State Coroner John Cain has used the case of a 78-year-old woman, who died in Maroondah Hospital in 2020, to highlight the need for an adult safeguarding framework.
The woman, identified only as YTR, was cared for by one of her two children (IJN) and was living in their family home in a regional Victorian town.
At the time of her death, YTR had a large lymphoma (cancer in the lymphatic system) in her right abdominal area, was malnourished and was suffering from sepsis, with large pressure sores having developed. YTR’s medical history also included schizophrenia, depression, underactive thyroid, high cholesterol, type 2 diabetes, high blood pressure and potassium deficiency.
IJN called Triple Zero at 6.18am on 3 November 2020, reporting that YTR’s legs were swollen, had a sore neck, had not been eating or drinking and groaned in pain when her shoulder was touched.
Paramedics arrived to find YTR sitting on the couch with her head slumped forward and a strong smell of faeces and urine. It was later clear that her clothes where encrusted with faecal matter and urine and had stuck to the couch where she was sat, with IJR confirming she had been sat in the same spot for about a week. YTR also presented as confused, in a low conscious state, with low blood pressure and had a body temperature of 35 degrees.
After arriving at a regional hospital, YTR was administered antibiotics and painkillers and had multiple bruises on her back, swollen legs, pressure ulcers on her buttocks, lower back and each heel and maceration (skin softening and breakdown) in the perineal area.
YTR was later transferred to Maroondah Hospital’s intensive care unit after beds weren’t available at the Royal Melbourne or Austin hospitals, and staff there notified Victoria Police due to their concerns about her condition.
Detectives from the Croydon Family Violence Investigation Unit (FVIU) visited the hospital and spoke to one of the treating clinicians, and received information about YTR’s condition, with uniform officers from the regional police station and the FVIU later executing a search warrant at the family home.
IJN showed police around the home, including YTR’s old mattress in the backyard which he claimed had been urinated on, the laundry which been flooded by an overflowing sink and a toilet which police assumed was out-of-order due to the toilet bowl being black.
IJN was arrested and taken for interview, where he said YTR had not taken her tablets for a week but he was unsure why, could not recall the last time she visited her GP, was uncertain what her prescriptions are for and that he believed she hadn’t eaten since AFL Grand Final day that year on 24 October, though she may have eaten a bit of ice cream on 2 November and he had encouraged her to drink through a straw.
IJN said YTR’s condition declined from September 2020 when she became unable to mobilise and didn’t want anyone to come to the house to help with cooking and cleaning. She had been on the couch for about a week and he was unable to move her, but she refused when he offered to call an ambulance and refused to see a doctor. IJN claimed he had tried to wash her face and hair as she had not had a shower since September and that when she was previously in her bed, had lifted her into a chair and pushed it to the bathroom for her to relieve herself in the bathtub.
Police applied for a Family Violence Intervention Order (FVIO) against IJN and YTR’s daughter PLK became the point of contact for Maroondah Hospital.
A CT scan revealed the cancer YTR was suffering from, and YTR began to fall in and out of consciousness and her condition deteriorated. After the decision was made to transfer YTR to palliative care, she died on 11 November 2020.
Police comprehensively investigated whether IJN’s actions or omissions contributed to YTR’s condition and eventually, no charges were laid in relation to the death. In response to a request for comment from the Coroner’s Court, IJN said IJN he did not know there was anything wrong with his mother and she did not mention that anything was wrong.
An expert report from a geriatrician later opined that at the point YTR presented to the regional hospital, her frailty meant that she was unlikely to tolerate any treatment other than palliative care by the time her lymphoma was discovered.
The geriatrician also concluded the extent of the pain and suffering YTR experienced was dependent on potential nerve damage suffered as a result of the lymphoma, which may have led to the development of her pressure sores.
Mr Cain said in the report that this case highlights the need for a comprehensive adult safeguarding framework to protect at-risk adults.
“Victoria does not have a comprehensive adult safeguarding framework for protecting at-risk adults from abuse, neglect and exploitation. Therefore, if PLK or YTR’s GP wanted to raise concerns about YTR’s wellbeing, there was no specific agency that they could contact,” it reads.
“If adult safeguarding legislation and/or an agency were implemented in Victoria, YTR would have likely met the criteria for an adult safeguarding response due to her care and support needs, her mental health conditions, her immobility, her risk of experiencing neglect and the fact that her care and support needs likely would have prevented her from protecting herself.”
“At-risk adults, particularly those who live in their own homes, continue to experience abuse and neglect at the hands of people known to them, and the service sector is not equipped to respond to this risk.”
Mr Cain cited a previous finding of his where he made 10 recommendations to the Office of the Public Advocate (OPA) and the Department of Families, Fairness and Housing (DFFH) under similar circumstances. The DFFH responded that those recommendations had been taken into account and that the Victorian Government is working with the Disability Reform Ministerial Council in responding to the Disability Royal Commission, which also recommended adult safeguarding legislation. Mr Cain endorsed recommendations four to 10 of his previous finding in relation to YTR’s case.
