Coroner's Finding: Gleeson, Bernice Valma

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of Bernice Valma Gleeson Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Bernice Valma Gleeson (Mrs Gleeson); b) Mrs Gleeson died as a result of a head injury which occurred due to a trip/slip or fall from standing which occurred on 20 October 2021; c) Mrs Gleeson’s cause of death was a left subdural haematoma; and d) Mrs Gleeson died on 30 October 2021 at Burnie in Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mrs Gleeson’s death. The evidence includes:

• The Police Report of Death for the Coroner;

• Tasmanian Health Service (THS) Death Report to the Coroner;

• Affidavits as to identity and life extinct;

• Report of the forensic pathologist Dr Andrew Reid;

• Affidavit of Mrs Judith Harris;

• Affidavit of Mr Christopher Blom;

• Affidavit of Mrs Maureen Heazlewood;

• Letter and records obtained from Community Transport Services Tasmania Inc.

(CTST);

• Medical records obtained from the North West Regional Hospital (NWRH);

• Medical records obtained from the Royal Hobart Hospital (RHH); and

• Medical records obtained from Mrs Gleeson’s general practitioner.

Background Mrs Gleeson was 84 years of age, widowed and she resided alone at the date of her death. Mrs Gleeson was born on King Island on 4 October 1937 to Cyril and Sylvia Denby. She was married twice first to Keith Gleeson and then to Geoffrey Gleeson (who was no relation of

Keith). Mrs Gleeson had four children to her first husband who died in a tractor accident in

1977. Mrs Gleeson married Geoffrey Gleeson in or about 1985.

Mrs Gleeson grew up on King Island and did not leave until 1973 or 1974 when the family moved to a farm in Wynyard. Her senior next of kin, her daughter Mrs Judith Harris, thinks her mother attended school until she was 14 years of age. After her first husband died Mrs Gleeson had to find work and she performed cleaning, cooking and caring for children for a local family for many years right up until her retirement at age 60.

Mrs Harris says her mother lived a healthy and active life and had no illness or time in hospital to her knowledge. She lived independently at home until she passed away and she was still licensed to drive. She had the occasional social drink, and she was not a smoker. Mrs Harris says her mother did have difficulties with her blood pressure, but this was controlled by medication.

The records of Mrs Gleeson’s general practitioner confirm what Mrs Harris says about her mother’s health. Mrs Gleeson was prescribed medication for high blood pressure. Her major health ailments in the 12 months prior to her death consisted of a number of urinary tract infections for which she was treated. Her last appointment, prior to her death, took place on 9 August 2021. The purpose of that appointment was to follow-up her recovery from a urinary tract infection. She indicated she felt much better at that time. She had also, during this period, attended her general practitioner for gastro-oesophageal reflux disease and I note she was prescribed Ventolin to assist with any breathing difficulties.

Circumstances Leading to Death On 20 October 2021 Mrs Gleeson was a passenger on a bus which was being operated by CTST. That organisation provides transport to people across Tasmania to assist them to continue living independently within the community. CTST provides door-to-door transport for both social and non-emergency medical appointments. On this particular day a bus operated by CTST had been booked by a group called the “Cam Retirees”. Mrs Gleeson had a number of friends in this group, and she regularly enjoyed the community bus tours the group would take.

CTST has advised the Cam Retirees group are a group of friends who reside in the community and who are all recipients of Commonwealth Home Support Program aged care services through My Aged Care. They are therefore eligible for subsidised community transport. They organise social activities and organise CTST to provide them with transport on a monthly basis.

The destination for the outings is chosen by the group. On this particular day the group had morning tea at Boat Harbour Beach, and they then travelled to Stanley for lunch.

While visiting Touchwood Cottages, Gallery and Cafe which is located at Stanley Mrs Gleeson stumbled on steps, which connect the gallery to the cafe at the premises and fell. Mrs Gleeson was assisted to her feet and then to a table in the cafe where she ordered and ate lunch. She was then taken to the local pharmacist in order to check her blood pressure and as a result of advice received an ambulance was called. The call was received at 2:03pm and by 3:30pm Mrs Gleeson was at the NWRH where she was assessed, a CT scan was ordered and then she was reassessed. The determination of medical staff at the NWRH was that she needed neurosurgical intervention and therefore transport was organised for her to be flown to the RHH which is the only public neurosurgical facility in Tasmania. The air retrieval team of Ambulance Tasmania was contacted at 7:00pm. By 9:40pm Mrs Gleeson was retrieved from the NWRH arriving at the RHH at 11:00pm.

After being assessed in the emergency department of the RHH she was admitted at 12:05am on 21 October 2021. At 8:30am on 22 October 2021 Mrs Gleeson underwent a procedure whereby a left sided acute subdural haematoma of the brain, resulting from the fall in the cafe, was evacuated. After surgery her Glasgow Coma Score1 remained low and the first day after the surgery was complicated by a number of focal seizures. Following her deterioration and after discussion with family members palliative care was provided. She was commenced on a syringe driver for comfort care and seizure prophylaxis and was transferred to the NWRH for ongoing care closer to her home. She passed away at approximately 11:35pm on 30 October 2021.

The Glasgow Coma Scale or Score (GCS) is a tool used to assess and calculate a patient’s level of consciousness. It uses a criteria scoring system: best eye opening (maximum 4 points), best verbal response (maximum 5 points), and best motor response (maximum 6 points). These scores are added together to provide a total score between 3 and 15. The GCS was initially used to assess levels of consciousness in patients after head injury, but the scale is now used in many acutely unwell patients. In hospitals it is also used to monitor patients in intensive care units.

Investigation A post-mortem examination was conducted by the State Forensic Pathologist Dr Andrew Reid on 2 November 2021. He noted after the neurosurgical procedure there was no further neurological recovery. As a result of his examination he determined Mrs Gleeson suffered a left subdural haematoma as a result of the slip/trip or fall from a standing position which resulted in a head strike, and this was the cause of death2. I accept his opinion.

As to the circumstances of the accident itself Mrs Maureen Heazlewood was on the trip with Mrs Gleeson on 20 October 2021. She says the group were not booked at any cafe and members of the touring party went to different places in Stanley for lunch. About eight of them, including Mrs Heazlewood and Mrs Gleeson, decided to go to the Touchwood Cottages, Gallery and Cafe. There are two entrances to the cafe, one directly from the footpath into the cafe and the second was via the gallery. The entrance to the cafe via the gallery involves two steps down into the lower part of the gallery then through a door into the cafe. A number of the group went into the gallery to browse and when Mrs Heazlewood decided to enter the cafe, she left the gallery to use the other entrance as she saw the steps leading from the gallery which she could not traverse as she uses a walker. Some other members had entered the cafe via the steps, and she says Mrs Gleeson appeared to be heading towards the steps.

Mr Blom who runs the gallery and cafe says he observed members of the group using the different entrances to the cafe. A short time later he says he was unaware that anybody was still in the gallery when he heard a noise in the direction of the cafe. He noticed a lady, later identified as Mrs Gleeson, on the carpeted floor on the lower level of the gallery. She was seated with her legs folded to one side and she appeared to be struggling to get up. He asked Mrs Gleeson if she was all right and she replied that she had stumbled on the steps and fell down. He advised her not to rush to her feet and when she was ready, he assisted her and he observed a white mark on her forehead. He indicated to Mrs Gleeson that she had obviously banged her head on the floor so he thought she would have a headache. Mrs Gleeson said she would be all right once she got up at which point Mr Blom suggested an ambulance be called however Mrs Gleeson declined. Mr Blom assisted her to her feet and held her by one arm while she was standing to ensure she maintained her balance and he then assisted her to the 2 Consistent with this opinion is the opinion set out in the Death Report to the Coroner of the THS that the cause of death is a traumatic subdural haematoma after a mechanical fall.

cafe about 20m away after which he seated her at a table with her friends and arranged an ice pack which was applied. He asked other staff to keep an eye on Mrs Gleeson. After consuming her lunch she indicated she was feeling unwell, and she thought her blood pressure had risen so a decision was made to take her to the pharmacist in Stanley to check her blood pressure as there is no doctor or other medical service available in that town. One of Mr Blom’s staff members assisted Mrs Gleeson to the pharmacy which was approximately 150 metres away.

Mrs Harris has raised a number of concerns which include questioning whether there was sufficient follow-up and ongoing risk prevention such as managing her blood pressure after Mrs Gleeson suffered a serious fall on 1 August 2021. She also queries whether or not her mother was subject to a care plan with one being updated following that fall or whether she had any referrals such as physiotherapy to assist with falls prevention. She says such referrals exist and she is sure that if one had been offered her mother would have taken up that offer enthusiastically. She says she encouraged her mother to take up physio as she had noticed Mrs Gleeson would lose her balance occasionally and was not lifting her left foot properly when she walked, and these were characteristics of her gait that were evident even before she fell on 1 August 2021.

In relation to the fatal fall, she wonders if her surgery had been done earlier could there have been a better chance of a successful outcome. The family was initially advised on Thursday, 21 October 2021 that her surgery would not take place until 25 October 2021 and she was surprised by the lengthy delay and the rationale was not explained in any detail apart from mentioning that she had been using aspirin. However, because her condition deteriorated emergency surgery took place on 22 October 2021. She also mentions the adverse effects of the COVID-19 pandemic lockdown and she feels immediate family should have been able to visit her mother as soon as possible after her transfer and the treating staff may have benefited from contact with the family by way of history. She also feels there was not enough contact from the treating surgeon. The family only received feedback from nurses via the telephone.

Dealing with Mrs Harris’ final concerns first. I have previously made comment in other investigations as to the difficulties which the COVID-19 pandemic caused, and in some cases continues to cause, many people in our community. For example, people in hospital, like Mrs Gleeson, were isolated from family members and the frail and elderly in nursing homes were

also isolated from loved ones. This had a deleterious effect on the mental health of many people. At the time the Tasmanian Government was attempting to protect the community from a deadly pandemic; a situation which had not been experienced for approximately 100 years. At the end of the day such matters are matters of Government policy over which a coroner has no jurisdiction. The only comment I make is that hopefully a review is conducted into the Tasmanian response to the pandemic and issues such as those raised by Mrs Harris are taken into account in that review. There being contact only with nurses rather than the surgical team is a communication issue over which a coroner has no jurisdiction. If Mrs Harris wishes to pursue this matter, I can only suggest she contacts the RHH and/or the Health Complaints Commissioner of Tasmania.

In so far as the fall on 1 August 2021 is concerned, I have considered the medical records in detail. On that day Mrs Gleeson was due to see her general practitioner for a review with respect to a urinary tract infection. Prior to her reaching the surgery Mrs Gleeson fell in the car park when it was raining, and she tripped over a concrete parking bollard and suffered a significant impact to her forehead and severe bruising to her right thigh. She was assessed by her general practitioner. It was noted she was known to have high blood pressure for which she took medication. A history was taken, and she was examined. Mrs Gleeson denied any loss of consciousness. Her blood pressure was taken and not surprisingly, given the significant injury sustained, it was elevated; that is her blood pressure was in excess of previous readings which appear on the file. A referral was provided to the NWRH and Mrs Gleeson was taken by ambulance to that facility. There she was admitted to the emergency medical unit where a history was taken, her forehead wound was treated, and a chest x-ray was organised as was a CT of the brain. No abnormality was detected on the chest x-ray and fluid was detected in the right maxillary sinus and there was a soft tissue haematoma of the right periorbital detected on the CT scan. Otherwise no other abnormalities were detected. There was no loss of consciousness, no syncope, no chest pain, and no dizziness before the fall. After the fall there was no loss of consciousness, no amnesia, no seizures, no nausea or vomiting, no headache, no dizziness, no blurring of vision and no chest pain. Her medical history was noted as was her medication regime and a full assessment was undertaken. It was determined after she had been assessed and diagnosed that she could go home. She was advised that if she developed a vision disturbance, a severe headache, syncope or any other concerning symptoms then she was to return to the emergency department. There are no ongoing effects of the fall recorded in the NWRH records.

On 2 August 2021 Mrs Gleeson was reviewed by her general practitioner. Her blood pressure had returned to its normal level. At the review on 9 August 2021, she indicated she was feeling a lot better.

Given the thorough assessment conducted at the NWRH and the reviews conducted by the general practitioner on 2 and 9 August 2021 it appears Mrs Gleeson had returned to her prefall level of function. She did not develop any of the symptoms in respect of which she was advised to seek further treatment. In those circumstances I do not believe Mrs Gleeson required a care plan or a physiotherapy referral because of that fall. The medical treatment she received was appropriate and thorough.

In so far as Mrs Harris’ concerns with respect to the surgery are concerned it is clear Mrs Gleeson suffered a very serious head injury which required neurosurgical intervention. The surgery was conducted by the surgeon Mr Charles Fish. The supervising consultant was the very experienced neurosurgeon Mr Nova Thani. In addition, it was noted Mrs Gleeson was taking aspirin which is a blood thinner. Blood thinners of themselves can increase the risk of bleeding and in so far as the brain is concerned that can cause haemorrhagic strokes.

Accordingly, before any major surgery, which clearly includes the surgery required in this case, a person needs to be weaned from their blood thinning medication and/or be provided with medication which restores platelet aggregation. The recommendation, in so far as aspirin is concerned, is that a person should cease taking that medication for up to a period of 7 days prior to surgery. Clearly that length of time was not appropriate in this case given the seriousness of the injury. A decision therefore had to be made as to the appropriate time to wait, given the seriousness of the injury and the effect of the blood thinner and the risk associated with that medication during such surgery, before the surgical team commenced the surgery.

In addition, a patient experiencing seizures after surgery is not an uncommon complication of brain surgery and a traumatic brain injury of itself can cause seizures. It is therefore not unusual that post operatively Mrs Gleeson suffered several focal seizures. A report in the medical records says Mrs Gleeson’s post-operative deterioration was “thought to be due to hemispheric infarcts secondary to the SDH3 itself, with possible contribution by the surgical treatment”. The infarct 3 Subdural haematoma.

is an area of necrosis of brain tissue caused by blood vessel blockages. These were a result of the head injury sustained in the fall and the report says they were possibly contributed to by the surgical treatment which was necessary if Mrs Gleeson was to have any chance of survival.

As to Mrs Harris’s ultimate question: that is if the surgery had been performed sooner would there have been a better chance of a successful outcome, I think this is unlikely. I say this because of a combination of factors which include the seriousness of the injury, the fact that some period of time had to elapse to reverse the effect of the blood thinning medication and the significant risks which are associated with surgery of this nature. In addition, and generally speaking an older person, such as Mrs Gleeson, does not do as well after such surgery as a younger person does.

Finally, when speaking to my associate Mrs Harris indicated she thought the steps which her mother was attempting to negotiate were too small to see and she was concerned that others could fall. A coroner must make recommendations with respect to ways of preventing further deaths if he or she considers such a recommendation is appropriate4. Accordingly, the scene of this accident has been examined. There are 2 steps in the gallery or gift shop which lead to a lower area of the gift shop at the end of which there is a door which leads into the cafe. The carpet above and below the steps is the same grey colour. The first step one would come to, before traversing the steps into the lower area of the gift shop, is carpeted and it has a metal strip at its edge. To the left of the first step as it is approached from the upper level of the gift shop is some shelving upon which items for sale are displayed. On the second shelf is a sign in black writing on a white background which says, “Please Mind The Steps.” The second step is not carpeted but is made of polished timber. On the front edge of that step is a red and white sticker which extends for the length of the step which is available for patrons to use, and which is obviously in place to warn people of its presence. Looking at the steps from the lower area of the gift shop there is the same warning sign fastened to the face of the first step.

These days Stanley is a popular tourist town on the North-West coast of Tasmania. There are a number of attractions to visit both in the town and its nearby surrounds. No doubt many of these tourists visit Mr Blom’s business to purchase a souvenir, attend the cafe and/or stay in one of the cottages. Many of the visitors to his business will be elderly and many of those will 4 Section 28(2) of the Coroners Act 1995.

have difficulties with mobility which is what occurred on 20 October 2021. Having assessed and considered the scene of the accident I do not think the steps were too small. I do however think the warning signs are not big and distinctive enough because the walls and ceiling of the shop are the same colour as the background of the signs which tend to fade into the background especially when people are concentrating on the very many gifts one could purchase from Mr Blom. I therefore recommend that a much larger sign in very bold and distinctive colours warning of the presence of the steps be erected in both directions so there is one facing foot traffic going down the stairs and one facing foot traffic coming up the stairs.

Comments and Recommendations A draft of this decision was forwarded to Mr Blom by email. In the email he was invited to provide any comments he wished to make about the decision. This was done to ensure he was afforded procedural fairness by providing him with an opportunity to comment and so that I could take into account any comments he wished to make, and amend the draft decision if needs be, before the decision was finalised and published. He did not respond.

The circumstances of Mrs Gleeson’s death are not such as to require me to make any further comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of Mrs Gleeson.

Dated: 2 May 2024 at Hobart in the State of Tasmania.

Magistrate Robert Webster Coroner