Finding into death of David Ronald Thompson

IN THE CORONERS COURT COR 2024 002180 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Catherine Fitzgerald Deceased: David Ronald Thompson Date of birth: 13 December 1959 Date of death: 18 April 2024 Cause of death: 1a: Complications of advanced rectal carcinoma Place of death: Eastern Health Wantirna 251 Mountain Highway Wantirna Victoria 3152 Keywords: Specialist Disability Accommodation resident, natural causes

INTRODUCTION

1. On 18 April 2024, David Ronald Thompson was 64 years old when he died at Eastern Health Wantirna. At the time of his death, Mr Thompson lived in specialist disability accommodation (SDA) in Mount Waverley, Victoria, managed by Life Without Barriers, where he had been residing since 1998.

2. Mr Thompson lived with his parents and siblings until 1968, from which time he lived in various care facilities. He was non-verbal and had a complex medical history which included diagnoses of severe intellectual disability, schizoaffective disorder, functional incontinence and issues related to swallowing. This led to Mr Thompson suffering from recurrent aspiration pneumonia, chest infections, bowel incontinence and persistent haemorrhoids. He required assistance with all daily living activities.

3. In August 2022, staff from the SDA noted that Mr Thompson had rectal bleeding. He was taken to his General Practitioner (GP), who referred him to Eastern Health for further management and colonoscopy.

4. In March 2023, Mr Thompson was examined at Eastern Health and a referral was made for him to see a colorectal surgeon. In April 2023, he was examined by the colorectal surgeon who booked him for surgery and colonoscopy. Following the surgery on 11 September 2023, Mr Thompson was diagnosed with advanced anorectal cancer. He received a course or radiotherapy, but following consultation with Mr Thompson’s family, it was determined that he could not tolerate further medical intervention, and thus he was referred for palliative management and comfort care.

THE CORONIAL INVESTIGATION

5. Mr Thompson’s death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (Vic) (the Act).1 The sole reason for the report was that Mr Thompson was a ‘person placed in custody or care’ pursuant to the definition in section 4 of the Act, being an ‘SDA resident residing in a SDA enrolled dwelling’ at the time immediately before his passing.2 1 Section 4(1), (2)(c) of the Act.

2 Pursuant to Reg 7(1)(d) of the Coroners Regulations 2019, a “prescribed person or a prescribed class of person” includes a person in Victoria who is an “SDA resident residing in an SDA enrolled dwelling”, as defined in Reg 5.

Information has been received from the NDIS that Mr Thompson resided at an address where the residents meet these criteria.

6. Victoria Police assigned an officer, Senior Constable Courteney Russell, as the coroner’s investigator for the investigation of Mr Thompson’s death. The coroner’s investigator conducted inquiries on my behalf, including taking statements from witnesses, and submitted a coronial brief of evidence.

7. This finding draws on the totality of the coronial investigation into the death of David Ronald Thompson, including evidence contained in the coronial brief. 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.3

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

8. On 11 April 2024, Mr Thompson was admitted to Box Hill Hospital with lethargy, anaemia and abdominal pain due to advancement of his cancer. He was transferred to Eastern Health Wantirna for end-of-life care.

9. Mr Thompson passed away on 18 April 2024 in palliative care. His death was not unexpected and there were no concerns identified relating to the care provided to Mr Thompson. He was lovingly supported by his family, including his parents and siblings, throughout his life. It was noted by his brother, Stuart Thompson, that Mr Thompson was well cared for in his accommodation in Mount Waverley.

Identity of the deceased

10. On 18 April 2024, David Ronald Thompson, born 13 December 1959, was visually identified by his brother, Stuart Thompson.

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

Medical cause of death 3 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.

12. Forensic Pathologist Dr Brian Beer from the Victorian Institute of Forensic Medicine conducted an external examination on 19 April 2024 and provided a written report of his findings dated 24 April 2024.

13. The post-mortem examination revealed findings consistent with the reported circumstances.

14. Examination of a post-mortem CT scan showed bilateral lower lobe consolidation and a rectal mass with anal protrusion, and no fracture of the head.

15. Dr Beer provided an opinion that the medical cause of death was ‘1(a) Complications of advanced rectal carcinoma’. He was of the opinion Mr Thompson’s death was due to natural causes.

16. I accept Dr Beer’s opinion.

FINDINGS AND CONCLUSION

17. Pursuant to section 67(1) of the Coroners Act 2008 (Vic) I make the following findings: a) the identity of the deceased was David Ronald Thompson, born 13 December 1959; b) the death occurred on 18 April 2024 at Eastern Health Wantirna, 251 Mountain Highway, Wantirna, Victoria 3152 from 1a: Complications of advanced rectal carcinoma; and c) the death occurred in the circumstances described above.

I convey my sincere condolences to Mr Thompson’s family 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:

Stuart Thompson, Senior Next of Kin Eastern Health Life without Barriers (C/- Barry Nilsson Lawyers) Senior Constable Courteney Russell, Coronial Investigator Signature: ___________________________________ Coroner Catherine Fitzgerald Date: 10 February 2026 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.