Coroner's Finding: Ferns, Patricia Dorothy

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 15th day of March and the 19th day of June 2024, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Patricia Dorothy Ferns.

The said Court finds that Patricia Dorothy Ferns aged 79 years, late of 34 Kapunda Street, Kapunda, South Australia died at the Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, South Australia on the 6th day of January 2022 as a result of cardiogenic shock following repair of fractured right femur on a background of aortic valve stenosis, atherosclerotic arterial disease and hypertension. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Mrs Patricia Ferns was born on 9 April 1942 and died at the Lyell McEwin Hospital on 6 January 2022 at the age of 79 years.

1.2. The formal report of death to the State Coroner by Dr Subhash Auti of the Lyell McEwin Hospital was reviewed by Forensic Science South Australia Senior Consultant Forensic Pathologist, Associate Professor Neil Langlois, who gave the cause of death as ‘cardiogenic shock following repair of fractured right femur on a background of aortic valve stenosis, atherosclerotic arterial disease and hypertension’, which I find to be the cause of Mrs Ferns’ death.

1.3. At the time of her death, Mrs Ferns was subject to an inpatient treatment order (ITO) under the Mental Health Act 2009, meaning that her death was a death in custody, as

defined in the Coroners Act 2003. A death in custody leads to a mandatory inquest unless the cause of death is natural, which Mrs Ferns’ death was not, as her fractured right femur was a contributing cause.

2. Background 2.1. Mrs Ferns married her late husband, Francis John Ferns, at the age of 19. They had four children together, Amanda, Susan, Tracey and Belinda. The family lived in Darwin.

2.2. Mrs Ferns and her husband moved to South Australia in 1988 and settled in Kapunda.

2.3. Mrs Ferns’ husband passed away in 2016 and Mrs Ferns remained living at the Kapunda property.

2.4. Mrs Ferns’ daughter Amanda described that her mother had become more reclusive in the years following her husband’s death, partly due to issues with her knees which affected her mobility.1

3. Mrs Ferns’ medical history 3.1. Mrs Ferns was a patient at the Kapunda & Eudunda Medical Practice since 2000. Over the years she saw a number of general practitioners, of whom Dr Henri Becker provided an affidavit.2 He described that Mrs Ferns was treated in the practice for hypertension, osteoporosis and hypercholesterolemia.

4. Circumstances of Mrs Ferns’ death 4.1. On 2 January 2022 Mrs Ferns was located by her daughter Amanda having fallen down the stairs at home. Amanda could not get into the home and communicated with her mother through the window. Police were called and attended. Entry was gained by Mrs Ferns’ son-in-law through an unlocked window. Mrs Ferns was conscious and advised that she had fallen during the night and had been there for approximately 12 hours. She had been unable to get up due to her injured knee.

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4.2. Mrs Ferns’ daughter reported her mother appeared delirious, as she requested all the cats be removed from the home; however, there were no cats present.

4.3. Mrs Ferns was taken to the Lyell McEwin Hospital and diagnosed with a fractured right femur.

4.4. On 3 January 2022 Mrs Ferns became aggressive due to delirium and removed her leg from traction. This resulted in her being placed on a level 1 inpatient treatment order (ITO). On 4 January 2022 the ITO was reviewed and confirmed by Dr Zarrabi. On that day Mrs Ferns underwent surgery to repair her fractured femur.

4.5. In consultation with Mrs Ferns’ family, a do not resuscitate plan was put in place. Her post operation recovery was complicated by episodes of desaturation.

4.6. On 5 January 2022 Mrs Ferns was placed in the intensive care unit (ICU) due to suffering from acute pulmonary oedema.

4.7. ICU Registrar, Dr Subhash Auti, has provided an affidavit,3 in which it is described that Mrs Ferns suddenly became breathless in her ward and was thus transferred to ICU.

4.8. During her time in ICU Mrs Ferns was reviewed by the cardiology team, who found evidence of myocardial ischaemia. A discussion was held with Mrs Ferns and her family about the possibility of an angiogram. However, Mrs Ferns’ condition became drastically worse over the next 24 hours, and she developed cardiogenic shock and worsening organ failure.

4.9. At about 7pm on 6 January 2022, Dr Auti was notified that Mrs Ferns’ condition was worsening due to a sudden drop in her blood pressure.

4.10. Following a conversation with Mrs Ferns’ next of kin about her worsening condition and her low likelihood of survival without resuscitation, it was confirmed that the nonresuscitation plan should be followed.

4.11. Mrs Ferns passed away peacefully and was pronounced deceased by Dr Auti in the ICU at 8:50pm on 6 January 2022.

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5. Conclusion 5.1. I agree with the conclusions of the SAPOL investigating officer, Detective Brevet Sergeant Justin Leverington, that the ITO was valid and appropriate.

5.2. I am satisfied that the care Mrs Ferns received at the Lyell McEwin Hospital was appropriate.

5.3. 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 19th day of June, 2024.

State Coroner Inquest Number 17/2024 (0058/2022)