Finding into death of Kim Elizabeth Taylor

IN THE CORONERS COURT COR 2024 004850 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: Kim Elizabeth Taylor Date of birth: 9 July 1968 Date of death: 19 June 2023 Cause of death: 1(a) Pneumonia - chest sepsis 2 Recurrent ventilator-associated pneumonia, bronchiectasis, weight loss - frailty, cervical-2 american spinal cord injury association level c quadriplegia secondary to vertebral artery dissection, ankylosing spondylitis, rheumatoid arthritis and tracheostomy Place of death: Austin Health 146 Studley Road Heidelberg Victoria 3084 Keywords: Specialist Disability Accommodation resident, supported independent living, disability support, reportable deaths, natural causes

INTRODUCTION

1. On 19 June 2023, Kim Elizabeth Taylor (Ms Taylor) was 54 years old when she died at Austin Hospital in Heidelberg in the context of declining health.

2. At the time of her death, Ms Taylor was a National Disability Insurance Scheme (NDIS) participant. She received funding to reside at the Victorian Respiratory Support Service, a Specialist Disability Accommodation (SDA) enrolled dwelling.1

3. Ms Taylor received support for her daily activities, including via her ventilator and wheelchair. She maintained contact with her family including her children and had goals to enrol in a business diploma and start her own charity.

THE CORONIAL INVESTIGATION

1. Ms Taylor’s death fell within the definition of a reportable death in the Coroners Act 2008 (the Act) as she 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 her 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.

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

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 Kim Elizabeth Taylor, 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 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. In the lead-up to her death, Ms Taylor was experiencing ongoing nausea, inappetence and resulting weight loss. She was being supervised by her general medical practitioner (GP) and clinicians at the Victorian Respiratory Support Service. It was believed that she had contracted recurrent ventilator-associated pneumonia.

6. On 31 May 2023, Ms Taylor was transferred to the Austin Hospital due to her worsening symptoms and abdominal bloating. An ultrasound, computed tomography (CT) and positron emission tomography (PET) scans did not identify the cause of Ms Taylor’s illness.

7. Ms Taylor’s condition declined, and medical practitioners referred her to the palliative care team. Clinicians contacted Mr Taylor’s family, and it was determined to transition her to an end-of-life pathway.

8. On 19 June 2023, Ms Taylor passed away.

Identity of the deceased

9. On 12 July 2023, Kim Elizabeth Taylor, born 3 February 1959, was identified by Medical Practitioner Dr Roy Arulrajah.

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.

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

Medical cause of death

11. On 12 July 2023, Medical Practitioner Dr Roy Arulrajah completed a MCCD. Dr Arulrajah provided an opinion that the medical cause of death was pneumonia – chest sepsis, with antecedent causes of recurrent ventilator-associated pneumonia, bronchiectasis, weight loss and frailty and with the significant contributing conditions of cervical-2 American Spinal Cord Injury Association Level C Quadriplegia secondary to Vertebral Artery Dissection, ankylosing spondylitis, rheumatoid arthritis and a tracheostomy.

12. 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.

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

FINDINGS AND CONCLUSION

14. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Kim Elizabeth Taylor, born 9 July 1968; b) the death occurred on 19 June 2023 at Austin Health 146 Studley Road, Heidelberg, Victoria 3084 from pneumonia – chest sepsis, with antecedent causes of recurrent ventilator-associated pneumonia, bronchiectasis, weight loss and frailty and with the significant contributing conditions of cervical-2 American Spinal Cord Injury Association Level C Quadriplegia secondary to Vertebral Artery Dissection, ankylosing spondylitis, rheumatoid arthritis and a tracheostomy; and, c) the death occurred in the circumstances described above.

15. 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 Austin Hospital, that caused or contributed to Ms Taylor’s death.

16. Having considered all the available evidence, I find that Ms Taylor’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 her death and to finalise the investigation of Ms Taylor’s death in chambers.

I convey my sincere condolences to Ms Taylor’s family, friends and carers for their loss, and acknowledge the distress caused by the delay in the reporting and investigation of Ms Taylor’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: Shaun Jang Minho Monger, Senior Next of Kin Victorian Respiratory Support Service Austin Health Signature: ___________________________________ Date: 5 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.