Finding into death of YTR

Contributing factors

• Retroperitoneal lymphoma with nerve invasion causing immobility
• Prolonged immobility on couch for approximately one week
• Severe malnutrition and dehydration
• Inadequate preventative measures for pressure injury
• Delayed medical treatment and presentation to hospital
• Impaired immune function secondary to malignancy and malnutrition
• Cancer-associated thrombosis in right leg
• Lack of engagement with primary care services
• Reduced oral intake and fluid consumption
• Inadequate hygiene and personal care

Coroner's recommendations

1. The Victorian Government implement as a priority, adult safeguarding legislation to establish adult safeguarding functions including assessment, investigation of, and coordination of responses to allegations of abuse, neglect, and exploitation of at-risk adults
2. The Victorian Government review the circumstances of YTR's passing and similar cases together with safeguarding recommendations of the ALRC, the OPA and the DRC when framing legislation
3. Any new adult safeguarding agencies be adequately funded by the Victorian Government to function in an effective manner
4. The Victorian Government ensure that new safeguarding agencies work cooperatively with other service providers to facilitate timely provision of or changes to support services for at-risk adults
5. The Victorian Government introduce legislation to permit an adult safeguarding agency to receive and share information in a timely manner, including information about neglect, with police, healthcare entities, government departments, the Office of the Public Advocate and other agencies
6. The Victorian Government implement the Office of the Public Advocate recommendation to build the capacity of mainstream service providers to identify and respond to abuse of at-risk adults
7. The Victorian Government make funding available for regular community awareness, media engagement and education campaigns about adult safeguarding functions