Record of Investigation Into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Timothy Hill, Coroner, having investigated the death of

Mr. W.


These findings have been de-identified by direction of the Coroner pursuant to S.57(c) of Coroners Act 1995 

Find :

(a) Mr W died on overnight on the 12 and 13 July 2010 at a shared care facility at 67 Russell Road, Claremont in Tasmania, aged 62 years.

(b) Mr W was born in Hobart in 1947.  He was a single man with no children and was a disability pensioner.

(c) Mr W died as a result of asphyxia due to choking on gastric contents. 


Mr W was born in Hobart, Tasmania in 1947.  He was unmarried and residing in a shared care facility in Claremont, Tasmania, with three other males.  Mr W had been under the care of the Department of Health and Human Services (D.H.H.S.) since childhood and had been a patient at the Willow Court Centre in New Norfolk until its closure.  He then resided in share house supported accommodation.  Mr Ws’ mother  would visit him each Sunday at the Willow Court however after her death in 1986 he had little contact from family. 

At the time of his death Mr W was no longer under a guardianship order.  A letter from the Public Guardian to the Board, dated 18 February 2008, indicated Mr W was settled in the share home on Russell Road, that he did not require authorisation of his medication, that he no longer needed a guardian and that the order could lapse on 27 April 2008.  An Administration (financial) Order, dated 24 April 2008, remained in effect at the date of Mr Ws’ death.

Mr W resided in a D.H.H.S. care home, which was subcontracted to Langford Support Services, from 2003 and attended Derwent Day Options every weekday for a supported activity based program.  He had a lower level of communication and was able to ensure his needs were understood using simple phrases and gestures. 

While residing at the Langford share house, Mr W received support for all areas of daily living including meal preparation, personal care, household tasks, community access and health care management (including the administration of his medication).

Mr W had an intellectual disability and chronic obstructive airway disease, having been a regular smoker until about three years prior to his death.  According to his Langford records, Mr W had periods of being unwell and had been admitted to hospital over recent few years following episodes of vomiting. Previous medical examinations had revealed reflux esophagitis. He also had a history of self injury behaviour including hitting and scratching himself.

Mr W had been admitted to hospital in March 2010 for community acquired pneumonia and iron deficiency anaemia, and had been discharged with antibiotic medication and iron supplements.  According to his medical records, he suffered from recurrent aspiration pneumonitis/pneumonia, which complicated his chronic obstructive pulmonary disease, and recurrent Haematemesis (vomiting of blood). 

According to his general practitioner, Dr Hamley Perry, “He had documented marked gastro-oesophageal reflux and Barrett’s oesophagus.  His presentation of lower respiratory tract infection was often atypical with sudden general deterioration in clinical status being the presenting symptom.  He also had a number of episodes of large haematemesis in the few years preceding his death.

Challenging behaviour was not able to be successfully managed by behavioural means alone and so Largactil and Endep were required on a regular basis with Kalma utilised intermittently on an as needed basis to defuse outbursts that could not otherwise be managed.” 

Circumstances surrounding death:

On the evening of 12 July 2010, the residents of the Russell Road share home had a dinner and small party to celebrate the birthday of one of the residents.  Between 3:00pm and 9:30pm there were two disability support workers present with the residents.  Mr W went to bed around 9:00pm that evening after taking his nightly medication.  Mr Ws’ medication is provided in a ‘Webster pack’, which is a pre-sealed pack of doses, with the times and days medication is required.  The packs are supplied by a pharmacist upon prescription from the patient’s doctor.  All residents were in bed in their separate bedrooms prior to the second carer leaving at 9:30pm.

Mr Richard Crowe was the carer who was rostered to stay overnight in the residence on 12 July 2010.  When the residents go to bed they are left alone until the next morning when they are called for breakfast.  On the morning of 13 July 2010, Mr Crowe knocked on the bedroom doors of the residents.  About 7:30am he opened Mr Ws’ door and saw him lying across his bed and not moving.  He noticed that there appeared to be gastric contents in his mouth, across one cheek and onto his bedding. He was unable to find a pulse and, after trying to call the Langford on-call person before the day shift carer arrived, called an ambulance.  Tasmania Ambulance personnel arrived a short time later and Mr W was pronounced deceased at the scene. 

Langford Support Services do not have any written standard operating procedure in relation to night care in group homes, however according to Mr Russell Drew, support worker and administrative officer, “our normal process for support workers on ‘sleep over’ to follow is that one worker will sleep over from 11:00pm until 6:30am.  They are not required to do anything other than sleep at the residence in case of an emergency.  The worker gets paid $60 a night to sleep over at the end of their shift.  The support workers have a number of tasks they need to do before they go to bed.  Some of those tasks consist of:

  • completing client night notes, which involved documenting any event of significance through out the day or night and anything that other staff may need to be aware of;
  • supplying the clients with their medication, however, staff need to have qualifications for this and there are a few of us with these qualifications;
  • giving them night baths;
  • providing them with nightly meals.”

A post-mortem examination was conducted by Forensic Pathologist, Dr Donald Ritchey.  He determined the cause of Mr Ws’ death to be asphyxia due to choking on gastric contents.  Dr Ritchey noted significant contributing factors were hiatus hernia, severe intellectual impairment, emphysema and history of recurrent aspiration pneumonias. 

Mr W died overnight on the 12 and 13 July 2010 at his residence due to asphyxia.


It is not possible to say with certainty but Mr W’s death may have been preventable if his bedroom had been fitted with some form of easily accessible emergency alert device. I recommend that the organisations that manage accommodation of this nature investigate the installation of such devices.

I would also recommend that support organisations review their procedures to assess the viability of night time carers carrying out periodic checks of residents particularly those who might from time to time be suffering any illness.

Before I conclude this matter I wish to convey my sincere condolences to Mr W’s family for their loss.

DATED:           27 September  2011 at Launceston in Tasmania


Timothy Hill