Finding into death of Fiona Lebner

57y · Female·Combined features of moderately stenosed right coronary ostium, aortic valve regurgitation with dilated aortic root, mitral valve prolapse and mitral valve regurgitation, dilated cardiomegaly clinical and heart failure

Fiona Lebner, a 57-year-old woman with severe intellectual disability living in a group home, died suddenly from acute cardiac arrhythmia secondary to multiple heart abnormalities including aortic valve disease, mitral valve disease, coronary artery stenosis, and cardiomegaly. She also had known aortic dissection and abdominal aortic aneurysm. Her death was from natural causes and occurred overnight in her bedroom. The Disability Services Commissioner investigation identified opportunities for service improvement including standardised hospital discharge planning and enhanced staff awareness of life-limiting conditions, but made no adverse findings against the care provider. The coroner noted concern about legislative gaps in coronial jurisdiction as disability services funding transitions from state to NDIS schemes.