Inquest into the death of Sybil ZIMMERMAN

STATE CORONER’S COURT OF NEW SOUTH WALES

Inquest: Inquest into the death of Sybil Zimmerman

Hearing dates: 10-13 February 2014

Date of findings: 14 March 2014

Place of findings: State Coroner's Court, Glebe

Findings of: Deputy State Coroner H.C.B. Dillon

Catchwords: CORONIAL LAW - Nursing home death -- Cause and manner of death - Whether deceased overdosed with medication ~ If so, whether overdose contributed to’ death - Whether gross negligence or homicide by, nursing staff - Unfounded allegations: comment by' coroner

File number: 2011/00389491

in Representation: Mr P. Griffin (Counsel Assisting} instructed by Ms J.

Geddes, Crown Solicitor’s Office

Mr R. Lewis, Solicitor (Michelle and Adele Zimmerman)

Ms K Richardson i/b Ms N Meadows, Tress Cox (Catholic Health Care & Nurses Tily, Rush and Pinkerton)

Mr C. Jackson {/b Mr T. Mineo, Avant Law (Dr Singh}

Ms L. Alexander, Nurses’ Association (RNs Chaplin & Handley)

Ms L. Toose, Nurses’ Association (RN Kuwaza)

Findings:

I find that Sybil Zimmerman died at the Blue Mountains District Hospital, Katoomba, New South Wales on 15 May 2011 and that it is more probable than not that the cause of her death was a coronary artery thrombosis ona background of multiple co-morbidities including cerebrovascular disease, cerebral infarcts, pneumonia and, dementia.

CONTENTS

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Introduction

Mrs Sybil Zimmerman, an 84 year-old woman suffering from multiple comorbidities, died in the Blue Mountains District Hospital at Katoomba on 15 may

2011. She had lived at the Bodington Aged Care facility in Wentworth Falls for about a year and had previously been cared for at another nursing home and before that by her children, especially Michelle Zimmerman, for about four years,

Following her death, her family, Michelle Zimmerman in particular, made a number of allegations that Mrs Zimmerman had been mistreated by Bodington staff and that she had died as a result of either gross negligence or perhaps had even been involuntarily “euthanased” [ie, murdered].

Mrs Zimmerman had a lengthy history of heart disease, stroke, dementia, chronic airways disease and atrial fibrillation, Any one of these conditions, or any combination of them, could have caused her death.

Her daughters Michelle and Adele Zimmerman, however, have alleged that their mother died not as a result of natural causes but because she was overdosed with morphine. They also assert that the nursing staff of the Bodington Aged Care facility responsible for this claimed overThe cause and circumstances of Mrs Zimmerman’s death, therefore, are the primary issues in this case.

{tis seltevident that such a claim is very grave and could have the most serious of consequences for the nurses responsible for the administration of the overdose, if such action were proven, Itis also self-evident that making such allegations -- implying, at best, gross negligence and, at worst, murder — without a reasonable or proper basis is damaging, unfair and, indeed, scandalous.

Ido not doubt that the Zimmermans were deeply upset by the death of their mother, to whom they were both very attached, and felt that the care and treatment their mother received at Bodington was unsatisfactory. It is, however, one thing to be dissatisfied with the care given to an elderly and vulnerable parent, altogether another to accuse the staff of Bodington of having fatally overdosed her.

In my view, for reasons that I will elaborate below, the evidence demonstrates, firstly, that it is highly unlikely that Ms Zimmerman was overdosed and, secondly, that even if she received a higher dose than was prescribed, it is unlikely to have had a fatal effect on her. It follows that I dismiss the suggestion of a cover-up.

Tt may have been reasonable initially for the Zimmermans to raise the question whether their mother had been overdosed and, if so, whether that had had a fatal effect on her. But to elevate such questions or suspicions into allegations of fact without a substantial foundation of evidence was misconceived and profoundly unfair to the nurses whom they accused. I also consider that, in taking this course as far as they did, they were badly advised. I will now explain my reasons for these conclusions.

The background

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The immediate events leading up to Mrs Zimmerman’s death were as follows:

On 10 May 2011, she was reported to suffering from suspected vaginal bleeding and was transferred to the Blue Mountains District Hospital where she was seen by a doctor in the Emergency Department. She was given fluids but no further treatment as the bleeding had stopped. Her guardian, Ms Michelle Zimmerman, had previously signed an Advance Care Directive with a stated goal of her care was that a “palliative” approach was to be taken. In the plan this was described as providing care in which “everything possible will be done to keep the resident comfortable and maintain the best possible quality of life, unti] natural death occurs.”

Of relevance to this case, the plan further explained that this would include giving her “medications to manage symptoms including pain and agitation.”! The medical records show that Mrs Zimmerman suffered chronic pain and was frequently agitated.

Later that day, Ms Michelle Zimmerman saw Dr Satwant Nijher Singh, Mrs Zimmerman’s General Practitioner at his practice in Leura. He reviewed her medications.

That evening Mrs Zimmerman was given 10mg of Ordine, an oral opoid analgaesic, to “settle” her. A further LOmg dose was given at 0115 hours the following morning.

At 0730 hours on 11 May, she was offered another 10mg dose of Ordine but spat most of it out immediately. Asa result, staff at Bodington decided to seek an order from Dr Singh for morphine to be administered subcutaneously (under the skin).

Subcutaneous morphine is absorbed more efficiently than oral morphine. The general rule of thumb applied is a 1:2 ratio (ie, one measure of subcutaneous morphine for each two measures of oral morphine}.

During the afternoon, at the request of Ms Chariotte Tily, the manager of the facility, Registered Nurse Chaplin got in touch with Dr Singh who faxed through an order for subcutaneous morphine. The first subcutaneous dese was administered at about 2030 hours that evening.

The quantity administered is in dispute. The contemporary medical records indicate that 5mg was administered. Michelle Zimmerman, however, asserts that 10mg was in fact administered and that there has been a cover up by nursing staff at Bodington. | will deal with the disputed evidence below.

Early in the morning of 12 May 2011, when seen by night Nurse Noah Kuwaza, Mrs Zimmerman was found to be drowsy and unresponsive. He made a note for the shift coming on duty, “Nil PRN [as needed] morphine required. If patient drowsy due to morphine dose may need to be reviewed.”

Mrs Zimmerman was drowsy and slept most of the day. Her daughters saw her at about 1500 hours. Michelle Zimmerman left soon afterwards. By 1700 hours or so,

1 Advanced Care Plan 17 September 2010 Part 3.

it was clear that she was deteriorating. Adele Zimmerman called Michelle Zimmerman and told her to come te the facility.

Shortly after her arrival, a friend of Michelle Zimmerman, Ms Moira McGhee, and Ms Zimmerman discussed Ms Zimmerman’s theory that Sybil Zimmerman had been overdosed with morphine, Ms McGhee suggested calling Crimestoppers. Ms Zimmerman agreed and asked Ms McGhee to make the call. Michelle Zimmerman then spoke to the operator claiming that Mrs Zimmerman had been given a narcotic overdose which had caused her to lapse into a coma and would be likely to result in her death. An ambulance was despatched and arrived at about 1800 hours that evening. Mrs Zimmerman was transported to hospital where she remained comatose, was kept comfortable but no attempt was made to resuscitate her.

Police also attended the hospital and Bodington. Even before Mrs Zimmerman had died, Michelle Zimmerman told police that she wanted an autopsy and a coronial investigation.

Mrs Zimmerman died at about 2050 hours on 15 May 2011. .

On 17 May 2011, an autopsy was carried out by Professor Johann Duflou, the Clinical Director of the Department of Forensic Medicine in Glebe. He found that the most likely cause of death was coronary artery thrombosis and that cerebrovascular disease with recent and remote infarcts and dementia were contributory causes. He also found that Mrs Zimmerman had been suffering from pneumonia and that this was a possible cause of her death,

He stated in his report that if she had received an excessive dose of morphine this may have depressed her Mrs Zimmerman’s respiratory system and brought on the pneumonia. On the other hand, he considered that the pneumonia may have been entirely coincidental, In his view, it was not possible to be certain as to the possible role morphine may have played in Mrs Zimmerman’s death.

Following Mrs Zimmerman’s death, her daughters made complaints to the Aged Care Complaints Investigation Scheme (a Commonwealth government agency) and the Health Care Complaints Commission {a NSW government agency).

Neither found the claims that Mrs Zimmerman had died as a result of an overdose had been made out. The ACCIS found that there was insufficient evidence to establish the subcutaneous dose was not in accordance with the prescribed and charted dose but left the question of the cause of death to the coroner. The HCCC’s medical advisers took the view that “itis unlikely that [Mrs Zimmerman] experienced an overdose of morphine.”

Following representations from the Zimmermans and their lawyer, the then State Coroner ordered that an inquest be conducted.

The role of the coroner

Where a known person has died at an identified place on a specific date, the coroner's role is usually to investigate the cause and manner, or circumstances, of that death. In this case, those are primary issues with which we are concerned.

Coroners have limited jurisdiction. It is not the role of coroners te conduct miniRoyal Commissions or general commissions of inquiry in every matter that may be of interest in a particular case. Superior courts have frequently emphasised that “the coroner’s source of power of investigation arises fram the particular death or fire’? and that an inquest is not a “roving Royal Commission” 3.

The issues

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The major issues with which this inquest has been concerned are: i) Whether Sybil Zimmerman was overdosed with morphine; (ii) ‘If so, whether that overdose caused or contributed to causing her death;

(iii) Whether there was a cover-up by nursing staff at Bodington of an overdose; and

(iv) [ff Mrs Zimmerman did not die as a result of a morphine overdose, what did cause her death.

Mr Lewis, on behalf of the Zimmerman family, also submitted that I should investigate issues to do with the chemical “restraint” (ie, sedation) of elderly patients and consent to the administration of anti-psychotic drugs and subcutaneous morphine and other matters relating to the general management of Mrs Zimmerman’s care and treatment.

In my view, those issues did not arise in this jurisdiction unless they related to the death of Mrs Zimmerman. The threshold questions are those outlined above. If Mrs Zimmerman was not overdosed, or ifany proven overdose did not accelerate her death, general questions concerning the care and treatment of Mrs Zimmerman had no relevance in this inquest.

For the reasons explained below, I have concluded that Mrs Zimmerman was not overdosed or, if she was, that the alleged overdose did not cause or contribute to her death. [ have therefore not addressed the more general issues raised by Mr Lewis.

They fall within the jurisdiction of other agencies.

Was Sybi! Zimmerman overdosed with morphine?

While there is some scanty evidence suggesting that Mrs Zimmerman may have been overdosed with morphine on the evening of 11 May 2011, the overwhelming weight of evidence suggests otherwise.

There are only three pieces of evidence supporting a possible finding of overdose.

Firstly, Michelle Zimmerman claims to have had a conversation with by RN Chaplin on the afternoon of 11 May in which she told RN Chaplin that Dr Singh had stopped

? Harmsworth v State Coroner (1989[ VR 989 at 996 per Nathan J.

3 Doomadgee v Deputy State Coroner Clements [2005] QSC 357 at [29]; see also R v Doogan, ex p. Lucas-Smith [2005] ATSC 74 and Lucas-Smith v Coroner’s Court of the ACT [2009] ACTSC 40,

Mrs Zimmerman’s Serenace medication (an anti-psychotic drug that is sometimes used for its sedative effects in patients suffering from dementia) and that he had prescribed 10mgs of Ordine at night instead. Ms Zimmerman’s evidence is that RN Chaplin and she then had an argument in which RN Chaplin stated that she would speak to Dr Singh about getting an order for 10mgs of morphine four-hourly by “butterfly needle” (ie, subcutaneously). Ms Zimmerman claims that she spoke to RN

Chaplin the following day and that Chaplin said to her, “I should have only given Smgs”.

Those conversations are denied by RN Chaplin. They are also contradicted by other evidence.

On 11 May, after Mrs Zimmerman had spat out her Ordine, Ms Charlotte Tily, the Bodington manager, sent a fax to Dr Singh requesting an order for subcutaneous morphine, That fax was sent at about 0950 hours. RN Chaplin's shift did not commence until 1430 hours, Whether or not RN Chaplin later spoke to Dr Singh, it could not have been she who initiated the order for subcutaneous morphine.

The pharmacy’s record shows that the order it received from Dr Singh was a script for 10mg ampoules of morphine with 5mg(0.5 mi} of the drug to be injected subcutaneously every four hours as needed,

The second piece of evidence advanced by Ms Zimmerman to support her claim is that she says that on the evening of 12 May she spoke te Dr Singh who told her that he had ordered only one injection of 10 mg of morphine.

Dr Singh, unfortunately, had died by the time the inquest took place and we do not have his version of that conversation. We do not know from him whether there was a conversation even broadly approximating the version given by Ms Zimmerman, If there was, we do not know whether he volunteered the figure “10” or whether that was put to him by Ms Zimmerman. We do not know whether he was confused by the sudden accusation that 10mg had been administered. We do not know whether Dr Singh was concentrating on the dosage amount or the fact that there had been only a single dose administered.

In a letter dated 7 September 2011 to the HCCC, Dr Singh wrote:

Mrs Zimmerman was In poor physical state for a few days before this episode. She was in congestive heart failure and was experiencing difficulty breathing and appeared to be in a lot of pain.

Mrs Zimmerman was provided morphine to keep her pain free. The morphine was to relieve her symptoms and to make her comfortable in an atternpt to relieve her discomfort from breathlessness...

Mrs Zimmerman had been prescribed 10mg oral Ordine on 10" May 2071.

Gn the evening of 11 May 2011, | was contacted by Registered Nurse Linda Verity. She described Mrs Zimmerman as being in pain and having difficulty breathing. f was asked to approve the administration of 10mgs morphine subcutaneously. Based on the advice given by the nurse | approved the administration of the morphine, (Emphasis added.)

| kept the family informed about the treatment provided to Mrs Zimmerman and | did not falsify my notes as they claim I have. In fact, | did speak to Ms Michelle Zimmerman on

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the afternoon of 12" May 2011. I was not aware that she was alarmed by my course of treatment at that time.

Anumber of comments must be made about this letter.

First, it was written several months after the events in question and Dr Singh ran a busy practice, This may have affected his recollection. He was incorrect in nominating RN Verity as the nurse to whom he had spoken.

Second, by September 2011 Dr Singh was well aware that Ms Michelle Zimmerman had been making complaints about him to the HCCC and ACCIS and that she was claiming that Mrs Zimmerman had been injected with 10mg of morphine. This too may have affected his recollection.

Third, the contemporaneous records not only from Bodington but from the pharmacy which dispensed the prescription show that Dr Singh in fact intended to prescribe Smgs of subcutaneous morphine on the evening of 11 May. The contemporaneous records are, prima facie, more reliable than reconstructed evidence produced months after the events in question.

Fourth, the contemporaneous records - the Schedule 8 drugs register and medications chart -- made at Bodington {as well as the evidence of the nurses) suggest that Dr Singh's order was carried out as directed.

Fifth, Dr Singh told the investigating police that he had prescribed Smg. Assuming that he was telling the truth, this contemporaneous record is likely to be more reliable than a statement made based on a recollection by then several months old and which may have been distorted by the claims of 10mg.

In the context of the complaints being made about Mrs Zimmerman being prescribed 10mgs , it seems likely that Dr Singh became confused and did not make an explicit distinction in the letter to the HCCC between ordering the supply of 10mg ampoules to Bodington and only 5mg being injected per dose. At most, his letter suggests that Dr Singh recalled having prescribed 10mg ampoules. Written months after the contemporaneous records, it cannot be relied on to prove an overdose was administered.

The Bodington records directly contradict the Zimmermans’ claims. They purport to show not only that Smgs of morphine was administered on the evening of 11 May but that when the allegations of an overdose were made, and checks were conducted on the Schedule 8 drugs, the $8 register balanced. If the Zimmermans are correct, not only did RN Chaplin administer an overdose but she and the checking nurse must have conspired to falsify the record. The person(s} who later checked the register against the drugs held in the $8 drugs vault presumably also later joined the conspiracy. While this is possible, it is implausible.

How and why Michelle Zimmerman jumped to the immediate conclusion on 12 May that her mother had been fatally overdosed is difficult to understand. The most compelling explanation is that Ms Zimmerman read Nurse Kuwaza’'s note about her mother being drowsy and perhaps needing her morphine adjusted, saw her mother’s and assumed that her mother’s condition was attributable to the morphine rather than to one or more of her co-morbidities. Despite an invitation to de so, no

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independent expert pharmacological or medical evidence has been produced by the family supporting their claims.

This appears to be a classic case of a person assuming a causal connection on the basis of a coincidence because there was no other positive and objective evidence of an overdose.

The court heard uncontested evidence that the relationship between Ms Zimmerman and the nursing staff at Bodington was tense and unhappy. She was dissatisfied with the care Bodington staff were giving her mother and spent hours in the home providing care herself.

The nurses at Bodington were not in a position to provide uninterrupted ane-onone care to Mrs Zimmerman. Nevertheless, Michelle Zimmerman, with her own nursing experience, cast a particularly critical eye over the way the Bodington staff managed her mother’s care. Whether there was substance in her general complaints [ am not in a position to say. [tis clear, however, that, because of her antipathy towards the Bodington staff, she could not bring an open mind to the question of whether her mother had received an overdose or the more probable answer that her mother had died naturally.

Given the relatively small dose of morphine administered and the fact that Mrs Zimmerman was suffering multiple potentially fatal co-morbidities, is it likely that RN Chaplin, a very experienced geriatric care nurse, would have concluded that the most likely cause of Mrs Zimmerman’s deterioration was the morphine dose? I doubt it.

And is it likely, given Michelle Zimmerman’s abrasive relationship with the Bodington staff, that on 12 May RN Chaplin woutd have admitted to her of all people that she had overdosed Mrs Zimmerman (thereby implying that she believed that this was the cause of Mrs Zimmerman’s lapse into unconsciousness)? | do not think

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In my view, the overwhelming weight of evidence shows that Mrs Zimmerman almost certainly received on a Smg subcutaneous dose of morphine sulphate.

Did Sybil Zimmerman die as a result of a morphine overdose?

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Even if, for argument’s sake, | am wrong and Mrs Zimmerman was was given more morphine than was prescribed, that is 10mg rather than Smg subcutaneously, the independent pharmacological and medical evidence does not support the claim that this caused or contributed to her death.

On the contrary, even if she received 10mg, the independent expert evidence is that this was a small dose that would have been unlikely to have had any adverse effect on her.

Dr Ernest Tam, a consultant physician and geriatrician, gave evidence that “the vital signs of Mrs Zimmerman at the ambulance showed no effect of morphine. Morphine administration, whatever the dosage given to Mrs Zimmerman at the Aged Care Facility, is not implicated in the cause of her death.” He gave evidence that had she

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been affected by morphine, he would have expected her to have a slow heart rate (bradycardia), pinpoint pupils and depressed respiration. None of those signs were evidenced by the ambulance records.

He gave evidence that caution should be exercised in administering morphine to elderly patients with co-morbidities but that the generally acceptable range was 520mg of morphine subcutaneously injected.

In his view, the medical records showed that Mrs Zimmerman was deteriorating, in pain and that the morphine administered by the nursing staff would have provided her with relief from her pain but not accelerated her death.

Dr Jonathon Arnold, a consultant pharmacologist, in a report dated 4 September 2012, stated “... it would be difficult to sustain that a S5mg subcutaneous dose would have provoked a dramatic decline in Mrs Zimmerman’s health.” He went to state that “Ifa subcutaneous dose of 10mg of morphine was administered this would be of greater concern.” In his oral evidence, however, he said that 5mg was a very low dose. In his view, a “high” dose would have been in the order of 30mg of morphine and 10mg was a low dose, unlikely to have had adverse effect on Mrs Zimmerman because of the long gap between doses.

At the Blue Mountains Hospital, Dr Jeffrey Franks found that she was deeply unconscious but displaying no signs of morphine overdose. She had a loud systolic murmur and decreased air to the right lung, Her vital signs were normal other than a rapid heart beat. The working diagnosis reached was that she had probably had a stroke.

Was there a cover up?

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Apart from the principal allegation that the nursing staff had overdosed their mother, the Zimmermans also alleged that they had covered up their misdeed by falsifying the records. Michelle Zimmerman did not claim that the records had been altered but that the $8 drug register and medication chart had been inaccurately filled out to show that 5mg had been administered when in fact 10mg had been.

As I have previously explained, to accept this theory, I would first have to make a finding that at least three people at Bodington had conspired together to cover the tracks of the errant nurse.

Further, I would have to make a finding that, contrary to the required practice, the S8 register was not filled out and witnessed at the time the drug was drawn up, but that RN Chaplin and Nurse Pinkerton went back afterwards and filled it out.

By advancing this theory in her evidence, Ms Zimmerman, in my view, was clutching at straws. Apart from the inherent implausibility of this suggestion, Ms Zimmerman presented as a witness whose evidence the time she gave it in courtin 2014 was largely reconstructed to conform with the theory that she had begun developing on the evening of 12 May 2011.

Signs of this tendency are found in her ever more detailed and elaborate statements produced over a period of years and in her propensity to view all sorts of

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behaviours and conduct on the part of the Bodington staff and Dr Singh as evidence of malfeasance. For example, in her first statement, she wrote that her friend Moira McGhee had told her that while the ambulance officers were attending to Mrs Zimmerman Ms McGhee had seen the duty nurse, RN Verity, “writing furiously within the nurses’ office together with Dr Singh.” She wrote:

| decided te walk to the nurses’ office after seeing a lot of people starting to congregate around the nursing office and was surprised to see Dr Singh within the nursing office, writing a document. | saw the look on the face of the doctor and at that point | knew he knew he had done the wrong thing.

Dy Singh had been Mrs Zimmerman’s GP for many years and had had, apparently, such a good therapeutic relationship with the Zimmermans up to that time that Michelle Zimmerman felt confident to approach him at any time to discuss her mother’s care and treatment. Yet her first reaction on seeing him at Bodington was to conclude that he had guilty conscience about something. She also assumed that Ms McGhee’s excited report of having seen nurses and Dr Singh “writing furiously” was untoward conduct and later suggested on a number of occasions that it was circumstantial evidence of a caver-up.

She also appeared on occasion to be inventing evidence to support her allegations. A number of examples could be given but one will suffice. She claimed that at the Blue Mountains Hospital Dr Franks had told her that Mrs Zimmerman appeared to suffered a narcotic overdose. He denied saying this and had no basis, except Ms Zimmerman’s own suspicions, for saying so. His preliminary diagnosis was entirely different as the hospital records demonstrate. Ms Zimmerman’s evidence was simply untrue.

Furthermore, the documentary evidence (fax records, pharmaceutical! records, etc) all demonstrate that the request for subcutaneous morphine had been initiated on the morning of 11 May by Ms Tily who sent a fax to Dr Singh after Mrs Zimmerman had spat out her oral morphine.

Ms Zimmerman was argumentative and frequently unresponsive when questioned by Counsel Assisting and other counsel. She was unable to make reasonable concessions even when confronted with incontrovertible evidence.

Because I have genuine respect for her devotion to her mother for many yeats, and the care she provided Mrs Zimmerman, and with sympathy for her as a child who has iost a much-loved parent, it was with some reluctance that I found that where the evidence is in dispute I could place no reliance on her version of events.

On the other hand, the “accused” nurses presented as honest and straight-forward witnesses. Unlike Ms Zimmerman, they were prepared to make reasonable concessions when that was appropriate, For example, they agreed that the relationship with Michelle Zimmerman had been unpleasant and tense. They also agreed that Mrs Zimmerman had, at times, been a disruptive patient. These concessions could have been held against them as evidencing tendencies to provide insufficient care for Mrs Zimmerman and a willingness to over-sedate her by using too much morphine,

Their accounts are broadly supported by the contemporaneous records. Qn 11 May, when the subcutaneous dose was given, there was no immediate sign that Mrs Zimmerman was about to deteriorate. A dose of 5mg (or even 10mg} was unlikely to push her over the edge. There was therefore no need for anyone to conspire with anyone else to cover up the administration of morphine to Mrs Zimmerman.

Rejected application to call Moira McGhee: reasons

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Some time before the inquest began, Mr Lewis requested that I call Ms McGhee asa witness in the inquest. I decided not to do so for a number of reasons. In his final address, Mr Lewis requested those reasons to be outlined. They are as follows:

First, she was not related to the deceased and was not an interested party in any other way. She had no right of appearance.

Second, she had no relevant expertise but had expressed strong suspicions and opinions even before Mrs Zimmerman died to the effect that Mrs Zimmerman looked to have been the victim of unlawful conduct on the part of the Bodington nurses. These views made it unlikely, in my opinion, that she could offer reliable objective evidence.

Third, she is a friend of Michelle Zimmerman’s. She and Ms Zimmerman held similar views about the quality of care at Bodington. Her statements contain several descriptions of things she saw or heard at Bodington. Almost all are interpreted in a manner that is adverse to the staff. She also appears to have accepted Ms Zimmerman’s interpretations and descriptions of events uncritically. She appeared to me to be a biased witness on whose testimony little weight could be placed.

Fourth, and most importantly, she had no direct knowledge of any of the key events, namely the medications prescribed for Mrs Zimmerman, the administration of the morphine or the alleged cover-up. Her opinions were based on speculation and unreliable hearsay. In my view, she offered little useful evidence.

What was the cause of death?

81. DrTam agreed with Professor Duflou’s autopsy report that the most likely cause of death was coronary artery thrombosis with cerebrovascular disease and dementia as contributing factors. | accept this evidence.

Conclusion

82. The loss of a much-loved parent is a heart-rending experience. Those who undergo

this almost universal experience react in different ways. Sadly, what might have been a sad but proud and affectionate celebration of a long life well-lived has been rendered bitter and hurtful by the long series of unsubstantiated complaints and accusations made by the Zimmermans and supported by Mr Lewis. That is the real tragedy of this case. Fortunately, Sybil Zimmerman is now resting in dignified peace blissfully ignorant of the unwarranted controversy that has followed her death.

Findings: s 81 Coroners Act 2009

83. [find that Sybil Zimmerman died at the Blue Mountains District Hospital, Katoomba, New South Wales on 15 May 2011 and that it is more probable than not that the cause of death was a coronary artery thrombosis on a background of multiple comorbidities including cerebrovascular disease and cerebral infarcts, pneumonia and

Hugh Dillon te Coroner