Coroner's Finding: PRESCOTT John Victor Sheen

CORONERS ACT, 1975 AS AMENDED SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 7th and 24th days of March, 2000, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of John Victor Sheen Prescott.

I, the said Coroner, do find that John Victor Sheen Prescott, aged 78 years, late of Alexam Place Rest Home, 24 Hazel Road, Salisbury East, died at Alexam Place Rest Home on the 22nd day of March, 1998 as a result of suppurative bronchitis complicating chronic obstructive airways disease (emphysema). The circumstances of death were as follows:-

1. John Victor Sheen Prescott was a resident of Alexam Place Rest Home at Salisbury East. Alexam Place is a licensed supported residential facility as defined in the Supported Residential Facilities Act 1992 (“the SRF Act”).

2. Mr. Prescott died during the night of 21-22 March 1998. He was examined by Dr.

Ralph Vida, legally qualified medical practitioner, at 9.00a.m. on 22 March 1998, and due to the absence of all vital signs he certified his life extinct (Exhibit C.2).

3. A post mortem examination performed by Dr. R.A. James, forensic pathologist, on 24 March 1998 determined that the cause of death was suppurative bronchitis complicating chronic obstructive airways disease (emphysema). Dr. James found signs of very severe emphysema in Mr. Prescott’s respiratory system, which he described as “end-stage emphysematous disease” (Exhibit C.4a, p2). Dr. James commented:- “The deceased was an elderly male with severe natural disease including end-stage chronic obstructive airways disease and established cirrhosis of the liver. He has

developed terminal muscular wasting with gross dental caries and terminal suppurative bronchitis”. (Exhibit C.4a, p4).

4. In a Report of Death form to my office, Mr. Prescott’s general practitioner, Dr.

Anthony Teh, said that Mr. Prescott had been suffering from chronic obstructive airways disease. He said that he had been “self-managing” his medications including Salbutamol and Atrovent inhalers, and Prednisolone. He said:- “Last seen on 20/6/97 condition stable - not called to see recently as he was well - as informed by staff”. (Exhibit C.5b).

5. Dr. Teh’s comments about self-managing medication do not correspond with the Resident Service Plan prepared for Mr. Prescott (Exhibit C.6a), which provides that his medication was to be managed “by the SRF”. The plan was not signed by the resident, and therefore is not a “contract in writing” as required by the SRF Act, Section 38.

6. The prospectus for Alexam Place provides:- “Medication can either be administered by yourself or under the supervision of qualified nursing staff. Medication provided by the complex is dispensed by the complex’s pharmacist who places it in a dossette box for your convenience”. (Exhibit C.8, p9) The evidence suggests that the licensed manager of Alexam Place at the time the prospectus was drawn up, Ms. Clarice Radcliffe, was a qualified nurse, although her successors, Ms. Robyn Bennett and then Ms. Kathryn Symons, were not so qualified.

I draw this anomaly to the attention of the management of the facility, as Section 37 of the Act makes it an offence to make an untrue statement in the prospectus.

7. This issue achieved some importance at the inquest, since Dr. Anthony Teh told me that he was under the impression that the manager was a registered nurse (T.9). He relied upon the staff at Alexam Place to notify him if there had been a deterioration in the health of one of his patients. Although Dr. Teh visited Mr. Prescott on numerous occasions up until July 1997, he did not visit him between 11 July 1997 and Mr.

Prescott’s death in March 1998. He said:- “I assumed he was well. I’m not very sure, but on some occasions I would have asked about his condition as well on my visits there”. (T.19).

8. Dr. Teh continued to renew prescriptions for Mr. Prescott’s medication without examining him further. I consider that this is a particularly unwise practice. At the

very least, Dr. Teh should have satisfied himself of the qualifications of the staff at the rest home before relying upon them to bring matters to his attention. Ideally, he should have set in place a regime whereby he visited his patients, particularly those with chronic illness such as Mr. Prescott, on a regular basis. He told me that he now visits such patients every eight weeks and has set a system in place to ensure that this occurs (T.19). I think that this is a wise practice.

9. The cessation of calls to Dr. Teh corresponded in time (July 1997) with an absence of entries in Mr. Prescott’s casenotes (Exhibit C.6). Ms. Kathryn Symons, who was then the assistant manager at Alexam Place and has been the manager since December 1998, acknowledged that there were no entries concerning Mr. Prescott’s health in the casenotes between 30 July 1997 and Mr. Prescott’s death. There is an entry concerning a visit by his daughter in January 1998, and an entry about taking him to a bank once a fortnight on 5 February 1998, but apart from those two matters there is nothing. Having regard to the frequency of the entries before July 1997 (there are entries every few days prior to that), this is surprising.

10. Monitoring The responsibility for licensing and monitoring Alexam Place pursuant to the SRF Act was, in this instance, with the City of Salisbury (see Section 10). Mr. Mark George, an Environmental Health Officer employed by the City of Salisbury, conducted a regular assessment of the SRF’s in his area (there were only two) before the licences for the owner, manager and the facility were renewed.

11. Mr. George confirmed that a visit to Alexam Place took place on 12 June 1997.

12. Mr. George Walker, a qualified social worker and a person with wide experience in the aged care industry, explained in his report (Exhibit C.7a):- “In these monitoring visits, the facility is rated against sixteen broad objectives which encapsulate 306 specific standards addressing issues such as safety, security, building maintenance, hygiene, residents’ rights, nutrition, staffing, personal care and medication management”. (p.2)

13. Following the June 1997 visit, Alexam Place was rated as satisfactory in relation to eight objectives, relatively minor problems were identified in five other areas, and serious issues to be addressed immediately were identified in relation to three objectives. It was noted that one of the issues in the last category, requiring urgent

action, had been identified during the 1996 monitoring visit and had still not been rectified (it concerned a light near the medication locker).

14. In relation to medication/medication administration, the report required upgrades including that:-

• a care plan be developed for each resident and cross-referenced to the service plan;

• a policy regarding management of residents’ medication be included in residents’ service plans.

On the evidence before me, this was not implemented in the period between July 1997 and Mr. Prescott’s death.

15. The monitoring team also recommended:- “To ensure safety and accountability in the area, the evaluation team recommends that management of Alexam Place consider the ‘credentialling of care-workers’ being offered by the Royal District Nursing Service. Further information regarding this course can be obtained from the RDNS”.

I was told by Mr. George that this recommendation was complied with (T.62).

16. The monitoring visit in June 1998 was much less satisfactory. The facility was rated as satisfactory in relation to two objectives, relatively minor issues were identified in relation to a further seven issues, and serious issues requiring immediate action were identified in relation to seven major objectives. The report of the monitoring team said:- “After evaluation of conditions at Alexam Place the evaluation team was extremely disappointed in the apparent deterioration of conditions at the facility since the last evaluation visit. It is fully realised that economic and possible political decisions may have some bearing on the day to day operations of such facilities. However, regardless of any outside influences, conditions and values relating to care and safety of residents must take precedence”.

17. As a result of this assessment, a declaration was made that Alexam Place did not satisfy the standards provided by the SRF Act and Regulations, and conditions with compliance dates were placed on the facility licence. If these were not complied with, prosecutions could have been launched against the facility. Mr. George told me that all of the conditions were complied with (T.62).

18. Improvements at Alexam Place I was told both by Ms Symons and Mr George that considerable improvements have taken place at Alexam Place since the unsatisfactory outcome from the monitoring visit in June 1998. Ms Symons said that service plans have all been reviewed and rewritten for each resident, the casenotes are written in regularly and continually updated, doctors visit patients on a regular basis and, generally, every requirement discussed with the monitoring team from the Council has been complied with. Ms.

Symons also told me that there had been considerable improvements in the physical environment of the facility, including the replacement of floor coverings and the like.

19. Mr George confirmed that there had been a “marked improvement” in standards at the facility since 1998, and that the Council was now generally satisfied with the standard of care being provided (T.61).

20. Conclusion The evidence clearly demonstrates that there was a serious deterioration in the standard of care being provided to residents at Alexam Place between June 1997 and June 1998. Proper practices, including regular doctors’ visits, and maintenance of care plans and casenotes, fell into disuse. Ms. Symons told me that, as far as she was aware, Mr. Prescott’s condition remained stable throughout that period. There was no objective evidence to demonstrate this - in particular Dr. Teh was unable to verify this to be true. As a result he was unable to sign the death certificate. It transpired that Mr. Prescott was in the end-stages of a terminal illness. There is no evidence that any drop in standards at Alexam Place contributed to the cause of his death. I therefore make no such finding.

21. It is reassuring that, on the evidence of Ms. Symons and Mr. George, marked improvements have occurred since December 1998 when Ms. Symons took over as manager. The fact that the Council continues to monitor standards at the rest home in accordance with the SRF Act is also reassuring. In those circumstances, I do not consider it necessary to make recommendations pursuant to Section 25(2) of the Coroners Act.

Key Words: Supported Residential Facilities; Institution In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 24th day of March, 2000.

……………………………..……… Coroner Inq.No.7/2000