Finding into death of JZA

Contributing factors

• prolonged immobility and bedbound state
• inadequate hygiene and pressure care
• malnutrition and low body weight (BMI 14.3)
• chronic alcohol misuse
• refusal of medical care and in-home support services
• sole carer (husband) with own health limitations unable to provide adequate physical care
• lack of adult safeguarding framework to coordinate intervention
• absence of formal supports following discharge from hospital
• untreated and recurrent urinary tract infection
• multiple severe comorbidities including emphysema, ischaemic heart disease, end-stage renal disease
• impaired immune function from malnutrition and alcohol use
• decline in engagement with medical services

Coroner's recommendations

1. That the Victorian Government make available appropriate funding to the Office of the Public Advocate to enable it to implement all of the recommendations from the VAGO report
2. The Victorian Government implement as a priority, adult safeguarding legislation to establish adult safeguarding functions including but not limited to the assessment and investigation of, and coordination of responses to allegations of abuse, neglect, and exploitation of at-risk adults
3. In framing legislation, the Victorian Government review the circumstances of JZA's passing and similar cases together with the safeguarding recommendations of the ALRC, the OPA and the DRC
4. That any new adult safeguarding agency be adequately funded by the Victorian Government to function in an effective manner
5. That the Victorian Government, when establishing a new safeguarding agency, should ensure that the agency works cooperatively with other service providers to facilitate the timely provision of, or changes to, the support services provided to at-risk adults
6. That 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 any other agencies involved
7. That the Victorian Government implement the recommendation of the Office of the Public Advocate, namely, to build the capacity of mainstream service providers to be able to identify and respond to the abuse of at-risk adults
8. That the Victorian Government make funding available for regular community awareness, media engagement and education campaigns about any new adult safeguarding function, as suggested by the Disability Royal Commission