Finding into death of TBL

Contributing factors

• Severe malnutrition from restricted diet (steamed vegetables and fruit only)
• Cessation of all psychiatric medications (risperidone, lurasidone, benztropine, donepezil, amisulpride, diazepam)
• Cessation of all cardiac medications (blood thinning agents, heart failure management)
• Progressive weight loss of 58% over four years (89kg to 37kg in June 2023)
• Hyponatraemia
• Untreated atrial fibrillation
• Untreated schizophrenia and dementia
• Reduced access to medical care (no GP or psychiatrist contact for 12+ months)
• Medical Power of Attorney holder directing non-evidence-based care based on internet research and religious beliefs
• Loose bowel motions (10-12 per day) contributing to malnutrition
• Moderate oropharyngeal dysphagia not addressed prior to acute deterioration
• Absence of coordinated adult safeguarding response
• Fragmented service system unable to escalate concerns about family-based neglect

Coroner's recommendations

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