Coroner's Court of Western Australia

Inquest into the Death of Leslie Troy OVENS

Inquest into the Death of Leslie Troy OVENS

Delivered on :26 April 2017

Delivered at : Perth

Finding of : Deputy State Coroner

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased suffered from Friedreich’s Ataxia, a progressive disease of the nerves leading to a loss of coordination and so muscle deterioration. The Deceased was wheelchair bound.  At the time of his death the deceased was 32 years of age.

The deceased lived independently but required help with physical aspects of daily living which were provided by carers, employed through a service provider, Cam Can & Associates, which was funded by the Disability Services Commission.

The issues which were explored at the inquest hearing was to consider systemic issues relevant to the care provided to the deceased as a person with disability living in the community.

On the evening of 24 July 2013 a carer did not attend at the deceased’s address to assist him to bed. In the morning a carer attended to assist him in getting ready for the day.  The carer found the deceased with his upper body suspended from his wheelchair onto the floor.  His mobile phone was on the floor, but out of reach.

The Coroner concluded the deceased was very independent and very anxious about his control over his life. The deceased was mentally alert and capable of independent living with the assistance of carers for the physical aspects of his daily life.  He was in June/July 2013 deteriorating physically and it was likely he would be requiring more care.

Prior to the deceased’s death his carer co-ordinator went on two weeks leave and provided a two week roster to a relief care co-ordinator. The deceased was at times difficult to manage and during this period he sacked one support worker.  Alterations were made to the roster to ensure there was adequate care for the deceased.  These changes were communicated by text and emails.

On his care co-ordinator’s return from leave the relief car co-ordinator did not provide her with a draft roster for the week of her return. Due to miscommunication and misunderstanding of the exact state of the deceased’s roster there was no cover for the evening of 24 July 2013.

On the morning of 24 July 2013 the deceased was seen by a carer who provided him with his usual routine.

In the evening the deceased was visited by a carer, who was not rostered to care for the deceased, but who called into the deceased’s home on his own way home to help the deceased. The carer was with the deceased for approximately 15 minutes during which time he microwaved a meal for the deceased and placed it ready for him to eat, and opened a can of Pepsi which he left on the kitchen bench for the deceased to drink.  When the carer left the deceased was unsure of whom his carer was to be that evening.  When the carer left the deceased was fine, in his wheelchair and about to eat his evening meal.  No one attended to the deceased later that evening.

The deceased was located on the morning of 25 July 2013 entangled in the clothes airer, suspended from his wheelchair. It was his usual routine to remove clothes from the airer to his bedroom for the evening carer to put away, before they arrived.

The deceased died because his disability meant he did not have the strength to return himself to an upright position once he fell towards the floor. He died of asphyxia, but it was not possible to determine how long it would have taken him to die.  It is not clear the rostered attendance of a carer would have saved his life but it may have improved his chances of survival.

The Coroner was satisfied there was no rostered carer to attend the deceased on the evening of 24 July 2013 and it is not the case a rostered carer failed to attended. The Coroner concluded this was not an individual problem but rather there was no system in place to ensure the lack of attendance of a carer would be detected in a timely manner, if the deceased was incapacitated in some way.

The Coroner found the deceased died on 24 July 2013 at his home and death occurred by way of Misadventure.

Comments on the care of people with a disability were made by the Coroner who was anxious that a better system be put in place for those very vulnerable persons, like the deceased, to ensure they are provided with reviews as to their ongoing physical capacity, their understanding that their desire for independence may expose them to additional risks, and some methodology be put in place to ensure the services for which they contract to be provided, are in fact provided.

Catch Words : Disability Services : Independent Service Organisations : Carers/Support Workers : Misadventure

Last updated: 30-Apr-2019

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