Coroner's Finding: ELLIOTT Eileen Sarah

CORONERS ACT, 1975 AS AMENDED SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 5th and 21st days of July, 2000, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Eileen Sarah Elliott.

I, the said Coroner, do find that Eileen Sarah Elliott, aged 77 years, late of Jacaranda Ward, Glenside Hospital, died at the Royal Adelaide Hospital on the 14th day of March, 2000 as a result of myocardial infarction.

1. Reason for inquest 1.1 On 22 April 1999 the Guardianship Board of South Australia made an order detaining Eileen Sarah Elliott in Glenside Hospital for the period up to and including 22 April 2000, pursuant to Section 13 of the Mental Health Act 1993. Accordingly, at the time of her death Mrs. Elliott was “detained in custody pursuant to an Act or law of the State” within the meaning of Section 12(1)(da) of the Coroners Act, and an inquest was therefore mandatory pursuant to Section 14(1a) of the said Act.

2. Background 2.1 Clinical Nurse Consultant J.A. Kennedy, of Glenside Hospital, states that Mrs. Elliott had been a patient there since about 1993. She suffered from chronic schizophrenia.

2.2 On 22 January 2000 Mrs Elliott had a fall, resulting in a fractured left leg. She was conveyed to the Royal Adelaide Hospital and admitted, and underwent external fixation of the leg.

2.3 Dr. Sharavanan Parasivam, medical practitioner at the Royal Adelaide Hospital, states that Mrs. Elliott’s general condition deteriorated following this incident “to the extent that she was bed-bound and poorly communicative” (Exhibit C.2a, p2).

2.4 Mrs. Elliott returned to the Glenside Medical Centre on 24 February 2000, where she remained until 3 March 2000, when she suffered a cardiac arrest. She was taken back to the Royal Adelaide Hospital, where it was diagnosed that she had suffered an

anterior myocardial infarction. She was transferred to the Intensive Care Unit, but her renal function deteriorated, and she was transferred to a Cardiology ward.

2.5 Dr. Parasivam said:- “Discussion with family was on the emphasis to make the late Mrs. Elliott comfortable, rather than performing any invasive investigation”. (Exhibit C.2a, p2).

2.6 Mrs. Elliott’s condition continued to deteriorate and she received palliative care. She died at 11.15a.m. on Tuesday 14 March 2000 (see Exhibit C.2a, p3).

3. Cause of death 3.1 Dr. Parasivam’s opinion is that the cause of death was myocardial infarction (Exhibit C.2a, p4). I accept this diagnosis and find accordingly.

4. Investigation 4.1 The statement of Detective Senior Constable PL Jaensch indicates that there was initially some confusion about whether Mrs. Elliott’s death was a death in custody within the meaning of Section 12(1)(da) of the Coroners Act. For that reason, it was not until Wednesday 15 March 2000 that it was established that the matter should be investigated in that way. As a result, investigators did not attend the scene, nor did they carry out any more extensive investigation (this case is to be compared with the standard of the investigation into the death of George Henry Landorf, Inquest 31/00).

Detective Jaensch concluded that there were no suspicious circumstances surrounding Mrs. Elliott’s death (Exhibit C.3a, p4), and I accept his conclusions about that.

5. Recommendations 5.1 There are no recommendations pursuant to Section 25(2) of the Coroners Act.

Key Words: death in custody.

In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 21st day of July, 2000.

……………………………..……… Coroner Inq.No.32/2000