Coroner's Finding: Kennedy, Beulah Laura

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 28th day of February 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 Beulah Laura Kennedy.

The said Court finds that Beulah Laura Kennedy aged 95 years, late of Bucklands Residential Care Facility, 333 Marion Road, North Plympton, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 7th day of October 2021 as a result of end-stage dementia and inanition complicated by fractured neck of femur (operated). The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Mrs Beulah Kennedy was born on 1 March 1926 and died on 7 October 2021 at the Royal Adelaide Hospital. She was 95 years of age.

1.2. A pathology review was undertaken by Dr Erin O’Connor of Forensic Science South Australia and discussed with Associate Professor Neil Langlois. The stated cause of death was ‘end-stage dementia and inanition complicated by fractured neck of femur (operated)’.1 I find this to have been the cause of Mrs Kennedy’s death.

2. Reason for inquest 2.1. From 15 September until 22 September 2021, when it was allowed to lapse, Mrs Kennedy was under an inpatient treatment order (ITO) under the Mental Health Act 2009. Although she was not subject to this order at the time of her death on 1 Exhibit C2a

7 October 2021, she had a fall during the currency of the ITO which resulted in a fractured neck of femur, which was a contributing cause of her death. As a result, Mrs Kennedy’s death was a death in custody, as defined in the Coroners Act 2003 and it could not be certified as due to natural causes. For these reasons, her death required a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

3. Background 3.1. Mrs Kennedy was born in Renmark to Tom and Laura Hendrick,2 the youngest of three children. She went to Renmark North Primary School and then Renmark High School.

She left school and began working as a nurse. In 1949 she went to the Royal Sydney Women’s Hospital where she obtained her obstetrics certificate. In 1950 she returned to the Riverland and worked at the Berri Hospital as a registered nurse, including for a time as the matron.

3.2. She married John Kennedy in 1950 and together they had six living children, and two children that were stillborn. In the mid-1950s they moved to Loxton, where Mr Kennedy had taken up the option of a Soldier Settlement Scheme fruit block.

3.3. Mrs Kennedy played piano and organ for her church, the school and various other groups. She did not return to work as a nurse as she was busy raising her children and helping out with the workers during harvest on the fruit block.

3.4. In 1997 Mrs Kennedy and her husband retired and moved into a retirement unit in Loxton. Mr Kennedy passed away in 2001.

3.5. Mrs Kennedy lived in their retirement unit until she moved to St Catherine’s Aged Care in Berri in 2014. In mid-January 2015 she transferred to the Southern Cross Care Bucklands Residential home at North Plympton.

4. Medical history 4.1. On 10 September 2021 Mrs Kennedy was conveyed to the Royal Adelaide Hospital due to increased agitation on background of progressive dementia and recurring falls. She was suspected at the time to have soreness to one of her legs from a fall, but no fracture was identified.

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4.2. Whilst at the Royal Adelaide Hospital Mrs Kennedy was reviewed by medical staff and changes were made to her medications which showed slight improvements. Attempts were made to transfer Mrs Kennedy back to the aged care home, however, due primarily to Mrs Kennedy being unwilling to go, this did not eventuate.

4.3. Following an incident where Mrs Kennedy entered another patient’s room and became combative towards staff trying to redirect her, an ITO was imposed on 15 September 2021 to allow medical staff greater authority in providing appropriate care. The next day that order was confirmed.

4.4. Mrs Kennedy was assigned 1:1 nursing care whilst under the ITO.

5. Circumstances leading to Mrs Kennedy’s death 5.1. On 18 September 2021 Mrs Kennedy suffered a fall whilst her 1:1 nurse was collecting her morning medication.

5.2. An SLS3 in relation to the fall indicated that this was an unwitnessed fall. The SLS recorded that Mrs Kennedy had been asleep in her bed and the nurse looking after her put her bed alarm on and went to the drug room to obtain Mrs Kennedy’s medication.

The nurse heard the bed alarm and returned to Mrs Kennedy’s room and found her on the floor. She was helped back to bed. A neck of femur fracture was identified that day.

5.3. On 19 September 2021 Mrs Kennedy underwent a palliative procedure involving a short intramedullary nail into the femur to stabilise the leg only, rather than a full repair of the fracture. This procedure was reportedly performed successfully.

5.4. On 22 September 2021 the ITO lapsed, and no new order was enforced.

5.5. Between 22 and 27 September 2021 Mrs Kennedy continued to decline fluid and food intake, and discussions with next of kin occurred in relation to moving Mrs Kennedy towards palliative care.

5.6. On 29 September 2021 transition to full-time palliative care commenced.

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5.7. On 1 October 2021 a sedative pump was initiated after Mrs Kennedy completely stopped taking food and fluids orally.

5.8. Mrs Kennedy passed away peacefully and was declared deceased at 2:52am on 7 October 2021.

6. Conclusions 6.1. I agree with the opinion expressed by the SAPOL investigating officer, Detective Brevet Sergeant Jordan Delbridge, that the ITO was valid and appropriate.4

6.2. In relation to the standard of care provided to Mrs Kennedy at the Royal Adelaide Hospital, I observe that although the fall leading to the fractured femur was not witnessed, at a time when Mrs Kennedy was to be receiving 1:1 nursing care, it seems that the nurse providing 1:1 care at that time took reasonable steps to ensure the safety of Mrs Kennedy when she exited the room to retrieve morning medications. However, despite that Mrs Kennedy awoke while the nurse was absent and attempted to get out of bed by herself, resulting in the fall.

6.3. In my opinion Mrs Kennedy’s care and treatment was appropriate.

6.4. 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 ??? day of June, 2024.

State Coroner Inquest Number 13/2024 (2166/2021) 4 Exhibit C5