Finding into death of Mr JNY

Male·Pulmonary thromboembolism and bronchopneumonia secondary to deep vein thrombosis

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.