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Contains: death in care settings

systemic failuresafeguardingcommunication barriersservice gapsresidential caremedical oversight

Louise's Disability Services Were Investigated.

Based on Victorian Coroner's FindingAI-Assisted Summary

Louise, aged 49, died from aspiration pneumonia in 2020. Her death, which occurred while she was in care, prompted an investigation by the Disability Services Commissioner.

Louise, aged 49, had cerebral palsy, left hemiparesis, epilepsy, and dysphagia. She was non-ambulant and non-verbal, requiring assistance with all aspects of daily living. She resided in a group home in Fawkner. This home was formerly operated by the Department of Health and Human Services prior to its transfer to a disability services provider in 2019.

In early 2020, Louise's health deteriorated, and she experienced increased seizures and recurrent aspiration pneumonia, leading to frequent hospitalisation. On 14 September 2020, Louise was admitted to the Northern Hospital with aspiration pneumonia. She was non-responsive to antibiotics and was refusing food.

Following consultation with medical practitioners and a family member, the decision was made to commence end-of-life care. Louise was transferred to The Kilmore and District Hospital on 24 September 2020 for palliative care. She died there on 29 September 2020. The cause of death was aspiration pneumonia in the setting of cerebral palsy and epilepsy.

As Louise was a person in care, her death was reported to the Coroner. The Disability Services Commissioner commenced an investigation into the disability services provided. I would be interested to understand what criteria are used to determine if adverse findings are made in such investigations. The investigation concluded that no adverse findings were made against the disability services provider.

Source: Original Document (opens in new tab) (COR 2020 005383)

Related to:

cerebral palsyepilepsydysphagianon verbalcomplex communication ABI

Topics:

coronerinquestdisability-carevicsystemic-issuescare-coordinationcommunicationsafeguardingsupport-services Louise HayesNDIS

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