Finding into death of Fiona Lebner
Deceased
Fiona Lebner
Demographics
57y, female
Date of death
2020-02-26
Finding date
2022-10-05
Cause of death
Combined features of moderately stenosed right coronary ostium, aortic valve regurgitation with dilated aortic root, mitral valve prolapse and mitral valve regurgitation, dilated cardiomegaly clinical and heart failure
AI-generated summary
Fiona Lebner, a 57-year-old woman with severe intellectual disability living in a group home, died suddenly from acute cardiac arrhythmia secondary to multiple heart abnormalities including aortic valve disease, mitral valve disease, coronary artery stenosis, and cardiomegaly. She also had known aortic dissection and abdominal aortic aneurysm. Her death was from natural causes and occurred overnight in her bedroom. The Disability Services Commissioner investigation identified opportunities for service improvement including standardised hospital discharge planning and enhanced staff awareness of life-limiting conditions, but made no adverse findings against the care provider. The coroner noted concern about legislative gaps in coronial jurisdiction as disability services funding transitions from state to NDIS schemes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Procedures
Contributing factors
- chronic descending thoracic aortic dissecting aneurysm
- abdominal aortic aneurysm
- hypertension
- peripheral oedema
Coroner's recommendations
- The coroner noted concern that the definition of 'person placed in custody or care' in section 3(1) of the Coroners Act 2008 no longer adequately captures vulnerable people in receipt of NDIS-funded disability services, and that legislative amendment may be warranted to ensure deaths of this cohort continue to be subject to coronial scrutiny.
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