Deceased
Glenn Charles Cook
Demographics
66y, male
Coroner
Coroner Simon McGregor
Date of death
2025-04-09
Finding date
2026-02-18
Cause of death
Cardiac hypertrophy and coronary artery disease secondary to obesity (WHO Class II) and hypercholesterolaemia
AI-generated summary
Glenn Cook, a 66-year-old man with moderate intellectual disability living in Specialist Disability Accommodation, died from cardiac hypertrophy and coronary artery disease secondary to obesity and hypercholesterolaemia. He was found struggling to breathe in his bedroom on 9 April 2025 and despite CPR efforts by paramedics, could not be resuscitated. The autopsy revealed severe coronary artery atherosclerosis and cardiac hypertrophy, likely due to untreated hypertension combined with obesity and high cholesterol. The coroner found his care was reasonable and appropriate. This case highlights the importance of aggressive cardiovascular risk factor management in vulnerable populations with disability, including blood pressure control, lipid management, and weight management strategies. Regular cardiac screening may have identified his significant coronary disease earlier.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
IN THE CORONERS COURT COR 2025 001886 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Simon McGregor Deceased: Glenn Charles Cook Date of birth: 2 April 1959 Date of death: 9 April 2025 Cause of death: 1a : CARDIAC HYPERTROPHY AND
CORONARY ARTERY DISEASE 2 : OBESITY- WHO CLASS II, HYPERCHOLESTEROLAEMIA Place of death: 258 Wilson Street Colac, Victoria 3250 Keywords: In care; Specialist Disability Accommodation; SDA resident; Natural causes; Obesity
On 9 April 2025, Glenn Charles Cook was 66 years old when he died at home. At the time of his death, Glenn lived in Specialist Disability Accommodation (SDA) at 258 Wilson Street, Colac, Victoria, 3250.
Glenn was the youngest of three, and his parents were Val and Robert Cook. The family resided in Ocean Grove and Glenn enjoyed a stable upbringing.1
Glenn had a moderate intellectual disability and was non-verbal, using only a few words to communicate.2 His past medical history included bipolar affective disorder, severe arthritis, a total left hip replacement, hypercholesterolaemia as well as mobility challenges.3 According to his general practitioner, Dr Shruthi Venkatesh, Glenn was obese with a Body Mass Index score of 35.4
For 13 years, Glenn resided in institutionalised care at Colanda Residential Services in Colac.
In 2019, he relocated to an SDA dwelling operated by Homes Victoria, part of the Department of Families, Fairness and Housing. While in care, he received Supported Independent Living (SIL) services for all personal activities of daily living from SCOPE, a National Disability Insurance Scheme (NDIS) provider.5 He resided there until his passing.
1 Coronial Brief, Statement of Kerry Gorski.
2 Coronial Brief, Statement of Dr Shruthi Venkatesh.
3 Coronial Brief, Statement of Nicole Elizabeth Standfield.
4 Coronial Brief, Statement of Dr Shruthi Venkatesh.
5 Coronial Brief, Statement of Nicole Elizabeth Standfield.
6 Ibid.
Because Glenn was a Specialist Disability Accommodation (SDA) resident residing in an SDA enrolled dwelling7 at the time of his death, his passing was determined to be ‘in care’ and, as such, is subject to a mandatory further investigation, pursuant to section 52(3A) of the Act. These findings are the result of that investigation.
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.
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.
Victoria Police assigned First Constable Lane Buckwell to be the Coronial Investigator for the investigation of Glenn’s death. The Coronial Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.
This finding draws on the totality of the coronial investigation into the death of Glenn Charles Cook 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.8
In considering the issues associated with this finding, I have been mindful of Glenn’s human rights to dignity and wellbeing, as espoused in the Charter of Human Rights and Responsibilities Act 2006, in particular sections 8, 9 and 10.
7 See Regulation 7(1)(d) of the Coroners Regulations 2019.
8 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.
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred
On the morning of 9 April 2025, Glenn was observed by staff members talking rapidly, holding food in his mouth and not interacting with staff. These behaviours indicated deteriorating mental health and at 8:10 am, staff administered quetiapine in accordance with his Mental Health Management plan.9
Glenn then remained in his bedroom, with staff intermittently checking on him.
At about 8:45 am, staff returned to his bedroom and found him struggling to breathe. Staff members attempted to reposition him to increase his breathing activity but were unable to do so. They subsequently made their first call to emergency services.10
While awaiting the arrival of Ambulance Victoria (AV), Glenn’s condition deteriorated and a second call to emergency services was made. The call taker stayed on the phone with staff members until the arrival of AV paramedics at about 9:22 am.
Upon AV arrival, Glenn was moved to the floor and paramedics commenced cardiopulmonary resuscitation (CPR). Notwithstanding these efforts, CPR was unsuccessful and Glenn was declared deceased at about 10:15 am.
Identity of the deceased
Medical cause of death
9 Coronial Brief, Statement of Nicole Elizabeth Standfield.
10 Ibid.
The post-mortem examination revealed cardiac hypertrophy11 and severe coronary artery atherosclerosis12 in the left anterior descending coronary artery. Dr Dayananda noted that hypertension is a common cause for cardiac hypertrophy due to increased cardiac activity against systemic blood pressure leading to compensatory hypertrophy. A hypertrophic heart makes it more vulnerable for ischeamia due to increased demand, making an individual more vulnerable to cardiac arrhythmia and sudden cardiac death.
Dr Dayananda further noted that small vessel disease of the myocardium is caused by damaged to the microvasculature of the heart. This damage can result from various factors, including high blood pressure, high cholesterol, obesity, and diabetes mellitus.
The post-mortem computerised tomography (CT) scan showed distended large bowel loops filled with gas and fluid, faecal impaction in the rectum, left total hip replacement, bilateral renal cysts and left 3rd anterior rib fracture.
Toxicological analysis of post-mortem samples identified the presence of carbamazepine (~ 8.4 mg/L) and its metabolite carbamazepine 0,11-epoxide (~ 4.0 mg/L) and olanzapine (~ 0.3 mg/L).
Based on the all the information available, Dr Dayananda formed the opinion that Glenn’s death was due to natural causes.
Dr Dayananda provided an opinion that the medical cause of death was 1(a) CARDIAC HYPERTROPHY AND CORONARY ARTERY DISEASE, secondary to 2: OBESITYWHO CLASS II, HYPERCHOLESTEROLAEMIA and I accept their opinion.
12 Atherosclerosis is the buildup of fats, cholesterol and other substances in and on the artery walls.
c) the death occurred in the circumstances described above.
Having considered all of the circumstances, I am satisfied that Glenn’s care was reasonable and appropriate at all material times.
As Glenn was residing in Specialist Disability Accommodation at the time of his passing, his death is considered to be ‘in care’ as defined by section 3 of the Act and subject to a mandatory inquest unless exceptions applied.13 I am satisfied by the available evidence that Glenn’s death was due to natural causes and, pursuant to section 52(3A) of the Act, have therefore determined not to hold an inquest.
I convey my sincere condolences to Glenn’s family 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: Kerry Gorski, Senior Next of Kin Scope (Aust) Ltd.
First Constable Lane Buckwell, Coronial Investigator Signature: ___________________________________ Coroner Simon McGregor Date: 18 February 2026 13 Section 52(2) of the Act.
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.
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