Coroner's Finding: Leane, Stewart Anthony

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 Stewart Anthony Leane.

The said Court finds that Stewart Anthony Leane aged 62 years, late of 8/10 Power Court, Mount Barker, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 29th day of August 2021 as a result of end stage renal failure complicating oxalate crystal nephropathy with contributing head injury. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Stewart Anthony Leane was born on 23 October 1958 and died on 29 August 2021 at the Royal Adelaide Hospital. He was 62 years of age.

1.2. A pathology review was conducted at Forensic Science South Australia by Dr Jane Alderman and discussed with Dr Stephen Wills, senior consultant forensic pathologist.

In accordance with the opinion expressed in the pathology review, I find the cause of death to be ‘end stage renal failure complicating oxalate crystal nephropathy with contributing head injury’.1 1 Exhibit C2a

2. Reason for Inquest 2.1. At the time of his death Mr Leane was under a guardianship order with special powers pursuant to Section 32(1)(b) of the Guardianship and Administration Act 1993, and his death was not from natural causes. Accordingly, a mandatory inquest was held pursuant to Section 21 of the Coroners Act 2003.

3. Background 3.1. Mr Leane was the middle child of three siblings, with an older sister Julie and a younger brother Ronald.

3.2. Upon leaving high school, Mr Leane took up an apprenticeship at a crash repair business.

3.3. At the time of his death Mr Leane was living in Clayton Bay but often stayed at his mother’s home in Mount Barker as he was having regular dialysis treatment at the Mount Barker Hospital.

4. Mr Leane’s medical history 4.1. In the lead up to his death Mr Leane had been suffering from kidney failure requiring dialysis therapy for several years.

4.2. He had a complex medical history including: likely oxalate crystal nephropathy • acute kidney injury • diet controlled diabetes • paranoid schizophrenia • tissue aortic valve replacement (2016) • gastro-oesophageal reflux disease •

5. Events leading to death 5.1. On 13 July 2021, Mr Leane attended for his regular dialysis treatment at Mount Barker and was found to be guarding his left wrist. He stated that he had fallen at home. He was taken to the Mount Barker Hospital Emergency Department and then conveyed to

the Royal Adelaide Hospital (RAH) for a fracture of his left wrist, as well as fluid overload. He was discharged on 14 July 2021.

5.2. On 17 July 2021 Mr Leane was readmitted to the RAH after having been found collapsed in the car park of the Mount Barker Hospital prior to his dialysis treatment.

He said he had fallen. He was first taken to the Mount Barker Hospital Emergency Department where was given a CT head scan, prior to being conveyed to the RAH.

5.3. The CT scan confirmed that Mr Leane sustained a brain injury as a result of the fall.

He was declined for rehabilitation by the Brain Injury Unit due to dialysis dependence and complex medical care needs.

5.4. Between 24 July and 21 August 2021, nursing staff from the Renal Ward submitted a number of incident reports regarding Mr Leane's behaviour, including pulling out dialysis lines, striking two staff members and absconding from the ward. He was considered to be at risk of falls, due to impulsivity.

5.5. On 28 July 2021, the South Australian Civil and Administrative Tribunal (SACAT) received an application by Mr Leane’s siblings, Julie Clamp and Ronald Leane, for a guardianship order with special powers and an administration order.

5.6. Following an urgent hearing on 5 August 2021, SACAT made a guardianship order appointing Mr Leane's' siblings as full guardians and administrators, with a special powers order authorising detention and use of force.

5.7. On 24 August 2021, a decision was made by the multi-disciplinary treating team and Mr Leane’s family that dialysis would be withdrawn, and Mr Leane would be given palliative care.

5.8. On 26 August 2021 SACAT conducted a full hearing and confirmed the orders made on 5 August 2021. This was the day Mr Leane received his final dialysis treatment.

5.9. Mr Leane's condition continued to deteriorate until he passed away on 29 August 2021.

6. Conclusion and recommendation 6.1. Mr Leane’s guardianship order with special powers was lawful and appropriate.

6.2. The standard of care provided at both the Mount Barker Hospital and the Royal Adelaide 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 14/2024 (1868/2021)