Coroner's Finding: Lane, Kevin Roy

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INQUEST INTO THE DEATH OF KEVIN ROY LANE [2025] SACC 13 Inquest Findings of her Honour Coroner Giles 20 May 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of an 81-year-old man who refused treatment for metastatic cancer which led to a guardianship order.

Held:

1. Kevin Roy Lane, aged 81 years of St Agnes, died at the Lyell McEwin Hospital on 7 September 2022 as a result of inanition complicating traumatic brain injury and disseminated malignancy.

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MR D EVANS Hearing Date/s: 11/04/2025 Inquest No: 11/2025 File No/s: 2293/2022

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INQUEST INTO THE DEATH OF KEVIN ROY LANE [2025] SACC 13 Introduction and cause of death Kevin Lane was born on 8 August 1941 and died on 7 September 2022 at the Lyell McEwin Hospital at the age of 81 years.

A pathology review informed by Mr Lane’s medical records was conducted by Dr Jane Alderman, medical practitioner, at Forensic Science South Australia. Dr Alderman concluded that Mr Lane died as a result of ‘inanition complicating traumatic brain injury and disseminated malignancy’,1 and I so find.

Reason for inquest The contribution of brain injury to the death of Mr Lane, while he was under a guardianship order with special powers pursuant to Section 32(1)(b) of the Guardianship and Administration Act 1993, meant that his death was a death in custody requiring a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

Background Mr Lane was in a defacto relationship with Ms Cynthia Gemmell for approximately 30 years. They had one daughter together.

In 2020 Mr Lane was diagnosed with bowel cancer. He had an extended right hemicolectomy, and he was treated with chemotherapy in 2021 with a remission achieved. Mr Lane had decided that he would do chemotherapy once only.2 He avoided oncology appointments as he got progressively unwell.

Mr Lane lived near to his general practitioner’s surgery, and he would walk there for appointments.

Circumstances leading to death On 17 August 2022, Mr Lane fell asleep and had to be woken by Ms Gemmell for his general practitioner appointment to follow up on flu-like symptoms which were treated with antibiotics.3 He tripped on the footpath on the way to his appointment and fell and hit his head. An ambulance arrived and took Mr Lane to the Modbury Hospital. He was then transferred to the Lyell McEwin Hospital for specialist treatment.

Upon arrival at the Lyell McEwin, a CT pan scan was conducted. Widespread haemorrhagic small intraparenchymal cerebral lesions were found which favoured the frontal lobes and involved the right thalamus, which was in keeping with cerebral contusions.4 They found a fracture involving the right inferior and lateral orbital walls.

1 Exhibit C4a 2 Exhibit C2 at [4] 3 Exhibit C2 at [6] and Exhibit C3 at [5] 4 Exhibit C3 at [9]

[2025] SACC 13 Coroner Giles Doctors consulted with the neurosurgical team at the Royal Adelaide Hospital about the traumatic multiple intracerebral bleeding and conservative management was recommended.5 The scan also showed progressive lymphadenopathy with omental thickening and nodularity demonstrating omental metastatic disease with suspicion of pleural metastasis.6 These findings were suggestive of metastatic disease likely secondary to bowel cancer, although tissue biopsy was required to formally confirm this.7 There were large right-sided pleural fluid collections and gross ascites. Fluid was drained from Mr Lane’s abdomen and samples confirmed possible malignant cell origin, but the results were not conclusive.8 Mr Lane was delirious and due to his brain injury, he presented challenging behaviours to care providers. There were occasions when intramuscular sedatives were required to be administered to de-escalate situations.9 In order to ensure that care was able to be provided, an application for guardianship was made10 and on 26 August 2023, Mr Lane’s daughter Ms Fogliano was appointed as Mr Lane’s guardian with a power to make decisions about his treatment, where he was to reside, and authorising his detention there.11 The order was to expire in 19 days.

During Mr Lane’s stay at hospital, he refused to eat.12 He told Ms Fogliano that he was dying and wanted to be left in peace.13 On 1 September 2022 he was assessed by a dietician. He was found to be likely malnourished.14 He was recommended for nasogastric tube feeding but removed the tube himself multiple times.15 On the final occasion of the insertion of the tube, three nurses and two doctors were required to achieve it.

On 4 September 2022, doctors discussed Mr Lane’s prognosis with his daughter. It was agreed that he should be transitioned to comfort care.16 A palliative care plan was initiated.

Mr Lane died peacefully on 7 September 2022. He was 81 years old.

The consultant within Mr Lane’s treating team, Dr Ravi Remeru, formed the opinion that Mr Lane’s head injuries would not have been fatal and that if he had not refused nutrition he may have survived, albeit with a diminished quality of life due to his brain injury.17 5 Exhibit C3 at [10] 6 Exhibit C3 at [10] 7 Exhibit C3 at [15] 8 Exhibit C3 at [14] 9 Exhibit C3 at [12] 10 Exhibit C2 at [9] 11 Exhibit C2a and Exhibit C3 at [13] 12 Exhibit C2 at [11] 13 Exhibit C2 at [12] 14 Exhibit C3 at [16] 15 Exhibit C3 at [16] 16 Exhibit C3 at [18] 17 Exhibit C3 at [21]

[2025] SACC 13 Coroner Giles Conclusion and recommendations I find that the guardianship order with special powers was valid at the time of Mr Lane’s death.

I find that the standard of care afforded to Mr Lane was appropriate in what were challenging circumstances.

I make no recommendations.

Keywords: Death in Custody; Section 32 Powers; Head Injury; Metastatic Cancer