Finding into death of Juvetta Pedruco Columbine

IN THE CORONERS COURT COR 2024 006286 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: Juvetta Pedruco Columbine Date of birth: 26/10/1977 Date of death: 27/10/2024 Place of death: Austin Hospital 145 Studley Road Heidelberg Victoria 3084 Keywords: specialist disability accommodation resident, disability support, independent living

INTRODUCTION

1. On 27/10/2024, Juvetta Pedruco Columbine (Ms Columbine) was 47 years old when she died at Austin Hospital, Studley Road Heidelberg Victoria, 3084 from an aspiration event.

2. At the time of her death, Ms Columbine was a National Disability Insurance (NDIS) participant. She received funding for a Specialist Disability Accommodation (SDA) enrolled dwelling operated by ‘gen U’ and resided in a Supported Independent Living residence at 39 Independence Boulevard, Doreen in Victoria (Independence Boulevard) that she shared with two other women. Ms Columbine suffered a Right Cerebrovascular Accident (stroke) in August 2019 and required ongoing care as a result of the severity of her cognitive and physical condition. Her NDIS funded supports were provided through ‘gen U’, a division of St Laurence Limited.

3. Ms Columbine had been living independently with a friend prior to August 2019 but was unable to return to this accommodation following the stroke and the resulting incapacity she suffered. Ms Columbine’s elderly foster parents were unable to provide residential support for her and NDIS support was obtained to assist her.

4. Ms Columbine was visited by her foster parents every one to two weeks while at the Independence Boulevard residence and she was also visited by friends who provided additional support for her.

5. The most recent NDIS approved plan commenced in May 2024 and was approved for a one-year period. In addition to funding SDA accommodation, NDIS also provided a range of supports to assist with Ms Columbines with her day to day needs together with medical and health support.

THE CORONIAL INVESTIGATION

6. Ms Columbine’s death fell within the definition of a reportable death in the Coroners Act 2008 (Vic) (the Act) as she was a ‘person placed in custody or care’ within the meaning of the Act, as a person with disability who received funded daily independent living support and resided in an SDA enrolled dwelling immediately prior to her death.1 This category of death is reportable to ensure independent scrutiny of the circumstances leading to death 1 This class of person is prescribed as a ‘person placed in custody or care’ under the Coroners Regulations 2019 (Vic), r 7(1)(d).

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.

7. 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.

8. 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.

9. This finding draws on the totality of the coronial investigation into the death of Juvetta Pedruco Columbine including information from the National Disability Insurance Agency (NDIA) and treating medical team and hospital records. 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

10. Ms Columbine had a complex medical history. In addition to suffering a stroke in 2019 she had a history of type 1 diabetes mellitus, diabetic nephropathy, a previous right MCA infarct with haemorrhagic transformation, acquired brain injury, recurrent deep vein thromboses and pulmonary thromboemboli, chronic irritable larynx, extensive burns, lung disease, anaemia (multifactorial aetiology), depression, intravenous drug use, peripheral vascular disease and post stroke epilepsy.

11. She had been admitted to The Northern Hospital from 4 October 2024 to 9 October 2024 with abdominal pain and likely aspiration pneumonia. She had been treated with 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.

intravenous antibiotics. There had been an incidental finding of a pelvic mass but this had not been further investigated consistent with her wishes.

12. She presented to the Austin Hospital on 25/10/2024 with a functional decline and worsening coughing episodes. She was admitted for end-of-life cares and died 27/10/2024.

According to the medical deposition from the Austin Hospital, a possible cause of death is provided as "Aspiration pneumonia" Identity of the deceased

13. On 27 October 2024, Juvetta Pedruco Columbine, born 26/10/1977, was visually identified by her foster mother Rosemary Brown.

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

Medical cause of death

14. Specialist Forensic Pathologist Dr Voctoria Francis from the Victorian Institute of Forensic Medicine (VIFM) conducted an examination on 29 October 2024 and provided a written report of her findings dated 13 December 2024.

15. Toxicological testing was not undertaken as there were no suitable anti mortem specimens available for testing

16. Dr Francis provided an opinion that the medical cause of death was; 1(a) Aspiration pneumonia in the setting of type 1 diabetes mellitus, previous cerebrovascular accident and other medical comorbidities, Dr Francis provided an opinion that the cause of death was due to natural causes.

17. I accept Dr Francis opinion.

FINDINGS AND CONCLUSION

18. Pursuant to section 67(1) of the Coroners Act 2008 (Vic) I make the following findings: a) the identity of the deceased was Juvetta Pedruco Columbine, born 26/10/1977; b) the death occurred on 27/10/2024 at Austin Hospital 145 Studley Road, Heidelberg Victoria, 3084 from:

1a Aspiration pneumonia in the setting of type 1 diabetes mellitus, previous cerebrovascular accident and other medical comorbidities; and c) the death occurred in the circumstances described above.

19. The available evidence does not support a finding that there was any want of clinical management or care on the part of the disability service provider, or clinical staff at Austin Hospital,145 Studley Road, Heidelberg Victoria 3084, that caused or contributed to Ms Columbine’s death.

20. Having considered all the available evidence, I find that Ms Columbine’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 Columbine’s death in chambers.

I convey my sincere condolences to Ms Columbine’s family, friends and carers 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: Rosemary Brown, Senior Next of Kin Kit Murdoch, Manager Quality and Safeguards, Karingal St Laurence Limited Coronial Investigator, Constable Scott Blackford Signature: ___________________________________ Judge John Cain State Coroner Date: 28 July 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.