Coroner's Finding: Lauder, Ian Ross

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 22nd day of February and the 14th day of April 2022, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Ian Ross Lauder.

The said Court finds that Ian Ross Lauder aged 80 years, late of Helping Hand, 2 The Strand, Mawson Lakes, South Australia died at Maswon Lakes, South Australia on the 30th day of October 2019 as a result of general inanition and pneumonia on a background of advanced vascular dementia, cerebrovascular disease and right hip fracture (operated). The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Ian Ross Lauder was born on 8 May 1939 and he died on 30 November 2019 at the Helping Hand Aged Care facility in Mawson Lakes. He was 80 years old.

1.2. A pathology review concerning his death was conducted by pathologist Dr Iain McIntyre from Forensic Science South Australia1 on 4 November 2019 with a suggested cause of death being general inanition and pneumonia on a background of advanced dementia, cerebrovascular disease and a right hip fracture which had been operated on. Dr McIntyre discussed his opinion with pathologist Dr Karen Heath, also from FSSA, who agreed with his conclusion. I accept Dr McIntyre’s and Dr Heath’s opinions and make a finding accordingly.

1 FSSA

1.3. At the time of his death, Mr Lauder was subject to a SACAT2 order including special powers pursuant to Section 32 of the Guardianship and Administration Act 1993.3 On 9 March 2018 Mr Lauder's two children, who had been appointed his guardians, were granted special powers that authorised that Mr Lauder reside at, and be detained at, such place as they determined. Based on these powers that still existed at the time of his death, Mr Lauder was legally in lawful custody. Therefore a mandatory inquest under Section 21 of the Coroners Act 2003 was conducted.

1.4. There are no concerns in relation to the lawfulness of custody.

2. Background 2.1. Mr Lauder was married for 54 years to his wife Joan. They had two children, a daughter Stacey and a son Gavin. They also had six grandchildren.

2.2. Mr Lauder was a self-employed plumber and tiler by trade until he retired when he was 69 years of age. He remained heavily involved in local football leagues following his retirement. He also enjoyed fishing.

3. Mr Lauder’s medical history 3.1. Mr Lauder was diagnosed with Type 2 diabetes at about 45 years of age. This was managed for some time through tablet medication until he was about 60 years old. He was then commenced on insulin.

3.2. In 2007 he suffered a stroke which led to a deterioration of his coordination and impaired the use of his right arm. Mr Lauder suffered a further two strokes. His daughter Stacey noted that each subsequent stroke led to a further deterioration in both her father's mental and physical health.

3.3. Mr Lauder was diagnosed with dementia in 2011 which largely affected his short-term memory. In that same year, he also broke his hip requiring surgical repair. Mr Lauder deteriorated following this injury. His wife was able nonetheless to continue to care for him at their home with some assistance from their daughter. Ultimately, Mr Lauder was admitted to the Infinite Nursing Home in Klemzig in February 2018.

2 South Australian Civil and Administrative Tribunal 3 GA Act

3.4. In addition to his dementia, Mr Lauder's medical history included glaucoma, middle cerebral artery syndrome, oedema, myocardial infarction, transient cerebral ischemic attacks, urinary tract infections, frequent falls, a fracture of his lumbar spine and pelvis delirium, Type 2 diabetes, high cholesterol, an enlarged prostate, osteoarthritis and Methicillin-resistant Staphylococcus aureus in his left toe.

3.5. After two weeks of being in the Infinite Nursing Home in Klemzig, the staff requested that Mr Lauder's family find another care facility with a dedicated dementia unit. They were having some difficulty adequately coping with and managing Mr Lauder. He was brought back to the family home for a brief period of approximately two weeks before alternate care was found. The alternate care was in the form of the Helping Hand Aged Care facility in Mawson Lakes where he commenced residing on 22 March 2018.

3.6. Whilst he was living at the Helping Hand care facility, Mr Lauder suffered a number of unwitnessed falls and that led to him being categorised as a high risk for falls. That categorisation resulted in Mr Lauder's bed being lowered to very close to floor height and the positioning of fall mats on each side of his bed with alarms connected to them, that would sound to notify staff in the event of a fall.

4. Mr Lauder’s decline in health and death 4.1. I turn now to the clinical circumstances leading up to Mr Lauder's passing. At about 6:30pm on 3 October 2019, staff attended his room after his fall mat/mats had been activated. He was located lying on his left side. Mr Lauder was returned to bed. There was a Range of Movement Assessment which appeared normal and he was not complaining of being in any pain at that stage. Staff did note that he was non-compliant after they had attended to him and helped him back into bed. He then wriggled back off his bed and onto the floor.

4.2. At about 7:45pm the same night, Mr Lauder started complaining of pain in his right hip. Paramedics were called and he was transferred to the Royal Adelaide Hospital.4 The admissions paperwork at the RAH noted that Mr Lauder was admitted as a result of a fall from a bed at floor height and he was suffering pain to his right hip and some skin tears to his left arm.

4 RAH

4.3. Medical investigations at the RAH discovered that Mr Lauder had suffered a right neck of femur fracture which was surgically repaired two days later on 5 October 2019.

4.4. Whilst he was in hospital, Mr Lauder suffered a posterior cerebral artery stroke. A 13mm legion was also discovered on his right lung. This was a legion that had been identified previously. The more recent scans on his lungs noted that it had grown significantly since the last scan. Whilst ideally further investigation was recommended, following discussion between doctors and Mr Lauder's children, a decision was made not to investigate that legion on the right lung any further.

4.5. Mr Lauder was also found to be anaemic as his haemoglobin levels had dropped following the operation to repair his hip. Doctors commenced packed red blood cell transfusions to try to stabilise the haemoglobin levels. Medical staff also discovered that Mr Lauder started to have blood in his stools and urine. Following discussion between doctors and Mr Lauder's children, a decision was made not to undertake an endoscopy to further investigate the potential cause or causes of the bleeding. He was administered proton pump inhibitors, which he used to reduce the production of stomach acids to help minimise the bleeding.

4.6. Upon his discharge from the RAH Mr Lauder was noted to have been suffering from increased delirium, a decrease in his liver function leading to jaundice and ongoing unstable blood glucose levels which had been caused by his diabetes. He was discharged from the RAH on 13 October 2019 and returned to the Helping Hand facility in Mawson Lakes. Following his return, Mr Lauder would regularly refuse medication and food. Despite his healing injury to his hip, he continued to attempt to leave his bed unassisted.

4.7. On 22 October 2019, Mr Lauder suffered a further fall and his condition declined until 27 October 2019 when he had stopped calling out to staff. His breathing became laboured and he was no longer able to tolerate food.

4.8. On 29 October 2019, palliative care was commenced and Mr Lauder was declared deceased on 30 October 2019 at 8:30am by Dr Martin Ooi.

5. Conclusion and recommendation 5.1. Consistent with the conclusions in the report of the investigating officer Detective Brevet Sergeant Eamon McGillion5, the circumstances surrounding Mr Lauder's death are not suspicious and do not indicate the involvement of any third party. There are no concerns in relation to his care. He was in lawful custody under the GA Act at the time of his death.

5.2. I make no recommendations.

Key Words: Death in Custody; Natural Causes; Section 32 Powers In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 14th day of April, 2022.

Deputy State Coroner Inquest Number 24/2021 (2235/2019) 5 Exhibit C8