Inquest into the death of MERREN ELIZABETH BARTLEY

CORONER’S COURT OF THE AUSTRALIAN CAPITAL TERRITORY Case Title: Inquest into the death of MERREN ELIZABETH BARTLEY Citation: [2023] ACTCD 9 Hearing Date: 27 June 2023 Decision Date: 27 June 2023 Before: Coroner Russell Decision: See [23].

Catchwords: CORONIAL LAW – death in care – cause and manner of death – whether issue with quality of care, treatment or supervision – whether matter of public safety arises.

Legislation Cited: Coroners Act 1997 (ACT) sections s3BB, 13(1)(i), 34A(2), 52, 74 Mental Health Act 2015 (ACT) Counsel Assisting: Ms Rebecca Evans File Number CD 332/2021

CORONER RUSSELL

1. Merren Elizabeth Bartley died at the Adult Mental Health Rehabilitation Unit of the University of Canberra Hospital in the early morning of 5 November 2021. At the time of her death she was subject to a Psychiatric Treatment Order made on 17 May 2021 for a period of six months.

Jurisdiction and functions of the Coroner

2. An inquest, including a hearing, is mandatory in relation to Ms Bartley’s death. The death of a person subject to a Psychiatric Treatment Order is a death in care (s3BB of Coroners Act 1997). A Coroner must hold an inquest into the manner and cause of death of a person who dies in care (s13(1)(i) of the Act) and, in such circumstances, a Coroner must not dispense with a hearing (s34A(2)).

3. Section 52 of the Act sets out, relevantly, the principal functions of a Coroner conducting an inquest. Those are to record the identity of the person who has died, the date and place of her death and the manner and cause of that death. The Coroner must

also state whether a matter of public safety is found to arise in connection with the inquest and, if so, comment on the matter.

4. In relation to a death in care, section 74 of the Act requires that findings also be made about the quality of care, treatment and supervision of the deceased person that, in the opinion of the Coroner, contributed to the cause of death.

Background

5. Merren Bartley was 67 years old at the time of her death. She grew up on a family farm in Narrandera, New South Wales with her parents, Muriel and George Bartley, and her brothers Glen and Maurice. In 1970 she married and moved to Canberra, where she lived, with her husband, in Torrens.

6. In the 1990s Ms Bartley’s mental health became significantly worse and she began experiencing paranoid delusions. In 1999, she and her husband divorced and she remained living in the Torrens residence.

7. In October 2013, a deterioration in Ms Bartley’s mental health necessitated an involuntary detention order followed by a Psychiatric Treatment Order for a period of six months, under the Mental Health (Treatment and Care) Act 1994. From that time, in order to manage her mental health, Ms Bartley was subject to a succession of Psychiatric Treatment Orders. The records indicate that she had been on clozapine, at times combined with other antipsychotic medication, since the late 1990s, to manage, what was diagnosed as, schizophrenia. Despite that treatment regime she required frequent admissions to hospital to manage psychotic symptoms and, in the community, ongoing monitoring of her compliance with the requirement to take clozapine in the quantity, and with the frequency, required. Side effects of clozapine were monitored through regular blood tests.

8. In addition to her mental health problems, Ms Bartley suffered from significant physical health problems. Those included atrial bigeminy, pulmonary hypertension, systemic hypertension, dyslipidaemia, hepatic steatosis and clozapine-related recurrent constipation.

Admission to hospital 2021

9. In March 2021, she was admitted to The Canberra Hospital in hypovolaemic shock with intra-abdominal sepsis and ileus.

10. Ms Bartley underwent surgery at The Canberra Hospital in March 2021. She was discharged from the surgical unit to the Adult Mental Health Unit of that hospital and then to the Older Person’s Mental Health Unit at Calvary Hospital. On 9 August 2021, she was discharged from the Older Person’s Mental Health Unit and admitted to the Adult Mental Health Rehabilitation Unit of the University of Canberra Hospital. At the time of her death, she was in that unit awaiting suitable supported accommodation in the community because it was the opinion of clinicians, supported, the records suggest, by Maurice Bartley, that she could no longer cope living on her own. A functional assessment of Ms Bartley, together with a home visit, had led those treating her to conclude that she could not safely return to her home and live on her own. On

application, the ACT Civil and Administrative Tribunal (ACAT) appointed Ms Bartley’s brother, Maurice, as her guardian.

Cause of death

11. An autopsy was conducted by Professor Johan Duflou, forensic pathologist, on 9 November 2021. Professor Duflou noted a. extensive heart disease, with advanced coronary arthrosclerosis, a benign tumour in the atrial wall and dilation of the heart (dilated cardiomyopathy) – the coronary artery disease additionally showed perimortem plaque haemorrhage, typical of a ‘heart attack’ immediately preceding death.

12. In his opinion, Ms Bartley’s death was caused by ischaemic heart disease.

13. I find that the cause of death was ischaemic heart disease.

Manner of death

14. At the time of her death, Ms Bartley was an inpatient at the Adult Mental Health Rehabilitation Unit of the University of Canberra Hospital.

15. The progress notes record that, about 6:30pm on Thursday, 4 November 2021, she had a minor fall onto her knees while she was putting her food tray on a trolley. She was observed to use the wall and the trolley to break her fall. Small, reddened areas were noticed on her knees but there was no bony tenderness. She was assisted to her feet by staff members and vital observations were taken.

16. In his autopsy report, Professor Duflou identified no injuries on Ms Bartley’s body. The evidence establishes that that minor fall had no impact on her death.

17. Hospital records note that Ms Bartley went to bed as usual and was to be monitored two hourly. Overnight observations on 4/5 November are recorded at 9:40pm, 11:30pm and 1:30am. At 1:30am, it was confirmed that she was asleep. The rise and fall of her chest was observed, as was the fact that she had changed position from that observed at 11:30pm. Those observations were done remotely. At the next observation, recorded at 3:40am, it was noted that her leg was off the bed. A member of the nursing staff entered the room and found Ms Bartley unresponsive. Resuscitation was started and the Medical Emergency Team were called. However, Ms Bartley’s body was cold and rigid. She was pronounced life extinct at 3:56am.

18. The evidence establishes, and I find, that Ms Bartley died of natural causes.

Date of death

19. Ms Bartley died in the early morning of 5 November, 2021.

Place of death

20. I find that Ms Bartley died at the Adult Mental Health Rehabilitation Unit of the University of Canberra Hospital, 20 Guraguma Street, Bruce, in the Australian Capital Territory.

Quality of care, treatment and supervision

21. Ms Bartley died, at the age of 67, as a result of ischaemic heart disease. An examination of her medical records provides no basis for any finding that the quality of care, treatment and supervision provided to Ms Bartley at The Canberra Hospital or at the Adult Mental Health Units at Calvary Hospital or the University of Canberra Hospital or that provided by the mental health services in the community, contributed to that ischaemic heart disease, the cause of her death.

Matter of public safety

22. I do not find that any matter of public safety arises in connection with the inquest.

Findings:

23. I make the following findings: i. Place of death: Merren Elizabeth Bartley died at the Adult Mental Health Rehabilitation Unit of the University of Canberra Hospital, 20 Guraguma Street, Bruce, in the Australian Capital Territory.

ii. Date of death: 5 November, 2021.

iii. Cause of death: ischaemic heart disease iv. Manner of death: Natural causes Concluding remarks

24. I extend my condolences to Ms Bartley’s family.

25. I close this inquest.

I certify that the preceding twentyfive [25] numbered paragraphs are a true copy of the Reasons for Decision of her Honour Coroner Russell.

Counsel Assisting: Rebecca Evans Date: 27 June 2023