Finding into death of Lani-Kay Roxanna Illsley

IN THE CORONERS COURT COR 2025 003599

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Amended pursuant to section 76 of the Coroners Act 2008 Findings of: AUDREY JAMIESON, Coroner Deceased: Lani-Kay Roxanna Illsley Date of birth: 5 April 1970 Date of death: 26 June 2025 Cause of death: 1a: Combined effects of influenza A infection, acute kidney injury, and aspiration pneumonia in a woman with Rett's syndrome (palliated) Place of death: Northern Hospital 185 Cooper Street Epping Victoria 3076

INTRODUCTION

1. On 26 June 2025, Lani-Kay Roxanna Illsley was 55 years old when she died at the Northern Hospital.

2. At the time of her death, Lani-Kay resided in a Specialist Disability Accommodation (SDA) dwelling enrolled under the National Disability Insurance Scheme (NDIS). Lani-Kay received funded daily independent living support due to her diagnosis of Rett syndrome and intellectual disability, which was provided by disability service provider, Aruma.

3. Lani-Kay was born in Canada and was immediately placed for adoption. Before her first birthday she was adopted by a couple from Adelaide.1

4. At the age of 4, Lani-Kay was diagnosed with the neurological disorder Rett Syndrome. Her adoptive parents placed her in the care of the state. She had no further contact with family and was supported by Joanne, a citizen advocate.

5. In 2014, Lani-Kay moved into Aruma’s care. She lived with four others, including a friend who she ultimately lived with for over 20 years.

6. Lani-Kay was non-verbal and communicated through facial expressions and gestures. She required support for mobility and all aspects of daily life. Her medical decision-making was managed by the Office of the Public Advocate (OPA).

7. Lani-Kay is remembered as a gentle, quiet and sweet lady. She enjoyed getting massages, going swimming, listening to music and exploring sensory activities. In the evenings she liked to relax and watch television.

THE CORONIAL INVESTIGATION

8. Lani-Kay’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.2 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 1 Amended on 26 February 2026 to correct the age at which Lani-Lay was adopted.

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

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.

9. 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.

10. 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.

11. This finding draws on the totality of the coronial investigation into the death of Lani-Kay Roxanna Illsley. 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

12. Care staff found Lani-Kay unwell on the morning of 19 June 2025. They called for an ambulance, and she was taken to Northern Hospital.

13. The clinical impression was that Lani-Kay had developed septic shock in the context of influenza A. It was decided she would be managed on the ward. The OPA provided consent for “emergent care/withdrawal of care/initiation of palliative care…at the discretion of the medical practitioner as deemed appropriate for the patient’s best interests.”

14. On 22 June 2025, Lani-Kay was observed to be opening her eyes and looking around the room. She was not in respiratory distress, and her blood pressure had returned to normal. There was a plan to reduce her analgesia and see if she could tolerate food or liquids the next day.

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.

15. On 25 June 2025, Lani-Kay’s conscious state was found to be deteriorating, and audible mouth secretions were noted. She was continued on analgesia to keep her comfortable.

16. On 26 June 2025, Lani-Lay was observed resting peacefully and not rousable to voice or light touch. She died later that night.

Identity of the deceased

17. On 26 June 2025, Lani-Kay Roxanna Illsley, born 5 April 1970, was visually identified by Aruma Operations Manager, Louise Stastnik, who completed a Statement of Identification.

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

Medical cause of death

19. Forensic Pathologist Dr Chong Zhou from the Victorian Institute of Forensic Medicine (VIFM) conducted an external examination of the body of Lani-Kay Illsley on 30 June 2025.

Dr Zhou considered the Victoria Police Report of Death (Form 83), post mortem computed tomography (CT) scan and the E-Medical Deposition Form from Northern Health and provided a written report of her findings dated 3 July 2025.

20. The findings at external examination were in keeping with the history. The post mortem CT scan showed features of pneumonia.

21. There was no evidence of significant injuries that may have caused or contributed to death.

22. Dr Zhou provided an opinion that the death was due to natural causes and ascribed the medical cause of death as 1(a) COMBINED EFFECTS OF INFLUENZA A INFECTION, ACUTE

KIDNEY INJURY, AND ASPIRATION PNEUMONIA IN A WOMAN WITH RETT'S SYNDROME (PALLIATED).

FINDINGS AND CONCLUSION

1. Pursuant to section 67(1) of the Coroners Act 2008 (Vic) I make the following findings: a) the identity of the deceased was Lani-Kay Roxanna Illsley, born 5 April 1970; b) the death occurred on 26 June 2025 at the Northern Hospital, 185 Cooper Street, Epping, Victoria 3076;

c) I accept and adopt the medical cause of death ascribed by Dr Chong Zhou and I find that Lani-Kay Roxanna Illsley, a woman with Rett Syndrome, died from the combined effects of influenza A, acute kidney injury and aspiration pneumonia;

2. AND, the available evidence does not support a finding that there was any want of clinical management or care on the part of Aruma, or clinical staff at the Northern Hospital, that caused or contributed to Lani-Kay Roxanna Illsley’s death.

3. AND FURTHER, having considered all the available evidence, I find that Lani-Kay Roxanna Illsley’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 in chambers.

I convey my sincere condolences to those who knew and cared for Lani-Kay 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: Carolyn Illsley, Senior Next of Kin Constable Nathan Browne, Coronial Investigator Signature:

AUDREY JAMIESON CORONER Date: 23 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.