Coroner's Finding: KOLAN Zygmunt

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 September 2020 and the 30th day of June 2021, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Zygmunt Kolan.

The said Court finds that Zygmunt Kolan aged 91 years, late of Oakden Green Nursing Home, 75-79 Hilltop Drive, Oakden, South Australia died at Oakden, South Australia on the 10th day of March 2017 as a result of intracranial haemorrhage (subdural, subarachnoid and parenchymal) complicating recurrent falls on a background of Alzheimer's dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Zygmunt Kolan was born on 10 July 1925 and died at the Oakden Green Nursing Home on 10 March 2017, aged 91 years.

1.2. A Forensic Science SA pathology review report was provided by Dr Iain McIntyre, in consultation with specialist forensic pathologist Dr Karen Heath.1 The opinion given as to cause of death was intracranial haemorrhage (subdural, subarachnoid and parenchymal) complicating recurrent falls in a man with Alzheimer's dementia.

1.3. Mr Kolan’s death falls within the definition of a ‘death in custody’ in the Coroners Act 2003, requiring that an inquest be held to determine the cause and circumstances of his death. At the time of his death Mr Kolan was subject to a guardianship order with 1 Exhibit C1

special powers of detention, pursuant to section 32(1)(b) of the Guardianship and Administration Act 1993, and his death was not from natural causes.

2. Background 2.1. Mr Kolan was of Polish origin. His wife passed away in 2015. He had no children or other family in Australia and, following his wife's death, he lived alone.

2.2. Jennifer Bennetts, coordinator of home care packages at the Federation of Polish Organisations in South Australia Inc., provided a statement.2 She states that an assessment of Mr Kolan was conducted on 26 May 2015, and a level 2 care package was allocated on 5 June 2015. This included four hours of assistance per week, including domestic assistance, transport, meals and banking. In September 2016, Mr Kolan signed for a level 4 care package, which increased the hours of assistance to ten hours per week.

3. Mr Kolan’s admission to the Royal Adelaide Hospital and SACAT order 3.1. On 4 January 2017, a care worker reported Mr Kolan's absence from his home. He was later located at the Royal Adelaide Hospital, where he had been taken the previous night, after calling an ambulance. During that hospital visit, he was diagnosed with prostate cancer and Alzheimer's dementia.3

3.2. On 17 January 2017, an application was made for the appointment of an administrator and guardian and for special powers of residence, detention, treatment and care. The application was made by a social worker at the Royal Adelaide Hospital, where Mr Kolan remained an inpatient.4 On 9 February 2017 the application was heard by the South Australian Civil and Administrative Tribunal (SACAT) with input from the social worker from the Royal Adelaide Hospital and Mr Kolan’s coordinator from the Federation of Polish Organisations in South Australia. Orders were made, namely a limited guardianship order pursuant to section 29 of the Act, appointing the Public Advocate as guardian, a full administration order pursuant to section 35 of the Act, appointing the Public Trustee as administrator and a special powers order in accordance 2 Exhibit C4 3 Exhibit C8 4 Exhibit C5

with section 32(1)(b) of the Guardianship and Administration Act, providing that Mr Kolan could be detained at the place at which he resided.5

4. Mr Kolan’s placement at Oakden Green 4.1. On 22 February 2017, Mr Kolan was discharged from the Royal Adelaide Hospital to respite care at the Oakden Green Nursing Home. Delores Coleman, a registered nurse, was site manager and stated that his records indicate that Mr Kolan had had many falls prior to his transfer to the facility, so he had a floor mat and a bell installed, to notify staff when he was attempting to get out of bed unassisted.6 His bed was also set at the lowest setting. As Mr Kolan would not use his walker and was unsteady on his feet, he was checked on every 30 minutes.

4.2. At about 6:30am on 5 March 2017, Mr Kolan was noted to have been lying in bed. By 6:50am on that same date, he was found lying on his left side, on the floor near his bed.

He was bleeding from the nose, he had a skin break on his left elbow and a bump to his head. An ambulance was called and he was transferred to the Royal Adelaide Hospital.

A CT scan of the brain revealed an acute right temporal lobe intra-axial haemorrhage and an acute-on-chronic subdural haematoma over the right temporo-parietal lobes with slight extension. The intra-parenchymal haemorrhage was treated conservatively and on this occasion his warfarin was stopped after a risk/benefit analysis due to his frequent falls. He was delirious and this was thought to be secondary to the haemorrhage. He also had a febrile episode for which no cause was found and all cultures were sterile.

4.3. On 7 March 2017, he was returned to the Oakden Green Nursing Home, following the resolution of his complications. On that date, he suffered another fall while attempting to walk to the bathroom. He was found face-down and bleeding from his left forehead.

He was treated with a cold pack and an ambulance was called and took him again to the Royal Adelaide Hospital. The incident reports from the falls on 5 March and 7 March at Oakden were received in evidence.7

4.4. On this occasion he was found to have multiple facial fractures and a left shoulder dislocation. A CT scan of the brain showed acute bilateral subdural haemorrhages.

There were multifocal haemorrhagic contusions in both frontal and the left parietal 5 Exhibits C5 and C10 6 Exhibit C2 7 Exhibits C2a and C2b

lobes, acute subarachnoid haemorrhages and a stable right intraparenchymal haemorrhage.

4.5. Mr Kolan's treating clinician, Dr Jane Conway noted that Mr Kolan had other major comorbidities, including what was stated to be a metallic aortic valve, which she could not locate on his X-rays, a pacemaker, and metastatic prostate cancer with bony metastases.8 He was also highly dependent for mobility and he required assistance generally. In addition, he took anticoagulation medication.

4.6. Dr Conway explains that the anticoagulation was a complicating factor with his falls.

This was a difficult situation to manage, as the primary reason for him being on anticoagulation medication was the high clot risk presented by his metallic aortic valve replacement, and reversing the anticoagulation thus posed a risk of clotting around the valve.

4.7. Palliative care was decided to be the best course of action, due to his comorbidities, recurrent falls and the issues with anticoagulation.

4.8. On 9 March 2017, Mr Kolan was again returned to the Oakden Green Nursing Home, for palliative measures only, with morphine if needed and instructions for comfort feeding only, as he was assessed as having an unsafe swallow.

4.9. Mr Kolan passed away at 6:30pm on 10 March 2017.

5. Conclusion 5.1. I find that the cause of Mr Kolan’s death was intracranial haemorrhage (subdural, subarachnoid and parenchymal) complicating recurrent falls on a background of Alzheimer's dementia.

5.2. The investigation report prepared by Detective Brevet Sergeant Liouxeese Hadley found that there was nothing to suggest that the care and treatment at the Royal Adelaide Hospital was not appropriate.9 I agree, and find that Mr Kolan’s care at the Royal Adelaide Hospital was appropriate. There was no indication of suspicious circumstances or any involvement of a third party at any time. The Guardianship and Administration Act orders, including the special powers order in accordance with 8 Exhibit C3 9 Exhibit C6

section 32(1)(b) were appropriate in the circumstances. Mr Kolan’s care and treatment at the Oakden Green Nursing Home were appropriate. There were no identified issues with his treatment and all reasonable protective measures were employed to minimise opportunities for injuries due to his falls.

5.3. I make no recommendations in this matter.

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 30th day of June, 2021 State Coroner Inquest Number 83/2020 (0461/2017)