Inquest into the death of Cameron De Vries
Deceased
Cameron De Vries
Demographics
20y, male
Date of death
2019-08-31
Finding date
2025-02-28
Cause of death
Drowning precipitated by a seizure
AI-generated summary
Cameron De Vries, a 20-year-old man with severe autism spectrum disorder and global developmental delay, died by drowning precipitated by a seizure in a bathtub at a disability support home. He had experienced a seizure on 11 March 2019 but was discharged against medical advice without formal neurological evaluation or epilepsy diagnosis. No seizure management plan was implemented. On 31 August 2019, Cameron was left unsupervised in the bath for approximately 15 minutes before being found unresponsive. Clinical lessons: (1) A single unprovoked seizure in a person with intellectual disability warrants neurological assessment and preventive treatment due to high recurrence risk; (2) People with disabilities are at disproportionate risk of bath drowning from seizures—supervised bathing is essential; (3) Disability support organisations must have clear, precise supervision documentation (avoiding vague terms like 'spot checks'); (4) Risk management plans must be consolidated, accessible, and clearly communicated to staff; (5) Medication administration records must be accurately completed by the actual administrator.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Seizure on 11 March 2019 not formally diagnosed or treated
- No epilepsy or seizure management plan implemented despite documented seizure
- Unsupervised bathing despite known risk factor
- Vague and inconsistent supervision documentation
- Risk management plans inadequate, confusing and inconsistently presented
- Discharge from emergency department against clinical advice
- Parents' refusal to accept seizure diagnosis or hospitalisation
- Lack of neurological follow-up after March 2019 seizure
- Inaccurate and fabricated progress notes by support workers
- Inadequate medication administration documentation
Coroner's recommendations
- IDS to audit progress note documentation at 24 Church Street to ensure accurate and timely recording by support workers
- IDS to review behavioural support documentation to provide clear guidance on risks and management strategies, including in a single summary document format
- IDS to use precise language in supervision documentation, replacing vague terms such as 'spot checks' and 'periodically' with specific timing, frequency and nature of checks
- IDS to develop updated 'Client Personal Profile' document including an 'All About Me' support plan, participant support needs and response strategies in summary format, and accurate cross-references to critical support documents
- IDS to review medication administration practices to ensure medication charts are appropriately completed and only the administering worker signs the chart
- IDS to engage a neurologist to review current epilepsy and seizure management policies and procedures
- IDS to review 'Family Involvement and Maintenance of Relationships policy' to include guidance on conflict resolution between family members, guardians and support workers regarding participant health concerns, with clear escalation guidelines to IDS management
Full text
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