Coroner's Finding: Roocroft, Bryan

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign King at Adelaide in the State of South Australia, on the 8th and 16th days of December 2022, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Bryan Roocroft.

The said Court finds that Bryan Roocroft aged 84 years, late of St Basil's Aegean Village, Christie Downs, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 29th day of December 2020 as a result of acute aspiration complicating periprosthetic fractured right femur (operated) on a background of severe dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mr Bryan Roocroft was born on 21 December 1936 in Liverpool, United Kingdom. He passed away at the Flinders Medical Centre1 on 29 December 2020. Mr Roocroft was 84 years of age.

1.2. A pathology review undertaken by Dr Erin O’Connor, in conjunction with Dr Cheryl Charlwood, both of Forensic Science South Australia2 determined the cause of death to be ‘acute aspiration complicating periprosthetic fractured right femur (operated) on a background of severe dementia’.3 I accept the cause of death found by FSSA in this review and make a finding accordingly.

1 FMC 2 FSSA 3 Exhibit C2a

2. Reason for Inquest 2.1. Following surgical repair of a femoral fracture on 25 December 2020, Mr Roocroft was placed on a Level 1 Inpatient Treatment Order4 pursuant to section 21 of the Mental Health Act 2009. The ITO was put in place post-operatively for delirium on top of dementia.5 That order was revoked moments before his life was declared extinct.

2.2. This Inquest was mandatory pursuant to section 21(1)(a) of the Coroners Act 2003,6 as part of his cause of death arose or existed during the time the ITO was imposed on him.

Mr Roocroft’s death is classified as a ‘death in custody’ under the Act as ‘the death occurred, or the cause of death, or a possible cause of death, arose or may have arisen while the person was detained…within the State under any Act or law’.7

3. Personal and medical background 3.1. Mr Roocroft was one of three sons born to his parents. In World War II his parents sent him to Wales to avoid the bombing raids by the German Luftwaffe. His parents and brother Alan emigrated to South Australia in 1954. Mr Roocroft’s other brother died as an infant.

3.2. Mr Roocroft was a practicing Jehovah Witness and had worked as a truck driver and then a groundsman for the Grange Primary School.

3.3. In 1961 Mr Roocroft was married to Audrey Bone. Together they had two sons, Bryn who was born in October 1969 and Ashley who was born in 1972.

In 1981 Mr Roocroft separated from his wife and lived with his eldest son Bryn.

Ashley lived with his mother until leaving home. Mr Roocroft was not involved in another long-term personal relationship after the separation.8

3.4. Mr Roocroft loved the speedway racing held in Adelaide and took his sons with him to speedway events from when they were of a young age. His sons continued to go to the speedway as adults independently of their father. Bryn became a speedway steward

4 ITO 5 Exhibit C10a 6 the Act 7 Section 3 of the Act 8 Exhibit C7

and Ashley was a flag controller. Ashley believed that his father would have been proud of those achievements if he was ‘…aware enough to realise that by the time he passed away’.9

3.5. Mr Roocroft’s son described how in 2008 his father’s health began to falter. By 2011 Mr Roocroft had been diagnosed with Alzheimer’s dementia and had lost his driver’s licence.

3.6. In 2013 Mr Roocroft was living alone in a two-storey unit at Semaphore Park when he required a right sided total hip replacement. Following the surgery, Mr Roocroft was not able to care for himself and was placed in St Basil’s Aegean Village for Aged Care.10 Mr Roocroft lived at St Basil’s for the remainder of his life.

3.7. By 2019 Mr Roocroft’s Alzheimer’s had deteriorated and his behaviour had become intrusive. He was entering into other residents’ rooms and engaging in verbal altercations. He was aggressive with other residents in general, including being involved in a number of physical altercations with them.

3.8. Mr Roocroft was suffering from severe dementia. His condition rapidly became worse in the last months of 2020, culminating in his admission to the FMC on 17 December 2020. He had worsening aggressive and agitated behaviour at the FMC.

His agitated behaviour was thought to be due to the highly stimulating environment in the hospital.11 As a result of this, Mr Roocroft was placed on a Level 1 ITO and his medication regime was completely changed.

3.9. On 23 December 2020, Mr Roocroft was discharged from FMC back to St Basil’s. The discharge summary recorded that Mr Roocroft’s behaviour had settled with the medication changes. His ITO was revoked that day.

3.10. It was recommended that consideration be given to placing Mr Roocroft on an order pursuant to section 32 of the Guardianship and Administration Act 1993,12 authorising his detention at St Basil’s or some other suitable facility.

9 Exhibit C7, paragraph 7 10 Exhibit C7, affidavit of Ashley Roocroft, dated 16 June 2021 - ‘St Basil’s’ 11 Exhibit C5, affidavit of Dr Elita Santosuptri, dated 27 July 2021, see also Exhibit C11 12 Exhibit C11

4. 24 December 2020 4.1. Mr Roocroft was being ‘specialed’, meaning he was subject to one-on-one nursing care on the afternoon shift due to his on-going aggressive behaviour.13 Mr Roocroft was given oxazepam at 7:55pm.14 In addition to this, Mr Roocroft was also on the following medications, namely olanzapine, melatonin, paracetamol, metformin and salbutamol.

4.2. Following the administration of the oxazepam Mr Roocroft was seated in a chair while the staff waited for the medication to take some effect. Unfortunately, in the interim, Mr Roocroft stood up and fell flat on his pelvis. Staff examined him and noted no injuries. They took a series of observations which were within the normal range.15

4.3. Mr Roocroft asked to be put to bed. He stood up and fell again flat on his pelvis. A lifter was then used to put him into his bed. Mr Roocroft was described as ‘yelling and unsettled’, quite probably due to the very severe pain he must have been in.16

4.4. Mr Roocroft had fractured his right femur around the femoral prosthesis inserted in 2013 as part of his total hip replacement. Whether Mr Roocroft fractured his right femur on his first or second fall was not known, nor relevant to my consideration.

Mr Roocroft was transferred to the FMC in the early hours of 25 December 2020.

4.5. Mr Roocroft’s fracture was repaired on Christmas day. The operation went as expected.17 Mr Roocroft underwent a general anaesthetic and a regional block for post-operative pain management. Following the general anaesthetic, Mr Roocroft was suffering from delirium. This exacerbated his severe dementia and he was placed on a Level 1 ITO.18

4.6. Mr Roocroft’s post-operative recovery from a non-orthopaedic point of view had difficulties.19 Mr Roocroft was described in the nursing notes as ‘disorientated, agitated, confused, in pain’, requiring one-on-one nursing at times.20 13 Exhibit C4, affidavit of Safin Loomba, dated 7 July 2021 14 Exhibit C10a 15 Exhibit C12 16 Exhibit C4 and Exhibit C10a 17 Exhibit C6, affidavit of Dr Ruurd Jaarsma, dated 24 March 2021 18 Exhibit 10a and Exhibit C11 19 Exhibit C5, affidavit of Dr Elita Santosuptri, dated 27 July 2021 20 Exhibit C11

5. 29 December 2020 5.1. On the morning of 29 December 2020, Mr Roocroft was being ‘specialed’, when the registered nurse observed Mr Roocroft to be aspirating vomit.21 A Medical Emergency Team22 call was made at 10:38am. Mr Roocroft was found to be hypoxic.

Dr Elita Santosuptri, the geriatrician associated with the Orthopaedic Department, attended and determined he was close to death. Dr Santosuptri consulted with Ashley Roocroft to recommend palliative care from that point. This advice was accepted.

5.2. The Level 1 ITO imposed on the evening of 25 December 2020 was revoked at 12:50pm on 29 December 2020. Mr Roocroft’s life was certified extinct shortly thereafter.

6. Investigation by South Australia Police23 6.1. Mr Roocroft’s death was investigated by SAPOL as is customary for a death in custody.

Detective Brevet Sergeant Jordan Delbridge of the Southern District Criminal Investigation Branch thoroughly investigated the circumstances of Mr Roocroft’s death and prepared a comprehensive report.24 He found that the care and treatment of Mr Roocroft at St Basil’s and FMC were appropriate. He found that the ITO was ‘justified’ and required to provide adequate care to Mr Roocroft.

6.2. I agree with the conclusions and findings of Detective Delbridge in his report. I find that the treatment of Mr Roocroft was appropriate and that he was professionally cared for at all times.

7. Conclusion and recommendations 7.1. Mr Roocroft suffered from a serious, debilitating and ultimately terminal disease, namely dementia. There was clear evidence that Mr Roocroft’s condition was deteriorating rapidly during the second half of 2020.

21 Exhibit C3, affidavit of Craig Cooper

22 MET 23 SAPOL 24 C10b

7.2. The two falls that Mr Roocroft suffered on the evening of 24 December 2020 were not the result of any individual negligence or structural failings on the part of St Basil’s.

7.3. The orthopaedic management of Mr Roocroft’s fracture was successful. The placement of a Level 1 ITO was appropriate.

7.4. Mr Roocroft’s end of life care was managed promptly and correctly.

7.5. I make no recommendations.

Key Words: Death in Custody; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 16th day of December, 2022.

Deputy State Coroner Inquest Number 28/2022 (2638/2020)