Coroner's Finding: ADAMS Debra Louise

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 5th day of February 2019 and the 15th day of April 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Debra Louise Adams.

The said Court finds that Debra Louise Adams aged 52 years, late of 18A Jellicoe Street, Port Pirie, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 3rd day of September 2015 as a result of hepatic encephalopathy due to Childs C cirrhosis of the liver on a background of alcohol abuse, diabetes and hepatitis C. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for Inquest 1.1. Debra Louise Adams was 52 years of age when she died at the Royal Adelaide Hospital on 3 September 2015. The cause of Ms Adams’ death was established following a pathology review by Dr Iain McIntyre of Forensic Science South Australia. In his report1 Dr McIntyre gave the cause of death for Ms Adams as hepatic encephalopathy due to child C cirrhosis of the liver on a background of alcohol abuse, diabetes and Hepatitis C, and I so find.

1.2. At the time of her death Ms Adams was subject to a Level 1 Inpatient Treatment Order (ITO) that had been imposed pursuant to the Mental Health Act 2009. Her death was 1 Exhibit C2a

therefore a death in custody within the meaning of the Coroners Act 2003 and this inquest was held as required by section 21(1)(a) of that Act.

2. Background 2.1. Ms Adams lived at Port Pirie. There is scant information about her personal life. Her daughter, Ms Talbot-Adams provided a statement2. Ms Talbot- Adams stated that her mother drank alcohol every day in excess.

3. Ms Adams’ detention and decline in health 3.1. Dr Abbas is a general practitioner at the Port Pirie Medical Centre3. Dr Abbas saw Ms Adams on 25 August 2015. Ms Adams had attended complaining of pain in her legs and abdomen as well as bleeding from her mouth, vagina and anus. Dr Abbas was unable to establish the cause of Ms Adams’ symptoms and was concerned for her health. He advised that she should be admitted to hospital. Ms Adams agreed and blood samples were taken. She was conveyed to the Port Pirie Regional Health Service and admitted on the same day at 2:30pm.

3.2. Dr Abbas attended Ms Adams that evening armed with the result of the blood tests.

They revealed that Ms Adams was anaemic and suffering from severe liver disease.

Dr Abbas stated that she had advanced liver disease and these were causing the clinical symptoms. On 26 August 2015 a CAT scan was conducted which indicated she had chronic pancreatitis. On that day she also became more confused.

3.3. The following day, 27 August 2015, Dr Abbas contacted the Royal Adelaide Hospital and it was agreed to have her transferred. On 28 August 2015 Ms Adams was transferred to the Royal Adelaide Hospital by air ambulance.

3.4. The Royal Adelaide Hospital progress notes reveal Ms Adams was confused with decompensated chronic liver disease. She was difficult to examine and uncooperative.

On 28 August 2015 Ms Adams was detained under an ITO pursuant to the Mental Health Act 20094. It was noted Ms Adams was drowsy, uncooperative and refusing treatment, asking to leave and unable to appreciate the risk to her health.

2 Exhibit C3 3 Exhibit C5 4 Exhibit C7b

3.5. The ITO was confirmed by psychiatrist, Dr Onilov, on 29 August 2015 at 1335 hours.

Dr Onilov provided a statement5. Dr Onilov saw Ms Adams on 29 August 2015 to review the Level 1 ITO. Dr Onilov reviewed Ms Adams’ medical notes and noted she was suffering from quite severe liver disorder and had presented as confused and agitated. There was concern as to her capacity to accept treatment and she was quite agitated.

3.6. Dr Onilov did make an attempt to interview Ms Adams face to face but she was confused and unable to describe any coherent history at the time. Dr Onilov was of the impression that she was confused due to her medical condition and she was suffering from severe decompensated liver failure in an advanced stage of the disease. Dr Onilov considered the ITO allowed safe management of Ms Adams. Her judgment was severely impaired, she could not make sound decisions for herself. She would put herself at greater risk of harm should she not receive treatment. Dr Onilov confirmed the ITO.

3.7. The Royal Adelaide Hospital notes state that on 30 August 2015 Ms Adams was reviewed by MET for consideration of further intervention by the Intensive Care Unit (ICU). She was reviewed on the same day by the ICU team.

3.8. The remainder of the Royal Adelaide Hospital notes record a chronology of care provided to Ms Adams until she died on 3 September 2015.

4. Investigation and conclusions 4.1. Detective Sergeant Mildrum provided an investigation report into Ms Adams’ death in custody6. His report concluded the care and treatment provided to Ms Adams was appropriate at Port Pirie and Royal Adelaide Hospital. The Level 1 ITO was appropriate. Detective Sergeant Mildrum concluded that he did not identify any deficiencies in the care and attention afforded to Ms Adams while detained at the Royal Adelaide Hospital. I agree with Detective Mildrum’s conclusion.

5 Exhibit C4 6 Exhibit C7a

4.2. Mr Bailey Adams, son of Ms Adams, provided a statement to the Court7. He visited his mother on 1 September 2015 at the Royal Adelaide Hospital along with other family members. There were no concerns raised by Ms Adams’ family as to her care.

5. Recommendations 5.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Inpatient Treatment Order; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 15th day of April, 2019.

State Coroner Inquest Number 4/2019 (1581/2015) 7 Exhibit C1b