Coroner's Finding: Harmer, Valerie Fay

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 Valerie Fay Harmer.

The said Court finds that Valerie Fay Harmer aged 91 years, late of Helping Hand Lealhome, 15 Halliday Street, Risdon Park, South Australia died at Risdon Park, South Australia on the 12th day of October 2021 as a result of dementia complicated by subdural haemorrhage. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Mrs Valerie Fay Harmer, whose preferred name was Fay, was born 30 July 1930 and died at Helping Hand in Port Pirie on 12 October 2021.

1.2. A pathology review was undertaken by Dr Erin O’Connor, medical practitioner at Forensic Science South Australia, and was discussed with Dr Cheryl Charlwood, senior consultant forensic pathologist. Ms Farmer’s stated cause of death was ‘dementia complicated by subdural haemorrhage’,1 and I so find.

2. Reason for inquest 2.1. Mrs Harmer’s death was deemed a death in custody pursuant to the Coroners Act 2003, as at the time of her death Mrs Harmer was under a guardianship order with special 1 Exhibit C1a

powers of detention, pursuant to Section 32(1)(b) of the Guardianship and Administration Act 1993, and her death was not from certified natural causes. Thus, this was a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

3. Background and medical history 3.1. Mrs Harmer was married to Patrick John Hayes in 1949. They had four children together, and later divorced. On 11 July 1979 she remarried George Keith Harmer.

George passed away 10 years prior to Mrs Harmer.

3.2. In the years leading up to her death, Mrs Harmer had been diagnosed with dementia, behavioural disturbance, anxiety, bilateral leg oedema, osteoporosis and osteoarthritis.2

4. Guardianship order 4.1. Due to Mrs Harmer’s declining cognitive ability, two of her children sought a guardianship order, which was made on 28 April 2017. The order appointed Judy Joy Mark3 and Peter John Hayes as Mrs Harmer’s guardians and included special powers as to residency and detention. Those orders were reviewed and varied on two occasions.

4.2. I am satisfied that at the time of her death there was a valid guardianship order with special powers, including powers of detention.

5. Circumstances leading to Mrs Harmer’s death 5.1. Mrs Harmer was admitted to the Helping Hand Aged Care Facility in Port Pirie in May 2017 and lived there until her death. Due to her dementia Mrs Harmer resided in Regent House, a secure wing mainly housing residents with dementia.

5.2. Mrs Harmer’s cognitive decline continued. On 29 July 2021 she was accidentally bumped into by a staff member, causing a fall.4 At 12:01pm she was taken by ambulance to Port Pirie Hospital.

2 Exhibit C4 3 Exhibit C3 4 Exhibit C2

5.3. Dr David Hooper saw Mrs Harmer and noted that she was uncooperative with staff and suffering progressed dementia. A haematoma to her right forehead was noted in the temporal region.5

5.4. A CT scan result indicated a 6mm subdural haematoma overlying the right frontal temporal parietal region. A small contusion was present within the right frontal lobe.

5.5. Dr Hooper discussed the results with a neurosurgical registrar from the Royal Adelaide Hospital and Mrs Harmer’s guardian, her daughter Judy Mark. As a result, it was decided that the injury was ‘not for heroic intervention’, with Mrs Harmer to be discharged back to the aged care facility. If Mrs Harmer deteriorated, she was to be commenced on palliative care. If she remained stable, she was to return in one week for a review, CT scan, consult with her general practitioner and further liaison with neurosurgery. Mrs Harmer was discharged back to the nursing home on the same day.

5.6. A further CT scan was conducted on 10 August 2021 and showed a significant increase in the size and mass effect of the subdural haematoma. As a result, a formal palliative care plan was instigated.

5.7. On 1 September 2021 Mrs Harmer was observed seated in a chair at the residential facility and had become unresponsive. It was noted she had a facial droop. The SA Ambulance Service were called, and Mrs Harmer was conveyed to the Port Pirie Hospital.6

5.8. At 1:22pm Mrs Harmer was seen by a doctor at the Port Pirie Hospital. It was noted she was comfortable on a current palliative care plan, and she was transferred back to Helping Hand Aged Care facility with no changes to her palliative treatment, which was continued.

5.9. Mrs Harmer passed away at Helping Hand on 12 October 2021 in the presence of family.

5 Exhibit C7 6 Exhibit C3

6. Conclusion and recommendation 6.1. I agree with the conclusions of the SAPOL investigating officer, Detective Brevet Sergeant Paul Clonan, that the guardianship order with special powers was lawful and appropriate.7

6.2. In my opinion Mrs Harmer’s care at both Helping Hand and the Port Pirie Hospital was appropriate.

6.3. I make no recommendations.

Key Words: Death in Custody; Section 32 Powers 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 15/2024 (2225/2021) 7 Exhibit C5