Coroner's Finding: SHAW Laurel Jean

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 11th day of June and the 9th day of July 2020, by the Coroner’s Court of the said State, constituted of Simon James Smart, Deputy State Coroner, into the death of Laurel Jean Shaw.

The said Court finds that Laurel Jean Shaw aged 84 years, late of 9 Abernathy Avenue, Port Augusta, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 20th day of May 2018 as a result of multiorgan failure arising from Staphylococcal septicaemia. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Laurel Jean Shaw was born on 9 October 1933 and died on 20 May 2018 at the Flinders Medical Centre (FMC). She was 85 years of age. Mrs Shaw’s body was identified by her relative, Darryle Shaw.1

1.2. A pathology review of Mrs Shaw’s clinical history and medical records was undertaken by Dr Iain McIntyre of Forensic Science South Australia in discussion with Dr Cheryl Charlwood, forensic pathologist.2 In his report of that review Dr McIntyre has stated the cause of Mrs Shaw’s death as multi-organ failure arising from Staphylococcal septicaemia, and I so find.

1.3. Dr McIntyre noted from Mrs Shaw’s medical records that from 4 April 2018 to 15 May 2018 Mrs Shaw was managed at Noarlunga Health Services, however on 15 May 2018 1 Exhibit C6 2 Exhibit C1

she deteriorated with abrupt desaturation and signs of lower lobe pneumonia and was returned to the Flinders Medical Centre. Blood, tracheal aspirate and sputum cultures grew Methicillin Resistant Staphylococcus Aureus. Mrs Shaw developed Adult Respiratory Distress Syndrome and acute-on-chronic renal failure which required intubation and high dose cardiovascular support with intravenous antibiotics.

Mrs Shaw developed lactic acidosis which worsened in spite of treatment. A CT scan of the abdomen showed no mesenteric ischaemia. As the cause of Mrs Shaw’s death could adequately be determined from the medical records an autopsy was not recommended.

2. Reason for inquest 2.1. Mrs Shaw’s death was the subject of a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mrs Shaw was detained under an Inpatient Treatment Order (ITO) pursuant to section 21 of the Mental Health Act 2009 at the time of her death. The Level 1 ITO had been instituted on 28 March 2018 following Mrs Shaw’s presentation to the Port Augusta Hospital on 27 March 2018 with an ongoing mental health episode that involved auditory and visual hallucinations.3

2.2. Mrs Shaw was transferred to the Flinders Medical Centre on 29 March 2018 so that she could receive appropriate psychiatric care. She was subsequently diagnosed with Lewy Body Dementia. Mrs Shaw was detained under a Level 2 ITO pursuant to section 25 of the Mental Health Act 2009 on 4 April 2018. This was the order in effect at the time of her death on 29 May 2018. There are no concerns in relation to the lawfulness of custody.

3. Background and medical history 3.1. Mrs Shaw was an elderly widow who lived independently in Port Augusta.4 She was mother to five children, eight grandchildren, seven great grandchildren and one great great grandchild. Mrs Shaw’s everyday living was of a high standard of independence and she managed her own finances, drove her own vehicle and mobilised without support. Mrs Shaw cooked, gardened and attended regular social commitments. She appeared to lead a healthy lifestyle.5 3 Exhibit C5 4 Exhibit C3 5 Exhibit C4

3.2. On 21 December 2017 a referral was made by the Port Augusta Hospital to the Community Mental Health Team in relation to concerns surrounding Mrs Shaw’s mental health. At that time Mrs Shaw was an inpatient in the Port Augusta Hospital having experienced auditory hallucinations. Mrs Shaw’s auditory hallucinations had her engaging with and becoming fixated on a male person called ‘Matthew Johnson’.

3.3. On 22 December 2017 Rebecca Mason, Mrs Shaw’s assigned social worker, met her for the first time at the Port Augusta Hospital. Over the following months Ms Mason continued to care for and assist Mrs Shaw in accessing and attending health professionals for treatment. Mrs Shaw was regularly consulting with Dr Anumpam Shivashankaraiah.

4. Mrs Shaw’s clinical circumstances 4.1. On 27 March 2018 Mrs Shaw presented at the Port Augusta police station having been told to attend by ‘Matthew’ and genuinely believing ‘Matthew’ was also present at the station. Ms Mason, her social worker, attended the police station and arrangements were made for Mrs Shaw to attend at Port Augusta Hospital.

4.2. On 28 March 2018 Mrs Shaw was assessed by Dr Hannah Myles as part of the ‘Telepsych’ service through Community Mental Health whilst at the Port Augusta Hospital. This resulted in the decision that Mrs Shaw should be admitted to the Hospital and placed under a Level ITO.6 Mrs Shaw remained at the Port Augusta Hospital until the decision was made to transfer her to the Flinders Medical Centre on 29 March 2018 for further treatment.7

4.3. Following her admission to the Flinders Medical Centre, Mrs Shaw was diagnosed with Lewy body dementia, a progressive neuro degenerative disease resulting in dementia and functional decline. She presented with a number of co-morbidities, namely peripheral vascular disease, and was noted to have a chronic leg ulcer.8

4.4. Mrs Shaw was admitted to ward 18 which is a new addition housing patients who previously would have been referred to the Repatriation General Hospital. Mrs Shaw’s insight was poor and the ITO remained in place.

6 Exhibits C4 and C5 7 Exhibits C3 and C5 8 Exhibit C3

4.5. On 14 May 2018 Mrs Shaw was developing an infection and on 15 May 2018 she was rushed to the Intensive Critical Care Unit (ICCU) following a MET9 call to her bedside in ward 18. She was found by medical staff to be hypoxic and developing sepsis.

Mrs Shaw required immediate medical treatment. Upon arrival in ICCU Mrs Shaw was intubated and given nitric oxide for her severe hypoxia and high oxygen requirement.

She had a significant inotropic requirement with worsening lactic acidosis.

4.6. A CT scan of her abdomen excluded significant mesenteric ischaemia. Following a chest X-ray she exhibited signs of left lower lobe pneumonia. Blood cultures revealed Methicillin Resistant Staphylococcus Aureus (MRSA) which appeared to have evolved during the previous 24 hours.10

4.7. Mrs Shaw was treated by medical staff with the primary goal being to return her to independent living. Although she had a very severe disease, she had a potentially reversible cause and there was a chance she would survive. There were however concerns that if she improved slowly, failed to respond to treatment or had a prolonged stay in the ICCU it was likely she would not regain enough strength to return to Port Augusta, particularly in light of her Lewy body dementia.

4.8. Treating doctors discussed Mrs Shaw’s medical circumstances with her family who made it clear that they did not wish for aggressive ICCU support if Mrs Shaw was not able to return to independent function. A do not resuscitate direction was in place. It was decided that aggressive and quick treatment be undertaken in the hope Mrs Shaw would make a speedy enough recovery to return to independent living.

4.9. Despite treatment Mrs Shaw improved only marginally over the next five days. Her response to treatment was not sufficiently rapid and it was clear that survival would require an extended period of intrusive ventilation.

5. Mrs Shaw’s decline and death 5.1. On 20 May 2018 Mrs Shaw remained in the ICCU with one-on-one care from nursing staff. Her care on that day was assigned to Registered Nurse Lauren McDonnell.11

5.2. During the course of Ms McDonnell’s shift Mrs Shaw’s family were in constant attendance. Dr Tim Weir had a number of discussions with them regarding Mrs Shaw’s 9 Medical Emergency Team 10 Exhibit C3 11 Exhibit C2

poor prognosis and the prospect of withdrawal of life support. At 2:45pm Mrs Shaw’s family consented to the withdrawal of life support. Her sedation was ceased, she was intubated and inotropic supports were ceased.12 Mrs Shaw passed away quickly and peacefully in the presence of her family. Dr Weir pronounced Mrs Shaw’s life extinct at 3:47pm.13

6. Coronial investigation 6.1. Detective Brevet Sergeant Peter Moore from the Coronial Investigation Section of SAPOL was appointed to investigate Mrs Shaw’s death in custody. Detective Moore conducted a thorough investigation and provided a report for the State Coroner which was tendered to the inquest.14

6.2. Detective Moore’s investigation concluded that the care provided to Mrs Shaw whilst she was detained was appropriate and that the detention order was lawful. No concerns relating to care were raised by Mrs Shaw’s next of kin. Mrs Shaw’s son did however express concern as to how Mrs Shaw acquired the Staphylococcus Aureus infection.

7. Conclusion and recommendations 7.1. Consistent with the views of Detective Moore I find that Mrs Shaw’s detention was lawful and did not contribute to her death. I further find that the care and treatment she received during her period of detention was appropriate in the circumstances.

7.2. I have no need to make any recommendations 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 9th day of July, 2020.

Deputy State Coroner Inquest Number 49/2020 (0876/2018) 12 Exhibits C2 and C3 13 Exhibit C2 14 Exhibit C6