RECORD OF INVESTIGATION INTO DEATH (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Robert Pearce, Coroner, having investigated the death of
Janice Zoey Barnes
WITHOUT HOLDING AN INQUEST
(a) The identity of the deceased person is Janice Zoey Barnes, born 18 August 1942;
(b) Miss Barnes died on 6 February 2012 at 99A George Town Road, Newnham in Tasmania;
(c) The cause of Miss Barnes’ death is sepsis;
(d) No other person contributed to the cause of Miss Barnes’ death.
1. At the time of her death Janice Zoey Barnes was aged 69. She suffered a severe intellectual disability from birth and lived in a group home at Newnham operated by Able Australia. Miss Barnes required full assistance for the activities of daily living including eating and drinking. She was able to walk. Communication, both verbal and otherwise, was minimal although she was able to express disapproval by vocal outburst.
2. At about 8.15 am on 6 February 2012 Miss Barnes appeared to her carers to be unwell. She could not stand and was lethargic. There was no history of a significant fall or head injury and no loss of consciousness. She was described as being cold and clammy and would not take medication or eat breakfast. She was taken to the Launceston General Hospital at about 11.00 am. She was examined and assessed. An x-ray was taken and blood tests and a dipstick test of urine were performed. A diagnosis of either lung infection or urinary tract infection was considered. She was given antibiotics and discharged at 12.45 pm for later review by her GP.
3. During the afternoon Miss Barnes still appeared to her carers to be unwell. At about 3.50 pm the staff noticed that she was not breathing. No pulse was found. CPR was performed and an ambulance called but she could not be revived and died.
4. It is relevant that Miss Barnes had surgery on 31 May 2011 to repair a rectal prolapse.
5. A post mortem examination was performed. It disclosed that Miss Barnes had a serious underlying infection – sepsis complicating ischemic colitis (inflammation and injury of the large intestine resulting from inadequate blood supply). That condition was the cause of her death.
6. The coronial investigation of Miss Barnes’ death has included, amongst other things:
(a) a post mortem examination conducted by Forensic Pathologist Dr Donald Ritchey;
(b) a report from the treating practitioners at the LGH;
(c) review of the records of and tests conducted by LGH;
(d) a report and advice in conference from a senior medical consultant engaged by the Coronial Division;
(e) advice in conference from a senior nurse investigator as well as Dr Ritchey.
Comments and Recommendations:
7. By s28 of the Coroners Act a coroner investigating a death is required to find, if possible, when and where the person died, how the death occurred, the cause of death and to identify any person who contributed to the cause of death. It is proper that an investigation should identify not only the direct means or mechanism of death but also the circumstances attending the death. The primary focus of an investigation is to seek out and record the facts concerning the death of a person. It is not the function of an inquest to attribute any moral or legal responsibility or liability for a death or to hint at blame although comments or recommendations can be made in appropriate cases.
8. I have decided not to hold in inquest into Miss Barnes’ death. The investigation has sufficiently disclosed her identity, the time, place, the relevant circumstances concerning her death and the particulars needed to register her death under the Births, Deaths and Marriages Registration Act.
9. I find that Miss Barnes’ treatment in hospital did not contribute to the cause of her death. She was fully assessed. Appropriate tests were undertaken. The view formed by her treating practitioners was reasonably based on the evidence and information available to them. This case highlights the difficulty of the diagnosis and treatment of this condition. Diagnosis of the condition and assessment of its severity is difficult even with patients able to communicate adequately. In the circumstances of this case the diagnosis was even more difficult. The urine test, usually reliable, gave a false positive. There was an absence of the usual clinical signs of the condition.
10. I do not consider that an inquest is likely to elicit any further significant and relevant information concerning the issues that I am required to determine.
I convey my sincere condolences to Miss Barnes's Family.
Dated: 19 day of February, 2013.