Finding into death of Stephen Ross Gamble

49y · Male·Complications of craniopharyngioma and pan-hypopituitarism

Stephen Ross Gamble, a 49-year-old man with long-standing craniopharyngioma and pan-hypopituitarism, resided in a community residential unit. His condition had been deteriorating in the months before July 2010, with multiple episodes of confusion, absconding, and hospital admissions. He was admitted to Austin Hospital on 6 July with seizures and low blood pressure, then transferred to the Repatriation Hospital's Palliative Care Unit for symptom management and end-of-life care. He developed aspiration pneumonia and died on 28 July 2010. The coroner found no autopsy necessary, with external examination and postmortem CT scanning confirming the cause as complications of craniopharyngioma and pan-hypopituitarism. Significantly, the coroner found no suggestion that any want of clinical care or management contributed to death. The death was subject to coronial investigation because Mr Gamble was a person in state care, providing scrutiny and accountability of care provided to vulnerable people.