death in chambers.

I convey my sincere condolences to Me Djurovich family, friends and carers for their loss, and acknowledge the distress caused by the delay in the reporting and investigation of Mr Djurovich 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: Andrew Djurovich, Senior next of Kin Eastern Health Signature: ___________________________________ Date: 9 December 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.