Coroner rules out malpractice after death of patient in Ballarat facility

According to a publication on the Coroners Court of Victoria website, Joseph David Jones died on December 6, 2022, while a patient at the Steele Haughton Residential Unit on Dana Street in Ballarat Central.

Mr Jones, who was suffering from manic and psychotic symptoms related to schizoaffective disorder, was involuntarily admitted to the facility on November 29, 2022.

During his time at the facility, Mr Jones' health was reviewed by medical officers, but he denied having shortness of breath, chest pain or palpitations.

On the morning of December 6, 2022, Mr Jones was found unresponsive by staff and was declared dead about 6.20am after receiving CPR from emergency services.

A subsequent post mortem found Mr Jones had underlying health conditions including congestive cardiac failure, atrial fibrillation, chronic obstructive pulmonary disease, diabetes and asthma.

The investigation also found the presence of seven different medications in his system at the time of death, but none were of a concerning level and all had been prescribed to Mr Jones.

As a result of these findings, coroner Ingrid Giles concluded Mr Jones died of natural causes.

"Having investigated the care provided to Mr Jones in the lead-up to his passing, I consider that the care and treatment provided by Grampians Health was appropriate," she said in the Coroners Court publication.

"Mr Jones was a complex patient who presented with acute mental health issues and multiple medical comorbidities, and who displayed challenging behaviours to his treating team.

"I convey my sincere condolences to Mr Jones' family for their loss."

Despite being of natural causes, Mr Jones' death was referred to the Coroners Court of Victoria under the Coroners Act 2008 which specifies it is mandatory to review the death of a person in care or custody.

Under this legislation, it is not required to hold an inquest if the coroner considers the death was due to natural causes.