Carol, aged 49, had an intellectual disability and a medical history including schizophrenia, epilepsy, depression, obsessive compulsive disorder, and tetralogy of fallot. In 1980, she underwent surgery to repair her tetralogy of fallot. She lived in a residential care facility in Werribee.
On 10 September 2025, Carol was admitted to the Royal Melbourne Hospital for a percutaneous pulmonary valve insertion to treat pulmonary regurgitation. The Office of the Public Advocate consented to the procedure. Following successful surgery, Carol was admitted to the Intensive Care Unit and then the Coronary Care Unit.
On 11 September 2025 at around 11.20am, Carol was found unresponsive by staff. She had sustained a severe hypoxic brain injury.
I would be interested to understand the standard monitoring protocols in place for patients with complex medical histories in the Coronary Care Unit.
Carol died at the Royal Melbourne Hospital on 13 September 2025 at 1.09pm. A carer visually identified her later that day. A Senior Forensic Pathologist performed an autopsy on 18 September 2025. The medical cause of death was coronary artery atherosclerosis in the setting of pulmonary valve replacement for treatment of tetralogy of fallot. The Coroner signed the finding on 27 April 2026.