Coroner's Finding: Bertram, Kerry Anne

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 May and the 10th day of June 2022, by the Coroner’s Court of the said State, constituted of Naomi Mary Kereru, Coroner, into the death of Kerry Anne Bertram.

The said Court finds that Kerry Anne Bertram aged 42 years, late of 70 Northcote Street, Kilburn, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 15th day of May 2019 as a result of multi-organ failure complicating hypothermia and metabolic acidosis following ingestion of caustic soda. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Kerry Anne Bertram was born on 18 August 1976 and died on 15 May 2019 at the Royal Adelaide Hospital (RAH). She was 42 years old.

1.2. A pathology review was conducted by Dr Iain McIntyre of Forensic Science South Australia (FSSA). Dr McIntyre’s suggested cause of death was ‘multiorgan failure complicating hyperthermia and metabolic acidosis following suspected ingestion of caustic soda and ethylene glycol’.1 Dr McIntyre discussed the case with Dr Cheryl Charlwood, forensic pathologist, FSSA who agreed with his conclusion.

1.3. The pathology review dated 22 May 2019 contained a recommendation that Ms Bertram's admission bloods be seized for toxicological analysis. This occurred after the pathology review was provided to the Court. A toxicology report dated 4 July 2019 was tendered 1 Exhibit C1a

to the Court.2 That toxicology report concerned Ms Bertram's admission bloods. The screening of that blood sample included a screening for ethylene glycol. No ethylene glycol was detected in that sample.

1.4. Accordingly, forensic pathologist Dr Charlwood was contacted in relation to whether the absence of ethylene glycol in the admission bloods affected the reference in the pathology review to suspected ethylene glycol ingestion, or the cause of death generally.

1.5. Dr Charlwood responded and advised that the toxicology results suggested that ethylene glycol had not been consumed. Dr Charlwood was of the view that the remainder of the contents of the pathology review remain the same, including the reference to the ingestion of caustic soda.3

1.6. Based on the toxicology report,4 the contents of Dr Charlwood’s email,5 as well as the clinical case notes, I make a positive finding that the cause of Ms Bertram's death was multiorgan failure complicating hyperthermia and metabolic acidosis following suspected ingestion of caustic soda.

2. Reason for Inquest 2.1. On 13 May 2019 Ms Bertram was admitted to the Royal Adelaide Hospital. At 10pm that evening Dr Andrew Giles placed Ms Bertram on a Level 1 Inpatient Treatment Order (ITO) under the Mental Health Act 2009. As Ms Bertram’s cause of death arose whilst she was the subject of an ITO, her death is a death in custody for which an inquest was mandatory.

2.2. In law this meant that Ms Bertram’s death was a death in custody within the meaning of that expression in the Coroners Act 2003 and this inquest was held as required by section 21(1)(a) of that Act.

2.3. I will detail the circumstances giving rise to the imposition of the ITO below.

2 Exhibit C2b 3 Exhibit C26 4 Exhibit C2b 5 Exhibit C26

3. Background 3.1. Ms Bertram was the mother of three children. She had a daughter and two sons with her former husband. Ms Bertram separated from her husband and the father of her children in mid-2017.

3.2. In March 2019 Ms Bertram secured a rental property through the South Australian Housing Trust at 70 Northcote Street, Kilburn. At the time of her passing Ms Bertram had been living at the Kilburn address alone. Her two sons resided with their father, and her daughter lived with Ms Bertram's mother, Maureen Bertram.

4. Ms Bertram’s medical history 4.1. Ms Bertram's relevant medical history and her mental health history are summarised in some detail in the affidavit of Ms Bertram's general practitioner, Dr Katriona Wylie.6 Ms Bertram reported to Dr Wylie that she had suffered long-term mood issues and depression since about the age of 10. Ms Bertram also reported having low self-esteem and issues with alcohol and methamphetamine.

4.2. In November 2017 Dr Wylie diagnosed Ms Bertram with depression and prescribed the antidepressant medication Effexor. She also referred Ms Bertram to a psychologist, Bernadette Murphy.

4.3. Ms Bertram had been admitted to the Glenside Hospital after being diagnosed with a drug-induced psychosis. She had also spent some time in the past at James Nash House.

On 4 June 2018 Dr Wylie prescribed Ms Bertram with the antipsychotic medication, olanzapine and antidepressant, escitalopram.

4.4. Ms Bertram's mother stated that her daughter's physical and mental health had deteriorated significantly in the two months leading up to her death.7

4.5. Dr Misha Yadav, an intensive care unit registrar at the RAH, conducted a general review of Ms Bertram's case notes and highlighted in his affidavit that, since January 2018, Ms Bertram had a total of 16 hospital presentations relating to mental health concerns, four of which resulted in hospital admissions.8 6 Exhibit C14 7 Exhibit C3, paragraph 6 8 Exhibit C9, paragraph 48

5. Circumstances of Ms Bertram’s death 5.1. In terms of the circumstances leading up to Ms Bertram's death, at about 1pm on Sunday 12 May 2019, which was Mother's Day, Maureen Bertram and her son Paul visited Ms Bertram's house. Through a rear window they observed Ms Bertram lying on the floor of her kitchen. She had her head resting on a pillow and her body was covered by a quilt. The pair tried to communicate with Ms Bertram, but other than tilting her head and looking towards them, Ms Bertram did not speak or attempt to speak to them or move from where she was positioned.

5.2. Ms Bertram's mother states in her affidavit that she and her son deliberated about whether to enter Ms Bertram's address at that time, but neither of them had keys and gaining entry would have meant one or both of them climbing through the rear window. They formed the impression from Ms Bertram's behaviour that she did not want to speak to them and decided against entering the house against her wishes.

5.3. The following morning on Monday 13 May 2019, Ms Bertram's mother telephoned the mental health triage to seek advice in relation to her concerns for her daughter. The mental health triage service advised her to contact an ambulance, but Ms Bertram instead decided to attend her daughter's premises to check on her daughter herself. To this end Maureen Bertram and her granddaughter travelled to Ms Bertram's house by car. When they arrived Maureen Bertram knocked on the front door. There was no response.

Maureen Bertram moved to the backyard and looked through the window to the kitchen.

This was the window that she had observed her daughter through the day before. She was unable to see her daughter.

5.4. Maureen Bertram's granddaughter ultimately climbed through the back window and opened the backdoor into her mother's house, allowing Maureen Bertram to enter. They located Ms Bertram in her bedroom on her bed under the covers. They each described Ms Bertram looking particularly unwell and emaciated. They attempted to carry Ms Bertram out of the room but were not able to do so and ultimately had to drag her out of her bedroom into the kitchen. It was in the process of doing so that Maureen Bertram noticed a tub of drain cleaner (caustic soda) on the floor of the kitchen next to a spray bottle that contained window cleaner (ethylene glycol). They also observed that the oven door in the kitchen was open.

5.5. Paramedics and the Metropolitan Fire Service (MFS) were contacted and they both arrived a short time later. Mr Brenton Barr of the MFS provided an affidavit and stated that a gas detection device used upon entry did not detect any gas.9

5.6. Ms Bertram did not respond to requests made by paramedics about what had happened or what was the cause of her being unwell. She was conveyed by ambulance to the RAH.

5.7. Upon arrival at the RAH, during a handover from ambulance staff to hospital staff, Ms Bertram became aggressive and was subject to what is referred to as a code black where a patient displays violent behaviour and requires restraint. Ms Bertram was restrained with soft shackles and placed under a section 56 Mental Health Act order.

Ms Bertram was subsequently transferred to the resuscitation area where she was observed to calm down and the soft shackles were removed.

5.8. As a result of Ms Bertram’s agitation, Dr Andrew Giles imposed a Level 1 ITO at 10pm on 13 May 2019. Dr Giles explained in his affidavit dated 5 December 2019, that at the time he imposed the order he was not aware of the fatal course that Ms Bertram was on and he was worried at that stage about the risk of hospital self-discharge by Ms Bertram.10

5.9. The information relating to the presence of the drain cleaner and window cleaner in Ms Bertram’s kitchen was clearly conveyed to those treating Ms Bertram at the RAH.11 The items were also seized by police.12 The RAH case notes reflect that the intensive care clinicians suspected the reason for Ms Bertram’s condition was related to the ingestion of caustic soda and window cleaner. Following physical examination, blood tests and CT scans, Ms Bertram was suspected to be suffering from ethylene glycol toxicity with increased anion gap metabolic acidosis. Accordingly, this was treated with continuous venovenous haemodiafiltration and ethanol infusion.13

5.10. Ms Bertram was also found to have had oesophageal perforation and mediastinitis. She was initially due for surgical intervention, but that was abandoned when there was a further finding on a CT scan of a brain oedema. In addition, Ms Bertram had an acute kidney injury with uremic encephalopathy which was treated with dialysis and septic shock which was treated with vasopressor infusions.

9 Exhibit C7 10 Exhibit C8 11 Exhibit C19 12 Exhibit C18, page 20

13 CVVHDF

5.11. In terms of the circumstances of Ms Bertram's death, on the morning of 15 May 2019 she was found to have fixed dilated pupils and a CT scan of her brain showed a diffuse cerebral oedema with mass effect and cerebellar herniation. A nuclear medicine scan was performed which confirmed brain death and Ms Bertram was declared life extinct at 5:15pm on 15 May 2019.

6. Conclusion and recommendation 6.1. I find that Ms Bertram ingested the caustic soda thereby causing her own death.

6.2. I agree with the conclusions of the investigating officer, Brevet Sergeant Anthony Armitage, as expressed in his report that the circumstances surrounding Ms Bertram's death are not suspicious and do not indicate the involvement of any third party.14

6.3. In my opinion Ms Bertram’s care and treatment was appropriate. A reading of the medical notes confirms she received very attentive care whilst at the Royal Adelaide Hospital.

6.4. I make no recommendations.

Key Words: Death in Custody; Inpatient Treatment Order; Poisoning; Psychiatric/Mental Illness; Suicide In witness whereof the said Coroner has hereunto set and subscribed her hand and Seal the 10th day of June, 2022.

Coroner Inquest Number Inquest Number 02/2022 (0972/2019) 14 Exhibit C18