Finding into death of Winfried Medenbach

IN THE CORONERS COURT COR 2023 006711 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Ingrid Giles Deceased: Winfried Medenbach Date of birth: 6 December 1957 Date of death: 3 December 2023 Cause of death: 1(a) MIDDLE CEREBRAL ARTERY STROKE

IN A MAN WITH MULTIPLE MEDICAL COMORBIDITIES.

Place of death: St Vincent's Hospital 41 Victoria Parade Fitzroy Victoria 3065 Keywords: Specialist Disability Accommodation resident, supported independent living, disability support, reportable deaths, natural causes

INTRODUCTION

1. On 3 December 2023, Winfried Medenbach (Winfried) was 65 years old when he died at St Vincent’s Hospital Melbourne (SVHM).

Background

2. Winfried was born on 6 June 1957 and grew up in Melbourne as the youngest of three siblings.

Winfried’s parents separated when he was an infant and he subsequently lived with his mother, before being placed into a care facility at the age of four or five.

3. Winfried lived with tuberous sclerosis (a genetic disorder), with associated severe intellectual and physical disability. He was predominantly non-verbal and had limited physical mobility.

Winfried suffered from epilepsy as a complication of his tuberous sclerosis, although this was under good control with antiepileptic medications.

4. Winfried also had a history of recurrent sigmoid volvulus, in relation to which he had undergone a Hartmann’s surgical procedure and formation of a colostomy in 2021. During the final years of his life, he experienced frequent abdominal symptoms.

5. Winfried’s brother, Walter Medebach, described that despite living with a severe disability, he believed that Walter was able to derive much enjoyment from his life. Winfried was passionate about eating chocolate and drinking coffee and would “always grab the chance to steal some of Helen [one of his carer]’s caffeinated coffee – ‘I know when they aren’t giving me the real stuff!’” Winfried’s favourite meal was tuna mornay and he would bounce in his chair, laugh and smile when was happy.

6. Winfried was a participant in the National Disability Insurance Scheme (NDIS). At the time of his death, he resided at a Specialist Disability Accommodation (SDA) enrolled facility located in Kew, Victoria and received Supported Independent Living (SIL) services from Scope (Aust) Limited (Scope) at his home.

7. Winfried resided with four other men, who had moved together following the redevelopment of their previous residence at Kew Residential Services, and were reportedly “like family”.

8. Prior to the COVID-19 lockdowns, Winfried attended a Social Connections Day Program operated by Scope several days per week.

9. Following his surgery in 2021, Winfried was unable to attend the day program and instead received one-on-one support in the community two days per week from Southern Start Care.

10. Winfried also received support from his brother, Walter Medenbach, who was his medical treatment decision maker (MTDM).

THE CORONIAL INVESTIGATION

11. Winfried’s death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). This is because, immediately before his death, Winfried was a person ‘in care’ within the definition under section 3 of the Act, as he was a person in Victoria who was an SDA resident residing in an SDA enrolled dwelling.1

12. 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.

13. Having considered a Medical Examination Report by Adjunct Associate Professor Sarah dated 8 December 2023, I consider that Winfried’s death was due to natural causes. In these circumstances, I have exercised my discretion under section 52(3A) of the Act not to hold an inquest into his death and to instead finalise the investigation in chambers.

14. 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.

15. 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.

1 The Coroners Regulations 2019 were amended on 11 October 2022 to create a new category of person considered to be ‘in care’ under Regulation 7 of the Coroners Regulations 2019, being a ‘person in Victoria who is an SDA resident residing in an SDA enrolled dwelling’. The amendments also introduced an associated reporting obligation under Regulation 8 for a person who: (ii) is funded to provide an SDA resident with daily independent living support; and (ii) has reasonable grounds to believe that the resident's death has not been reported to a coroner or the Institute.

16. Victoria Police assigned an officer, First Constable Maddison Young, to be the Coroner’s Investigator for the investigation of Winfried’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and carers – and submitted a coronial brief of evidence.

The coronial brief also included a copy of Winfried’s NDIS care plan.

17. This finding draws on the totality of the coronial investigation into the death of Winfried Medenbach 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.2

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

18. On 19 October 2023, Winfried’s carers observed that he appeared to be experiencing pain or discomfort as he was crying, rolling on the floor, and refused his lunch. Winfried was supported to attend an appointment with his General Practitioner (GP), who prescribed Buscopan.

19. Winfried became increasingly lethargic and so Scope staff determined to call an ambulance.

20. Winfried was admitted to St Vincent’s Hospital Melbourne (SVHM) under the General Surgical team. A computerised tomography (CT) scan of Winfried’s abdomen revealed evidence of a bowel perforation with free gas in the jejunum (small bowel).

21. On 21 October 2021, with consent from Winfried’s MTDM Walter, a laparotomy was undertaken where a portion of the small bowel was resected and an end-to-end anastomosis performed. Over the following days, functional ileus (bowel distension) developed as a complication of the procedure and was treated with nasogastric decompression.

22. On 28 October 2023, a postoperative CT scan demonstrated several intra-abdominal collections, likely infection, as a result of the bowel perforation. The markers of inflammation 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.

were elevated in the blood consistent with infection. The SVHM Infectious Disease unit were consulted and recommended a course of intravenous antibiotics.

23. On 1 November 2023, a repeat CT scan demonstrated some reduction in size of the largest collection and stability of the other two. Winfried also received total parenteral nutrition, administered intravenously.

24. Winfried made a slow recovery and was discharged from hospital on 8 November 2023, with a plan to continue oral antibiotics for six weeks.

25. Winfried had an appointment with his GP on 11 November 2023 who carried out health checks, reviewed his recent hospital discharge summary and updated his Comprehensive Health Assessment Program and medication record.

26. On 12 November 2023, Winfried’s carers observed that he did not eat breakfast and only consumed some fluids, and had not been eating or drinking as usual for the previous two days.

Staff continuously monitored Winfried who was observed to be “quite weak”. During the afternoon, Winfried vomited several times and so was transported by ambulance to SVHM Emergency Department.

27. A CT scan demonstrated further improvement with resolution of the largest intra-abdominal collection and no evidence of a bowel obstruction. He was received by the General Surgical team and given intravenous fluids and antiemetics. His symptoms settled and he was able to be discharged back to the SDA facility in the early hours of 13 November 2023.

28. On 15 November 2023, Winfried was supported by a carer to attend a telehealth appointment with SVHM Infectious Disease clinic. He was advised that his blood test and CT scan results were fine, and he would be referred to an infectious disease specialist.

29. On 16 November 2023, Winfried vomited and had been unwell and not eating well for several days. His carers observed that he had abdominal pain when he made noises whilst moving from his chair. Scope staff called an ambulance and Winfried was again taken to SVHM Emergency Department.

30. Winfried was readmitted under the General Surgical Team. Examination revealed mild dehydration which was managed with intravenous fluids. His stoma was working well and there was no clinical evidence of a bowel obstruction. Blood tests were unremarkable and the

markers of inflammation had improved. Abdominal X-rays were also unremarkable and did not show any evidence of a bowel obstruction.

31. Discussions were held with Winfried’s MTDM and carers regarding the best care for him and long-term goals including nutrition supplementation given his reluctance to eat. Antibiotic management for the intra-abdominal collections was discussed with the Infectious Disease team and modifications made to the regime.

32. Winfried was discharged on 17 November 2023 with a multi-disciplinary meeting planned for 20 November 2023 between Scope representatives and SVHM treating team to discuss ongoing management plans. The meeting occurred on 23 November 2023, after being rescheduled, and was attended by Winfried’s MTDM Walter, Scope staff including his Supporting Coordinator, his dietician and surgical teams.

33. It was concluded that the best plan going forward was to involve a community-based dietician to assist with nutrition, to continue weekly surgical reviews via telehealth, ongoing review by the Infectious Diseases team, and for Walter to formulate an advanced care plan for Winfried in consultation with Winfried’s General Practitioner.

34. On 27 November 2023, Winfried refused breakfast and had his usual medications. He refused to eat lunch and vomited after taking his lunch time medications and after eating his dinner.

Carers observed that his stoma bag contents were watery, called ‘Nurse on Call’ for advice and made an appointment for Winfried to see his GP the following day.

35. On 28 November 2023, Winfried spat medications out when administered, continued to pass watery stools, and had a reduced appetite. Staff supported him to be seen by his GP who noted that he looked tired and less energetic than normal. The GP arranged for tests to be conducted at SVHM as he thought Winfried may be developing another infection and asked questions in relation to antibiotics taken by Winfried.

36. On 29 November 2023, Winfried was supported to attend a specialist appointment at the Hospital’s Infectious Disease clinic, following referral by the SVHM surgical team on 15 November 2023. During this appointment, it was reported by his carers that his antibiotics had been ceased on 23 November 2023 due to nausea. Three days later he had several episodes of vomiting and high volume watery stomal output. He was not eating and drinking very little.

His carers reported that he was very fatigued and not his usual self.

37. Winfried was then reviewed by the General Surgical team and admitted to the Emergency Department for intravenous fluids and further assessment. The surgical team did not feel that there was any acute surgical issue and felt that he would be best admitted under the medical teams for further management.

38. Winfried was admitted under General Medicine. On admission assessment his vital signs were within normal range and his abdomen was soft and non-tender. The stoma was draining watery stool. Blood tests revealed markedly abnormal renal function secondary to dehydration, mildly abnormal liver function, and moderately high markers of inflammation. The provisional diagnosis was felt to be antibiotic-related diarrhea or infectious (bacterial or viral) diarrhea leading to dehydration and secondary renal failure.

39. Winfried was treated with intravenous fluids and antibiotics directed to treat possible infectious diarrhea. Stool samples were sent for culture which did not reveal any causative organism. After appropriate rehydration his renal function returned to normal baseline over the ensuing 48 hours.

40. Goals of care were discussed with Walter and it was agreed that Winfried would be suitable for ward-based management by the medical teams and that it would not be in his best interest to perform aggressive resuscitation in the case of further deterioration. The surgical and Infectious Disease teams were consulted and it was felt that the medical plan was appropriate and that there were no additional investigations required at this time.

41. Over the next 48 hours, Winfried appeared comfortable and recommenced eating food supplied by his carers as he seemed to dislike the hospital food. He was afebrile and was progressing satisfactorily. Blood tests did reveal an increase in inflammatory markers and although this was likely due to the acute diarrheal illness, a CT of his abdomen was ordered to monitor the known intra-abdominal collections. He became unsettled when taken to radiology and the scan could not proceed. It was planned to undertake a further attempt with his carers in attendance to assist in settling him.

42. On the evening of 2 December 2023, unfortunately, Winifred was noted to have an acute decline in his conscious state. There was no improvement over several hours of close observation and his pupils were noted to be fixed and dilated. An urgent CT scan of the brain was performed which demonstrated that Winifred had suffered a catastrophic ischaemic stroke which was deemed to be un-survivable.

43. After discussion with Walter, Winfried was transitioned to comfort care and he died at 7.00 am on 3 December 2023 with Walter by his side.

Identity of the deceased

44. On 3 December 2023, Winfried Medenbach, born 6 December 1957, was visually identified by his brother, Walter Medenbach.

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

Medical cause of death

46. On 5 December 2023, Adjunct Associate Professor Sarah Parsons, a Forensic Pathologist from the Victorian Institute of Forensic Medicine (VIFM), conducted an external examination. Adj A/Prof Parsons also reviewed a post mortem CT scan, as well as the Medical Deposition and Victoria Police Report of Death (Form 83) and provided a written report of her findings dated 8 December 2023

47. The post mortem CT scan showed a left middle cerebral artery stroke with midline shift, a full bladder, colostomy, fatty liver and increased lung markings.

48. Taking into account all available information, Adj A/Prof Parsons provided an opinion that Winifred died from natural causes and that the medical cause of death was: 1 (a) Middle cerebral artery stroke in a man with multiple medical co-morbidities.

49. I accept Adj A/Prof Parson’s opinion.

FINDINGS AND CONCLUSION

50. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Winfried Medenbach, born 06 December 1957; b) the death occurred on 3 December 2023 at St Vincent's Hospital 41 Victoria Parade Fitzroy Victoria 3065, from middle cerebral artery stroke in a man with multiple medical co-morbidities; and c) the death occurred in the circumstances described above.

51. Having considered all of the circumstances, I am satisfied that Winfried died from natural causes and have not identified any factors related to the provision of clinical or disability care, or otherwise, which may have contributed to his death.

I convey my sincere condolences to Winfried’s family for their loss.

ORDERS AND DIRECTIONS 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: Karolina Medenbach, Senior Next of Kin Scope (Aust) Limited St Vincent’s Hospital First Constable Maddison Young, Coroner’s Investigator Signature: ___________________________________ Coroner Ingrid Giles Date : 08 January 2025 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.