Finding into death of Carol Denise Jackson

IN THE CORONERS COURT COR 2025 000438

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Leveasque Peterson Deceased: Carol Denise Jackson Date of birth: 18 December 1949 Date of death: 20 January 2025 Cause of death: 1a : Pneumonia Place of death: Austin Hospital 145 Studley Road Heidelberg Victoria 3084 Keywords: Specialist Disability Accommodation resident, supported independent living, disability support, reportable deaths, natural causes

INTRODUCTION

1. On 20 January 2025, Carol Denise Jackson (Ms Jackson) was 75 years old when she died at Austin Hospital, 145 Studley Road Heidelberg Victoria 3084 following a short admission.

2. At the time of her death, Ms Jackson resided at Home@Scope in Coburg, a Specialist Disability Accommodation (SDA) dwelling enrolled under the National Disability Insurance Scheme (NDIS). Ms Jackson received funded daily independent living support due to her medical conditions including cerebral palsy, intellectual disability and dysphagia. She also had a history of cholelithiasis (gallstones), kidney stones, subserosal fibroids, asthma and a suspected stroke in January 2024. She received funding through the Disability Support for Older Australians program of the Commonwealth Department of Health, Disability and Ageing.

3. Ms Jackson attended a day program five days a week where she participated in group activities with a social and recreation focus, including arts and crafts, music and gardening. Ms Jackson was unable to communicate verbally, she required mobility aids including a wheelchair and hoist and required assistance for all tasks of daily living.

THE CORONIAL INVESTIGATION

4. Ms Jackson’s death fell within the definition of a reportable death in the Coroners Act 2008 (Vic) (the Act) as she was a ‘person placed in custody or care’ within the meaning of the Act, as a person with disability who received funded daily independent living support and resided in an SDA enrolled dwelling immediately prior to her death.1 This category of death is reportable to ensure independent scrutiny of the circumstances leading to death given the vulnerability of this cohort and the level of power and control exercised by those who care for them. The coroner is required to investigate the death, and publish their findings, even if the death has occurred as a result of natural causes.

5. 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.

1 This class of person is prescribed as a ‘person placed in custody or care’ under the Coroners Regulations 2019 (Vic), r 7(1)(d).

6. 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.

7. This finding draws on the totality of the coronial investigation into the death of Carol Denise Jackson. 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.2

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

8. On 10 January 2025, Ms Jackson ‘appeared not to be her normal self’. Her head was drooped, her mouth was ajar, and she took an uncharacteristically long time to eat dinner. She also demonstrated right-sided weakness in her arm. Staff contacted emergency services, and she was transported to the Austin Hospital Emergency Department.

9. Upon arrival, Ms Jackson had an elevated respiratory rate – 44 breaths per minute, her breathing demonstrated a ‘coarse crackle’, had low blood pressure and her extremities were cool to the touch. She had a Glasgow Coma Scale3 of 10 – which was her baseline. Clinicians formed the view that she had community acquired pneumonia due to aspiration.

10. Emergency Department clinicians spoke with Ms Jackson’s family regarding her goals of care, and it was decided to transition her to an end-of-life pathway. Ms Jackson was declared deceased at 4:26am on 20 January 2025.

Identity of the deceased

11. On 22 January 2025, Carol Denise Jackson, born 18 December 1949, was visually identified by her brother, Rodney Jackson.

2 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.

3 This is a clinical tool used to assess a person’s level of consciousness, particularly after a brain injury. It evaluates three aspects of responsiveness: eye opening, verbal response and motor response with a total score ranging from 3 to 15.

The GCS is used to assess and monitor a patient’s neurological state and to guide treatment decisions.

12. Identity is not in dispute and requires no further investigation.

Medical cause of death

13. Forensic Pathologist Dr Glengarry of the Victorian Institute of Forensic Medicine (VIFM) conducted an examination on 23 January 2025 and provided a written report of her findings dated 24 January 2025.

14. The post-mortem computed tomography (CT) scan showed occipital hypoattenuation at the left posterior cerebral artery territory with associated cerebral oedema, in keeping with subacute ischaemic changes in the left posterior cerebral artery territory.

15. Imaging of the chest showed numerous bilateral pulmonary nodules (mostly cavitating) and mass lesions, the largest in the right lower lobe. There was no focal consolidation, however, lividity obscured the fine details. There was no pleural effusion.

16. There was also rectal and sigmoid wall thickening with associated mesenteric lymph node enlargement, in keeping with an advanced infiltrating rectal carcinoma with associated local disease (and likely metastatic disease in the lungs). The left adrenal gland was enlarged, which may have been in keeping with metastasis.

17. Dr Glengarry provided an opinion that the medical cause of death was 1(a) Pneumonia.

18. Dr Glengarry provided an opinion that the cause of death was due to natural causes.

19. I accept Dr Glengarry’s opinion as to cause of death.

FINDINGS AND CONCLUSION

20. Pursuant to section 67(1) of the Act, I make the following findings: a) the identity of the deceased was Carol Denise Jackson, born 18 December 1949; b) the death occurred on 20 January 2025 at Austin Hospital, 145 Studley Road, Heidelberg Victoria 3084 from 1(a) Pneumonia; and, c) the death occurred in the circumstances described above.

21. The available evidence does not support a finding that there was any want of clinical management or care on the part of the disability service provider, or clinical staff at Austin Hospital, that caused or contributed to Ms Jackson’s death.

22. Having considered all the available evidence, I find that Ms Jackson’s death was from natural causes and that no further investigation is required. As such, I have exercised my discretion under section 52(3A) of the Act not to hold an inquest into her death and to finalise the investigation of Ms Jackson’s death in chambers.

I convey my sincere condolences to Ms Jackson’s family, friends and carers 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: Mr Rodney Jackson, Senior Next of Kin Home@Scope Austin Health First Constable Benjamin Campbell, Reporting Member, Victoria Police Signature: ___________________________________ Coroner Leveasque Peterson Date: 28 November 2025 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.