Finding into death of Ronald Nieuwenhuis

IN THE CORONERS COURT COR 2025 000936 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Paul Lawrie Deceased: Ronald Nieuwenhuis Date of birth: 1 January 1960 Date of death: 16 February 2025 Cause of death: METASTATIC DISEASE WITH

GASTROINTESTINAL PRIMARY (ADENOCARCINOMA) Place of death: Barwon Health Bellerine Street Geelong Victoria 3220 Keywords: Specialist Disability Accommodation resident, supported independent living, disability support, reportable deaths, natural causes

INTRODUCTION

1. On 16 February 2025, Ronald Nieuwenhuis was 65 years old when he passed away at the McKellar Centre, Barwon Health in North Geelong.

2. At the time of his death, Mr Nieuwenhuis resided at Rossack House, 15 Boyne Avenue, East Geelong, a Specialist Disability Accommodation (SDA) dwelling enrolled under the National Disability Insurance Scheme (NDIS). Mr Nieuwenhuis received funded daily independent living support due to his intellectual disability, which was provided by disability service provider, genU. Mr Nieuwenhuis’ medical history also included type 2 diabetes, hypertension, obesity, hypertension, bilateral lower limb lymphoedema, left eye glaucoma and chronic knee pain.

3. Mr Nieuwenhuis was one of six siblings born to Dutch immigrants. He grew up with his four brothers and one sister in the greater Geelong area. Mr Nieuwenhuis was diagnosed with an intellectual disability when he was in primary school.

4. Mr Nieuwenhuis completed high school to Year 10, then started working. He held various jobs including at a shoe factory and fish and chip shop. Mr Nieuwenhuis worked for about 20 years at genU in various roles. He performed lawn maintenance and mail room duties.

5. Mr Nieuwenhuis’ family described him as someone who “loved life” and was “full of banter, always happy and loved helping people”.

THE CORONIAL INVESTIGATION

6. Mr Nieuwenhuis’ death fell within the definition of a reportable death in the Coroners Act 2008 (Vic) (the Act) as he 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 his death.1 This category of death is reportable to ensure independent scrutiny of the circumstances leading to death given the vulnerability of this cohort. The coroner is required to investigate the death, and publish their findings, even if the death has occurred as a result of natural causes.

7. 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 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).

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.

8. Senior Constable (SC) Cassandra D’Alessandro acted as the Coronial Investigator for the investigation of Mr Nieuwenhuis’ death. SC D’Alessandro conducted inquiries on my behalf and compiled a coronial brief of evidence

9. This finding draws on the totality of the coronial investigation into the death of Ronald Nieuwenhuis 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.2

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

10. Mr Nieuwenhuis suffered a general decline in his physical health in the months prior to his death. His brother, Gerrit (Gerry) Nieuwenhuis observed his brother was taking longer to walk to their regular Saturday morning coffee. Mr Nieuwenhuis told his family on Christmas Day 2024 that his legs were “falling asleep” and he needed to go for a walk.

11. On 2 January 2025, Mr Nieuwenhuis reported to his carers that he was in pain, but he declined to see his general practitioner. The next day, he reported stomach pain. However, his carers were unable to obtain an appointment with his GP for several days, so Mr Nieuwenhuis agreed to be transported to hospital for further investigation.

12. Mr Nieuwenhuis attended the University Hospital Geelong emergency department that same day. He underwent a CT scan which showed large volume ascites and a right kidney nodule.

Blood test results demonstrated a significant decline in kidney function. He also underwent an ultrasound-guided ascite tap, which indicated an adenocarcinoma which was likely of gastrointestinal origin.

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.

13. Hospital staff discussed Mr Nieuwenhuis’ condition and prognosis with his family. They agreed to transition him to palliative and comfort care. He was transferred to the Palliative Care Unit at Barwon Health’s McKellar Centre and passed away on 16 February 2025.

Identity of the deceased

14. On 18 February 2025, Ronald Nieuwenhuis, born 1 January 1960, was visually identified by his brother, Gerry Nieuwenhuis.

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

Medical cause of death

16. Senior Forensic Pathologist Dr Michael Burke from the Victorian Institute of Forensic Medicine conducted an examination on 19 February 2025 and provided a written report of his findings dated 20 February 2025.

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

18. Examination of the post-mortem CT scan showed ascites and probable thickened peritoneum, right renal lesion, and a right pleural effusion with no obvious metastases.

19. Toxicological analysis of post-mortem samples was not indicated and was therefore not performed.

20. Dr Burke provided an opinion that the death was due to natural causes, and the medical cause of death was 1(a) Metastatic disease with gastrointestinal primary (adenocarcinoma).

21. I accept Dr Burke’s opinion.

FINDINGS AND CONCLUSION

22. Pursuant to section 67(1) of the Coroners Act 2008 (Vic) I make the following findings: a) the identity of the deceased was Ronald Nieuwenhuis, born 1 January 1960; b) the death occurred on 16 February 2025 at Barwon Health Bellerine Street Geelong Victoria 3220 from metastatic disease with gastrointestinal primary (adenocarcinoma); and c) the death occurred in the circumstances described above.

23. There is nothing to suggest that the care (including the medical care) received by Mr Niewenhuis was anything other than appropriate.

I convey my sincere condolences to Mr Nieuwenhuis’ family, friends and carers for their loss.

I thank the Coronial Investigator and those assisting for their work in the investigation.

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: Gerry Nieuwenhuis, Senior Next of Kin Barwon Health Senior Constable Cassandra D’Alessandro, Coronial Investigator Signature: ___________________________________ Coroner Paul Lawrie Date: 07 April 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.