A coroner has found several shortcomings in the treatment provided to a Wangaratta woman in the lead up to her death.
Julie-Anne Marie Kettle, 56, lived in Department of Health and Human Services disability support accommodation on Williams Road.
She died in hospital from bronchopneumonia on March 4, 2018.
High levels of lithium were detected after her death.
The Victorian coroner investigated her passing given Ms Kettle was in care.
The 56-year-old was intellectually disabled, had limited communication skills and a range of health problems.
Coroner Katherine Lorenz said she was concerned about the treatment provided by DHHS, including the unauthorised use of restrictive interventions, a failure to treat her swollen legs in a timely way, management of her risk of falling, management of her behaviours, and inadequately addressing issues she had with another resident.
There was also a delay in providing her with compression tights.
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She was taken to Wangaratta hospital two days before her death amid concerns about elevated lithium levels, which she was prescribed by a psychiatrist.
While the coroner raised concerns about her treatment, she said the issues did not contribute to her death.
"Julie-Anne had complex physical and intellectual disabilities and required assistance with all the activities of daily life, including assistance in accessing medical attention and treatment," Ms Lorenz said.
"She was entirely dependent (on) others for her care and wellbeing.
"The coronial investigation and the earlier investigation by the Disability Services Commissioner identified a number of shortfalls in the care provided by DHHS at the group home where Julie-Anne resided.
"None of these shortfalls directly related to either the cause of death or the circumstances of the death, but nonetheless are cause for concern in the context of caring for residents with complex needs, such as Julie-Anne."
The coroner said the department had made "appropriate concessions" about the issues and said the problems had been addressed.
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