Coronial
VIChospital

Finding into death of Mr JNY

Deceased

JNY

Demographics

male

Coroner

State Coroner Judge Liberty Sanger

Date of death

2023-06-29

Finding date

2026-04-24

Cause of death

Pulmonary thromboembolism and bronchopneumonia secondary to deep vein thrombosis

AI-generated summary

JNY, a man with metastatic small cell carcinoma, COPD, and ischaemic heart disease, died from pulmonary thromboembolism and bronchopneumonia. He received palliative care at home provided by his partner PJN, who had undisclosed mental health issues and a history of violence. Multiple healthcare workers documented concerns about PJN's capacity to provide safe care, her alcohol use, and emotional distress. PJN attempted to smother JNY multiple times in the days before his death. The coroner found no deficiencies in clinical care but identified a systemic gap: Victoria lacks comprehensive adult safeguarding legislation to protect vulnerable adults from abuse and neglect. Healthcare workers and family had no centralised mechanism to escalate concerns about a capable adult's safety when the care-provider refused additional support. The death highlights the need for adult safeguarding frameworks similar to those in the UK.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

palliative caregeneral practiceoccupational therapyphysiotherapyforensic medicine

Error types

system

Drugs involved

desvenlafaxinesertraline

Clinical conditions

pulmonary thromboembolismdeep vein thrombosisbronchopneumoniametastatic small cell carcinomaischaemic heart diseasechronic obstructive pulmonary diseasecerebral oedemacommunity acquired pneumonia

Contributing factors

  • metastatic small cell carcinoma
  • ischaemic heart disease
  • chronic obstructive pulmonary disease
  • likely immobility
  • underweight BMI
  • reduced physiological reserve

Coroner's recommendations

  1. That the Minister for Disability and 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 (and the Minister for Disability provide funding for) 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 JNY'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 and Minister for Disability 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 and the Minister for Disability make funding available for regular community awareness, media engagement and education campaigns about any new adult safeguarding function
Full text
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Source and disclaimer

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