Finding into death of George Scott Boyens

IN THE CORONERS COURT COR 2025 003431 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Simon McGregor Deceased: George Scott Boyens Date of birth: 13 July 1958 Date of death: 19 June 2025 Cause of death: 1a : COMPLICATIONS OF MULTIPLE

SCLEROSIS AND LEFT TONGUE SQUAMOUS CELL CARCINOMA Place of death: Austin Hospital 145 Studley Road Heidelberg Victoria 3084 Keywords: In care; Specialist Disability Accommodation; SDA resident; Natural causes

INTRODUCTION

1. On 19 June 2025, George Scott Boyens was 66 years old when died at the Austin Hospital. At the time of his death, George lived at Watsonia Home – Supported Living Accommodation, 303 Greensborough Road, Watsonia, Victoria, 3087.

2. George was born in the United Kingdom and grew up travelling globally, first in Africa (Sudan and Kenya) and then in New Zealand. George’s father worked for British Government and there was a period of time that George was involved with the French Foreign Legion and then in Australia as part of a surveillance team for a private security firm.

3. George was diagnosed with Multiple Sclerosis in 1995 and later with Leukemia in 2022.

George reportedly received chemotherapy treatment in a two-week cycle with the first week administered at Austin Health and the second week coordinated through Austin Health but delivered at Watsonia Home.

4. In the lead up to his passing from December 2024, George experienced a noticeable decline in his health. He was managed by the oncology team at Austin Health and during this period, he experienced significant nausea and also had contracted COVID-19. These illnesses delayed subsequent chemotherapy and contributed to his ongoing decline. George’s condition continued to worsen and he progressed from tolerating a normal diet and thin fluids to experiencing severe pain when swallowing and accompanied weight loss. Support staff at Watsonia Home assisted with ensuring George consumed supplements and meals.

THE CORONIAL INVESTIGATION

5. George’s death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury. The death of a person in care or custody is a mandatory report to the Coroner, even if the death appears to have been from natural causes.

6. Because George was a Specialist Disability Accommodation (SDA) resident residing in an SDA enrolled dwelling1 at the time of his death, his passing was determined to be ‘in care’ and, as such, is subject to a mandatory further investigation, pursuant to section 52(3A) of the Act. These findings are the result of that investigation 1 See Regulation 7(1)(d) of the Coroners Regulations 2019.

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 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. 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.

9. Victoria Police assigned Senior Constable James Doney to be the Coronial Investigator for the investigation of George’s death. The Coronial Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

10. This finding draws on the totality of the coronial investigation into the death of George Scott Boyens 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

11. In considering the issues associated with this finding, I have been mindful of George’s human rights to dignity and wellbeing, as espoused in the Charter of Human Rights and Responsibilities Act 2006, in particular sections 8, 9 and 10.

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

12. On 26 May 2025, was admitted to Austin Health for moderate malnutrition and required dietary support and analgesia management.3 During his admission, a PET scan revealed evidence of ‘tongue malignancy with probable FDG-avid left upper cervical nodal 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 Coronial Brief, Statement of Kylie Johnson (Austin Health).

metastases’, a subsequent biopsy confirmed, ‘left cervical lymph node: Squamous cell carcinoma’.4

13. On 2 June 2025, George had a nasogastric tube inserted for nutritional supplementation but experienced ongoing pain and he was prescribed high dose analgesia. After consultation with George’s family, his medical treatment team commenced a short course of palliative radiotherapy on 16 June 2025. The aim of the radio therapy was to limit tumour growth, pain and dysphagia.5

14. On 17 June 2025, George and his family met with the treating medical team, George stated that he had a ‘horrible experience at radiotherapy, he felt breathless and claustrophobic’ and did not want to pursue further sessions. George confirmed that he wanted to focus on comfort care, cease active treatment and remove his nasogastric tube.6 George was consequently transferred to the palliative care ward on the same day and passed away on 19 June 2025.

Austin Health staff confirmed that the time of death was 5:59 am.7 Identity of the deceased

15. On 19 June 2025, George Scott Boyens, born 13 July 1958, was visually identified by his sister, Linda Ann Boyens.

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

Medical cause of death

17. Forensic Pathologist Dr Michael Burke from the Victorian Institute of Forensic Medicine (VIFM) conducted an external examination on 23 June 2025 and provided a written report of his findings dated 25 June 2025.

18. The post-mortem CT scans revealed coronary calcification but no other significant features.

19. Dr Burke provided an opinion that the medical cause of death was 1(a) COMPLICATIONS OF MULTIPLE SCLEROSIS AND LEFT TONGUE SQUAMOUS CELL CARCINOMA and I accept his opinion.

4 Squamous cell carcinoma is a common type of skin cancer.

5 Coronial Brief, Statement of Kylie Johnson (Austin Health).

6 Ibid.

7 Coronial Brief, Austin Medical Records page 801 of 1319.

FINDINGS AND CONCLUSION

20. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was George Scott Boyens, born 13 July 1958; b) the death occurred on 19 June 2025 at Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, from 1(a) COMPLICATIONS OF MULTIPLE SCLEROSIS AND LEFT TONGUE SQUAMOUS CELL CARCINOMA; and c) the death occurred in the circumstances described above.

21. Having considered all of the circumstances, I am satisfied that George’s care was reasonable and appropriate at all material times.

22. As George was residing in Specialist Disability Accommodation at the time of his passing, his death is considered to be ‘in care’ as defined by section 3 of the Act and subject to a mandatory inquest unless exceptions applied.8 I am satisfied by the available evidence that George’s death was due to natural causes and, pursuant to section 52(3A) of the Act, have therefore determined not to hold an inquest.

23. I convey my sincere condolences to George’s family for their loss.

24. 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.

8 Section 52(2) of the Act.

I direct that a copy of this finding be provided to the following: Linda Boyens, Senior Next of Kin Klara Pauls, Austin Health Senior Constable James Doney, Coronial Investigator Signature: ___________________________________ Coroner Simon McGregor Date: 19 March 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.