Coroner's Finding: Icke, Frances Veronica

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 14th day of May and the 13th day of September 2024, by the Coroners Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Frances Veronica Icke.

The said Court finds that Frances Veronica Icke aged 74 years, late of 5 West Court, Golden Grove, South Australia died at the Modbury Hospital, Smart Road, Modbury, South Australia on the 5th day of February 2022 as a result of intracranial haemorrhages (non operated) on a background of dementia. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Frances Veronica Icke was born on 11 February 1947 and died on 5 February 2022 at the Modbury Hospital. She was 74 years of age.

1.2. A pathology review undertaken by Dr Erin O’Connor1 of Forensic Science South Australia, and discussed with Senior Consultant Forensic Pathologist Professor Roger Byard, gave a suggested cause of death as ‘intracranial haemorrhages (non-operated) on a background of dementia’, which I find to have been the cause of death.

2. Reason for inquest 2.1. As at the time of her death Mrs Icke was under a guardianship order with special powers pursuant to Section 32(1)(b) of the Guardianship and Administration Act 1993, and her 1 Exhibit C2

cause of death was not certifiable by a medical practitioner as due to natural causes, this is a mandatory inquest pursuant to section 21 of the Coroners Act 2003.

3. Background 3.1. Mrs Icke was one of seven children. She had five children of her own. Throughout her working life she was employed as a nurse, her last place of employment being Gawler Supportive Care. At the time of her death, she resided alone in a Housing SA property in Golden Grove.

3.2. Mrs Icke had been legal guardian to her grand-nephew from the time of his birth.

4. Mrs Icke’s medical history 4.1. According to the Modbury Hospital and Lyell McEwin Hospital patient medical notes the following medical history was noted: hysterectomy, heavy smoker, osteoporosis, aggressive early onset dementia with vulnerability, cognitive and memory loss decline, poor nutrition and medication discipline, vitamin D deficient, tonsillectomy, allergic to penicillin and hayfever sufferer.

4.2. In 2019 Mrs Icke’s family started to become concerned that she was showing signs of being forgetful. Her daughter, Dannielle Icke,2 took Mrs Icke to a general practitioner, who referred her to a geriatrician. Mrs Icke was reluctant to engage in any further testing.

4.3. In 2020, her family organised an ACAT assessment for Mrs Icke and an aged care plan was prepared. However, Mrs Icke refused service provider support and denied access to her home. She stopped leaving her house and declined medical treatment.

4.4. In 2020 and 2021 family assisted Mrs Icke with support and assistance for her daily tasks. In August 2021 there was an incident in which Mrs Icke became disorientated and left her motor vehicle in reverse gear in a petrol station. This prompted her family to contact the Older Persons Mental Health Service (OPMHS) as they believed her condition was deteriorating.

4.5. The OPMHS referred Mrs Icke to the Community Geriatric Evaluation and Management (GEM) team at the Modbury Hospital. The GEM team assessed her mental health, residential care status and a possible rehabilitation program and, in 2 Exhibit C7

September 2021, confirmed Mrs Icke was suffering from dementia. Professional inhome support and an eventual move into residential care were recommended.

5. SACAT order 5.1. On behalf of the family, the GEM team made an application to the South Australian Civil and Administrative Tribunal (SACAT) pursuant to the Guardianship and Administration Act 1993 (the Act). An administration and guardianship order with special powers3 pursuant to section 32(1)(b) of the Act was made by SACAT on 1 November 2021 and was in force at the time of Mrs Icke’s passing.

6. Circumstances leading to Mrs Icke’s death 6.1. In November 2021 her family made several unsuccessful attempts to arrange residential care for Mrs Icke.

6.2. At the end of November 2021 family members were able to place Mrs Icke in short term respite care at the Anglicare SA Dutton Court facility in Elizabeth East. Mrs Icke was at this facility for only one week when it was determined that she needed to go into a memory support unit, but no rooms were available.

6.3. Mrs Icke returned to reside at her home with the support of family while awaiting a suitable placement.

6.4. The Wesley House facility at Semaphore Park scheduled a room for Mrs Icke to move into on 22 December 2021. Unfortunately, the facility went into COVID-19 lockdown and the scheduled date was extended out to 3 January 2022.

6.5. On 31 December 2021, Craig Icke (Mrs Icke’s son) attended at her home address and located her lying on the floor of her bathroom, where she had apparently been lying for some time after a fall the night before. An ambulance was called and took her to the Modbury Hospital Emergency Department.

6.6. The medical team at Modbury Hospital sought review by the neurosurgery team at the Royal Adelaide Hospital after a CT brain scan showed two bleeds on the brain. It was determined that Mrs Icke did not require surgical intervention at that time, and that she was unlikely to be a candidate for future surgical intervention given her age and cognitive impairment. Active ward-based management was deemed appropriate. As 3 Exhibit C8

Mrs Icke was not for surgical intervention, the neurosurgical team advised that no further follow up CT scans were required at that time.

6.7. Mrs Icke was then transferred to the Lyell McEwin Hospital (LMH) due to bed availability. Dr Ashley Gaw4 became involved in Mrs Icke’s care at the LMH. Dr Gaw noted that upon transfer to the LMH, Mrs Icke’s condition appeared stable and the plan was to seek a nursing home placement for Mrs Icke.

6.8. Mrs Icke reportedly remained stable with no concerns until 16 January 2022 when there was an emergency response call due to a decline in her conscious state and new neurological signs.

6.9. At that time Mrs Icke underwent a repeat CT brain scan which showed new extension of a pre-existing haemorrhage which had been noted on 1 January 2022. This appeared to have occurred spontaneously as, until then, Mrs Icke had been stable and there was no identified precipitating event.

6.10. On 17 January 2022 Mrs Icke was returned home for palliative care by her family with the support of the Northern Palliative Care Team.

6.11. Mrs Icke was eventually transferred back to the Modbury Hospital Palliative Care Unit on 2 February 2022. She passed away on 5 February 2022.

7. Concerns of next of kin 7.1. In her affidavit, Mrs Icke’s daughter Dannielle has raised some matters of concern. One concern expressed related to the lack of communication from the hospital. Mrs Icke stated she contacted the hospital a number of times enquiring as to her mother and why no further CT scans were being done, but despite leaving messages she never received a call back from a doctor. She also found out through a third party (Uniting SA) that her mother was a COVID close contact. Mrs Icke’s legal guardians were not advised of that fact by hospital staff.

7.2. In an affidavit of Laurel Walters,5 it is stated that on 9 January 2022 Mrs Icke was identified as a COVID close contact and was moved into a single room. During the time of her admission the Northern Adelaide Local Health Network (NALHN) had implemented a no visitor policy. On Mrs Icke’s ward (2A) exemptions could be made for patients who were subject to end-of-life care, or had special circumstances.

4 Exhibit C4 5 Exhibit C5

Mrs Icke did not fit the criteria for exemptions until 16 January 2022, when her son and three other family members were granted exemptions to visit, as she was then receiving end-of-life care.

7.3. Ms Walters also noted that as a result of the no visitor policy, conversations with family members were to take place over the phone. Ms Walters reported it was difficult for staff to manage at times, with so many calls to answer and return. She also noted that a medical officer had recorded an attempt to contact Mrs Icke’s family on 15 January 2022 but noted the number was incorrect, so the medical team were unable to call and had to wait for family to call and then provide the correct number. It seems this administrative error, possibly combined with the high number of calls staff were required to make and receive, contributed to the family going for many days without information about what was happening to their mother and being unable to visit.

7.4. I acknowledge the concerns of Mrs Icke’s daughter, expressed on behalf of her family, and acknowledge the additional stress and trauma which must have been caused. Those concerns are not directly related to the cause of Mrs Icke’s death.

8. Conclusion and recommendation 8.1. I find the administration and guardianship order with special powers was valid at the time of Mrs Icke’s death.

8.2. The standard of care afforded to Mrs Icke at the Lyell McEwin Hospital and Modbury Hospital appears to have been appropriate, although the experiences and concerns of Mrs Icke’s family about lack of communication during the difficult time of COVID-19 restrictions are noted and acknowledged.

8.3. 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 13th day of September, 2024.

State Coroner Inquest Number 27/2024 (0307/2022)