Coroner's Finding: DAVIES Brian

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 28th day of May and the 2nd day of November 2020, by the Coroner’s Court of the said State, constituted of Brian Malcolm Nitschke, Deputy State Coroner, into the death of Brian Davies.

The said Court finds that Brian Davies aged 79 years, late of 1614 Main North Road, Brahma Lodge, South Australia died at Noarlunga Hospital, Alexander Kelly Drive, Noarlunga Centre, South Australia on the 19th Day of March 2019 as a result of myocardial infarction. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Brian Davies was born on 23 April 1939 and died on 19 March 2019 at the Noarlunga Hospital. He was 79 years old.

1.2. A pathology review based upon Mr Davies’ medical records and case notes was undertaken by Dr Iain McIntyre in consultation with Associate Professor Neil Langlois, forensic pathologist, from Forensic Science South Australia. An autopsy was not recommended as the cause of death could be determined from the medical notes. In accordance with the review I find the cause of Mr Davies' death to have been myocardial infarction.

2. Reason for inquest 2.1. As Mr Davies was subject to an Inpatient Treatment Order (ITO) under the Mental Health Act 2009 at the time of his death, his was a death in custody requiring a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003.

2.2. A Level 1 ITO had been made by Dr Katherine Flynn at the Flinders Medical Centre on 9 March 2019 and confirmed by psychiatrist, Dr Richard Weeks, on the same day.

That order expired on 15 March 2019. On that date, a Level 2 ITO was made by consultant psychiatrist, Dr Rasa Hiremani.1 This was the order current at the time of Mr Davies’ death.

3. Background and medical history 3.1. Mr Davies was father to two sons, Greg and Phillip. He had resided in his home at Brahma Lodge for 35 years. Mr Davies’ partner, Greta Hart, passed away on 3 March 2019, sixteen days before his own death.2

3.2. Mr Davies’ general practitioner, Dr Kin Chan, provided a statement to the Court dated 18 July 2019.3 His first consultation with Mr Davies was on 16 August 2017.

3.3. Mr Davies’ had no medical history of any great concern. When Dr Chan first examined Mr Davies he noticed deficits in his memory that appeared to be consistent with mild dementia. A Mini Mental State Examination was conducted by Dr Chan on 17 January 2018 with results suggestive of a mild cognitive impairment.

3.4. Dr Chan wrote to the Department of Planning, Transport and Infrastructure on 15 October 2018 expressing concerns about Mr Davies’ ability to drive. Mr Davies’ licence was cancelled in February 2019, although Mr Davies did not understand this and thought he could still drive.

3.5. Dr Chan referred Mr Davies for an Aged Care Assessment through SA Health on 28 February 2019 citing concerns over apparent moderate to severe dementia with worsening cognition, into which Mr Davies had no insight.

3.6. Mr Davies’ son Greg and his daughter-in-law noticed a marked decline in Mr Davies’ cognitive function, memory and self-care following the passing of his partner on 3 March 2019.4 1 Exhibit C10a 2 Exhibit C6 3 Exhibit C7 4 Exhibit C6

3.7. On 7 March 2019 Mr Davies’ daughter-in-law contacted Dr Chan to express these concerns and was advised to take Mr Davies to hospital for an assessment.5 Mr Davies was taken to the Emergency Department of the Flinders Medical Centre by his daughter in law.6

4. Mr Davies’ admissions to Flinders Medical Centre and Noarlunga Hospital 4.1. Dr Dhanashri Desai provided a detailed statement setting out Mr Davies’ treatment at the Flinders Medical Centre and subsequently the Noarlunga Hospital prior to his death, based on the medical case notes.

4.2. When Mr Davies arrived at Flinders Medical Centre he was examined by the on-duty doctor and found to be disorientated with poor attention. There was no apparent focal neurological deficit and Mr Davies’ blood tests on admission did not suggest any cause for his apparent cognitive decline. A chest X-ray showed no evidence of infection or heart failure and his electrocardiogram was normal.

4.3. A Mini Mental State Examination was conducted by an occupational therapist, the results of which suggested that Mr Davies had moderate cognitive impairment.

4.4. On 9 March 2019 Mr Davies exhibited verbally aggressive behaviour; swearing at staff and wandering around the hospital. Mr Davies appeared paranoid and disorientated and attempted to abscond from the ward. A code black was initiated by staff and Mr Davies was returned to his room. Mr Davies required one-on-one monitoring by a nurse special as his behaviour was unsettled.

4.5. Mr Davies was assessed by Dr Katherine Flynn, a geriatric consultant from the Flinders Medical Centre Older Persons Assessment and Liaison team. Mr Davies was agitated when being examined and tried to abscond. He was not aware of his reason for admission and had no insight into his cognitive deficits. Mr Davies was agitated and resistive to care.

4.6. Dr Flynn diagnosed Mr Davies with most likely Alzheimer’s dementia with moderate severity and placed Mr Davies under the Level 1 ITO. This was because of concerns 5 Exhibit C7 6 Exhibit C11

regarding his safety due to his lack of insight and previous attempts to abscond from the ward.

4.7. On 9 March 2019 psychiatrist Dr Richard Weeks assessed Mr Davies at the Flinders Medical Centre. Dr Weeks was of the view that Mr Davies suffered moderately advanced Alzheimer’s dementia and confirmed the ITO. The practical effect of this order was to enable Mr Davies to be safely and effectively assessed and managed in circumstances where he had stated a desire to leave the hospital, had attempted to abscond against medical advice, was demonstrating impulsive and labile behaviour and had impaired judgment arising from his confused state. Mr Davies was unable to make appropriate decisions for himself about his health care needs.7

4.8. Mr Davies was transferred to a specialised behaviour management ward, the Myles Ward, at the Noarlunga Hospital on 9 March 2019.8 Upon arrival Mr Davies remained paranoid and resistive to examination. His vital signs were stable and he was not in any obvious distress.

4.9. Mr Davies’ behaviour escalated on the evening of 9 March 2019 and a code black was called. Mr Davies wanted to leave the ward and had called 000 for help. He refused oral Oxazepam, a benzodiazepine designed to reduce his anxiety, and was subsequently provided subcutaneous Clonazepam. Mr Davies settled for two hours before his behaviour again deteriorated. He attempted to abscond and, in doing so, was threatening to staff, hitting the front nurses’ station windows with his fists in an apparent attempt to gain access to the nursing station.

4.10. Security guards helped secure Mr Davies and he was administered further Clonazepam.

This again subdued him for a period of a two hours or so before he required a further dose. Five staff members were required to hold him while the medication was administered.

4.11. At 8:30am on 10 March 2019, a nurse observed that Mr Davies had tachycardia with an irregular pulse. He was complaining of feeling awful and having abdominal pain so an ECG was performed. This which was suggestive of a Non-ST-elevation myocardial infarction (NSTEMI). Mr Davies was transferred to the Flinders Medical Centre for 7 Exhibit C5 8 Exhibits C4 and C12

treatment following consultation with the on-call cardiology registrar at the Flinders Medical Centre.

4.12. Mr Davies was seen by the cardiology team registrar at the Flinders Medical Centre at 12:10pm on 10 March 2019 and a diagnosis of NSTEMI with rapid atrial fibrillation was made. He was treated with medication.9

4.13. A code black was called at 2pm due to Mr Davies’ agitated behaviour. He was administered haloperidol and remained calm until 9:35pm when a further code black was initiated.

4.14. On 11 March 2019, Dr Minson, a cardiology consultant, assessed Mr Davies and recorded his vital signs as stable. Mr Davies’ difficult and disturbed behaviour continued and a further code black was called at 11:05pm that day.

4.15. A meeting was held on 12 March 2019 involving the cardiology team, a social worker, Mr Davies’ son Greg and his partner. The cardiology team recommended that Mr Davies’ condition be managed through medication rather than surgery as he was not suitable for invasive intervention with coronary angiography. Mr Davies’ family agreed.10 A further code black was called at 1pm on 12 March 2019.

4.16. Mr Davies was returned to the Myles Ward at Noarlunga Hospital on 12 March 2019.

His vital signs were stable at that time. On 13 March 2019 Mr Davies’ vital signs remained stable and there were no signs of cardiorespiratory distress.

4.17. On 14 March 2019 Mr Davies’ vital signs remained stable, but his poor behaviour continued. Nurses administered 0.25mg of risperidone in error and notified a doctor.

Mr Davies was reviewed by the registrar at 3:45pm. His vital signs were stable and he was settled.11 Mr Davies’ daughter in-law was advised of the medication error.

Mr Davies’ vital signs remained stable at 4:49pm on 14 March 2019.

5. Mr Davies’ ultimate decline 5.1. On the morning of 18 March 2019 Mr Davies’ vital signs were stable and his cardiorespiratory examination was normal. A medical officer updated his daughter-inlaw about the medical issues, updated list of mediations and explained the risk of using 9 Exhibits C4 and C12 10 Exhibit C6 11 Exhibit C4 - Long term usage of risperidone can increase the risk of cardiovascular side effects like arrhythmia, cardiac arrest. Dr Desai advised that the low single dose of Risperidone would not directly contribute to Mr Davies’ death

antipsychotics, including increased risk of cardiac events. Mr Davies’ daughter-in-law agreed that his behaviours were impacting on his safety and quality of life and he needed the antipsychotic medications to settle his behaviour notwithstanding the risks.12

5.2. On 19 March 2019 Mr Davies was seen by the registrar during the morning ward round.

He appeared distressed with abdominal pain, but his vital signs were stable. Tests suggested that Mr Davies had suffered a further NSTEMI. Contact was made with Mr Davies’ daughter-in-law to discuss the goals of care for Mr Davies given his poor quality of life. Mr Davies’ daughter-in-law preferred that he was not transferred back to the Critical Care Unit as he was not to be subject to any invasive interventions. The desire was expressed that Mr Davies remain on the Myles Ward at the Noarlunga Hospital.

5.3. Mr Davies’ family were advised that without cardiac monitoring at Flinders Medical Centre doctors would not be able to tell if Mr Davies was developing a fatal irregular heart rhythm. The family understood this and reiterated that Mr Davies should remain at the Myles Ward. The focus of care was then on managing his symptoms and keeping him comfortable.

5.4. Mr Davies’ vital signs were normal when checked at about 4pm on 19 March 2019 and at 6:15pm he was observed walking around his room without distress. He was subsequently seen sitting with other patients watching television in the lounge room.13

5.5. At 7pm that evening Mr Davies was found unresponsive in the lounge room by nursing staff with shallow breathing. The on-duty medial officer, Dr Ellen Dunaiski, was called and she certified Mr Davies as deceased at 7:25pm.14

6. Coronial investigation 6.1. Detective Brevet Sergeant Andrew Plumb of the Northern Criminal Investigation Branch of SAPOL investigated the death in custody of Mr Davies and prepared a comprehensive report for the State Coroner.15 12 Exhibit C12 13 Exhibit C3 14 Exhibit C3 and Death Report to Coroner - Medical Practitioner’s Declaration 15 Exhibit C10

6.2. Detective Plumb considered Mr Davies was in lawful detention at the time of his death and he found no issues of concern regarding the treatment of Mr Davies at either the Flinders Medical Centre or the Noarlunga Hospital.

6.3. No concerns have been raised by the family of Mr Davies. In his statement, Mr Davies’ son Greg said that he had no complaints at all about the service the staff and doctors provide to Mr Davies whilst he was at either the Flinders Medical Centre or the Noarlunga Hospital.16

7. Conclusions 7.1. In the period before his death Mr Davies displayed behaviours that were manifestations of his illness and not indicative of his usual demeanour. Naturally, they are no reflection upon the good character that he had displayed during his life.

7.2. I find that Mr Davies was in lawful detention at the time of his death. I further find that the care and treatment provided to Mr Davies during his admissions to both the Flinders Medical Centre and the Noarlunga Hospital was appropriate.

7.3. I have no recommendations to make in this matter.

Key Words: Death in Custody; Natural Causes; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 2nd day of November, 2020.

Deputy State Coroner Inquest Number 72/2020 (0564/2019) 16 Exhibit C6