Coroner's Finding: RAU Edward Morgan

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 15th day of July 2016 and the 12th day of September 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Edward Morgan Rau.

The said Court finds that Edward Morgan Rau aged 77 years, late of Hammill House, 151 The Terrace, Port Pirie, South Australia died at the Port Pirie Regional Health Service, corner The Terrace & Alexander Streets, Port Pirie, South Australia on the 31st day of October 2014 as a result of aspiration pneumonia due to dysphagia on a background of dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Mr Edward Morgan Rau, aged 77 years, died on 31 October 2014 at the Port Pirie Regional Health Service hospital. At the time of his death Mr Rau was subject to orders under the Guardianship and Administration Act 1993. Because the orders in place contained provisions requiring Mr Rau to be and remain in a particular place he was, for legal purposes, under detention when he died. His was therefore a death in custody within the meaning of that expression under 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. Cause of Death 2.1. An opinion as to cause of death was provided by Dr Iain McIntyre of Forensic Science South Australia. Dr McIntyre’s pathology review report1 gives the cause of death as aspiration pneumonia due to dysphasia on a background of dementia, and I so find.

1 Exhibit C2a

3. Background 3.1. Mr Rau was diagnosed with dementia in April 2014 after his general practitioner noted that he had become dishevelled, malnourished and confused whilst living at home with his wife. In May 2014 Mr Rau was admitted to the Port Pirie Regional Health Service for multi-agency assessments and an aged care assessment to determine if he could be supported at home, or whether an aged care placement was necessary. These tests determined that neither Mr nor Mrs Rau were capable of looking after Mr Rau in the home.

3.2. On 29 May 2014 representatives from the health service made application to the Guardianship Board for the Public Advocate to be made Mr Rau's guardian, and that the guardian be given special powers under section 32 of the Guardianship and Administration Act 1993 requiring Mr Rau to be and live in a particular place.

Arrangements were subsequently made for Mr Rau to remain hospitalised until suitable accommodation could be found for him.

3.3. On 21 June 2014 he was admitted to Hammill House, an aged care facility attached to the Port Pirie Regional Health Service. Over the ensuing months Mr Rau's behaviour deteriorated and he became increasingly confused, disoriented, agitated, aggressive, incontinent and unsteady on his feet. He sustained a number of minor falls.

4. Mr Rau’s decline 4.1. In July 2014 Mr Rau began experiencing dysphasia. He was reviewed several times by a speech pathologist and was placed on a varied diet of soft food and thickened fluids.

On 6 October 2014 Mr Rau was admitted to the Port Pirie Regional Health Service suffering pneumonia, a chest infection and a urinary tract infection. A chest X-ray revealed his right lung base had atelectasis2. The likely cause was aspiration. He was put on a ‘nil by mouth’ diet and antibiotics were used to treat the infection. He was discharged a week later.

4.2. Once back at Hammill House Mr Rau's health continued to deteriorate. On 29 October 2014 he was again admitted to the Port Pirie Regional Health Service after choking on food. A speech pathologist reviewed him and determined that he was at significant risk of aspiration and needed to be admitted to hospital for intravenous fluids. He could no longer swallow properly.

2 Partial collapse or incomplete inflation of the lung

4.3. Throughout this admission Mr Rau's chest remained very congested and moist.

Nebulisers and oxygen were administered as required, and his mouth was regularly suctioned to ensure his airways were kept clear. At approximately 7am on Friday, 31 October 2014 nursing staff at the Port Pirie Regional Hospital found Mr Rau unresponsive in his bed. Life was certified extinct at 7:27am.

4.4. I have nothing to add.

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 12th day of September, 2016.

State Coroner Inquest Number 30/2016 (1902/2014)