Coroner's Finding: CLAYTON James Edmund

CORONERS ACT, 2003 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 day of July 2015 and the 19th day of August 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of James Edmund Clayton.

The said Court finds that James Edmund Clayton aged 59 years, late of Helping Hand Aged Care, 37 Sussex Street, Glenelg, South Australia died at Helping Hand Aged Care, 37 Sussex Street, Glenelg, South Australia on the 3rd day of March 2013 as a result of ischaemic heart disease due to coronary atherosclerosis. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. James Edmund Clayton died on 3 March 2013. He was 59 years of age. Mr Clayton suffered from a number of medical conditions, including ischaemic heart disease, paranoid schizophrenia, unstable type 2 diabetes, peripheral vascular disease and chronic renal failure requiring haemodialysis. As a result of these medical conditions Mr Clayton was prescribed numerous medications by doctors at the Flinders Medical Centre.

1.2. At the time of his death Mr Clayton was subject to a detention order pursuant to section 32 of the Guardianship and Administration Act 1993. This order required him to be detained at the residential facility. By virtue of the orders under this Act Mr Clayton was, in the eyes of the law, regarded as under detention at the time of his death. Accordingly his was a death in custody within the meaning of that expression

in the Coroners Act 2003 and this Inquest was held as required by section 21(1)(a) of that Act, and for no other reason.

2. Background 2.1. Mr Clayton was the youngest of five children. His parents separated when he was 5 years old and this loss apparently affected him greatly.

2.2. In 1963 Mr Clayton's mother remarried and gave birth to two more children. Three years after the marriage Mr Clayton's stepfather died. Sadly, Mr Clayton witnessed and was a victim of domestic violence at the hands of both his father and stepfather.

2.3. As a youth Mr Clayton often came to the attention of the South Australian police and spent time in detention at Windana Reform School. At the age of 15 Mr Clayton left school and for the next four years he was employed as a painting contractor.

2.4. In 1982 Mr Clayton was diagnosed with paranoid schizophrenia. He became aggressive and experienced religious delusions. At this stage his illness was being managed by the Hillcrest Mental Health facility. In that same year his mother applied to have him placed under guardianship.

2.5. During his life Mr Clayton was transient and lived in various boarding houses and often spent time living on the streets. Prior to his death he resided at Glenelg House, a supported residential facility owned by Helping Hand. Mr Clayton was admitted to Glenelg House on two separate occasions, the first admission was from 18 June 2010 to 24 May 2012. The second admission was from 24 September 2012 until his death on 3 March 2013.

2.6. Whilst residing at this facility Mr Clayton attended the Flinders Medical Centre three times a week for renal dialysis. He had been undergoing this treatment for some three years.

2.7. It was well-known by staff at Glenelg House that Mr Clayton did not want to be housed there as he thought he was capable of living independently. Further, he was sometimes difficult with staff and would not take his medication as required.

2.8. Over the years the Guardianship Board made orders with respect to Mr Clayton, including a community treatment order, administration order with the Public Trustee, and the appointment of a guardian being the Office of the Public Advocate. At the time of his death Mr Clayton was subject to an order empowering his guardian to give directions as to his placement and residence.

2.9. Prior to his death Mr Clayton was admitted to the Flinders Medical Centre from 6 February 2013 to 11 February 2013 with a silent myocardial infarction.

Echo-cardiology showed severe left ventricular dysfunction with a very poor ejection fraction.

2.10. Unfortunately, Mr Clayton became agitated and unhappy during his admission and discharged himself from hospital against medical advice and before a coronary angiography could be performed. Mr Clayton returned to Glenelg House.

3. The events of 3 March 2013 3.1. In 2013 Ms Debbie Newell was a carer at Glenelg House. On 3 March 2013 she was working at the facility and she saw Mr Clayton at about 5:45pm. At the time she observed him outside the facility obtaining a mop. Mr Clayton told Ms Newell that he had vomited some of his renolin (a liquid nutritional supplement that Mr Clayton was taking to assist with weight gain on the advice of his nutritionist).

3.2. At around 6pm Ms Newell heard Mr Clayton making a loud grunting sound in a disabled toilet. Ms Newell went to check on Mr Clayton and found him with his head slumped back and eyes rolled back. She immediately called an ambulance. Mr Clayton was gasping for air and quickly became unresponsive.

3.3. Ambulance officers arrived and treated Mr Clayton but their attempts at resuscitation were unsuccessful.

4. Cause of death 4.1. Dr John Gilbert, a forensic pathologist at Forensic Science South Australia, performed the autopsy on Mr Clayton. He determined the cause of death as being ischaemic heart disease due to coronary atherosclerosis. Autopsy examination revealed a large area of

recent myocardial infarction involving a posterior receptacle region of the left ventricle, and the adjacent posterior wall of the right ventricle. Analysis of a specimen of vitreous humor showed evidence of hypoglycaemia at the time of death. The urea and creatinine levels were raised in keeping with the presence of chronic renal failure.

Key Words: Death in Custody; Section 32 Powers; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 19th day of August, 2016.

State Coroner Inquest Number 9/2015 (0326/2013)