Coroner's Finding: McTYE Alice Louise

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 14th days of April, 2000, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Alice Louise McTye.

I, the said Coroner, do find that Alice Louise McTye, aged 34 years, late of Kangaroo Villa, Strathmont Centre, Grand Junction Road, Oakden, died at Modbury Hospital on the 24th day of September, 1998 as a result of hypoxic brain damage complicating fresh water drowning. I find that the circumstances of death were as follows:-

1. Background 1.1 Alice Louise McTye was 34 years old. She suffered from severe intellectual disability and epilepsy. She was a resident of Kangaroo Villa at the Strathmont Centre, Grand Junction Road, Oakden.

1.2 On 23 September 1998 Ms. McTye arose late, about 9.10a.m., because she had suffered an epileptic seizure the night before.

1.3 Ms. McTye was taken to the bathroom by Graham Brown, a Disability Services Officer employed at Strathmont by the Intellectual Disability Services Council (“IDSC”). Mr. Brown offered her a shower, but she insisted on taking a bath, so he filled it for her and she got in unassisted. After he had washed her, Mr. Brown said that the following occurred:- “I finished shampooing her hair and washing her and decided to pick up the towels and put them in the linen bag. I then put the shampoo away. This meant walking out of the bathroom and into the mudroom. I took the linen trolley into the room and put the shampoo and soap away into the locked cupboard. When I put the shampoo away I decided to sort out the cupboard while I was there. I returned to the bathroom area and looked to see how Alice was and I found her submerged in the bath. I proceeded over to

lift her head out of the water, thinking she was just putting her head under the water. I then realised that she was unconscious so I decided to lift her out of the bath, which was unsuccessful, as she kept falling out of my arms and back into the bath. I then reached for her head, holding her to keep her head above the water. I lifted her out of the bath by putting my arms around the top of her shoulders and wedging her between the side of the bath and pulling her on to the bathroom floor. I then started First Aid (CPR). While I was doing this, I was thinking how I could contact the other staff members. Realising that the intercom was not working I made a decision to stay with Alice and continue with the First Aid, for approximately a period of two minutes. I then realised that I needed more support because the First Aid I was giving was receiving no response at all. I then got up from Alice, ran to the main entrance door of the unit, and shouted for help into the courtyard where the other staff members were. I then ran back immediately to Alice and continued with the First Aid until the other staff members arrived” (Exhibit C12, p2).

1.4 The staff members present continued with CPR until the ambulance arrived and then Ms. McTye was conveyed to Modbury Hospital and transferred to the Intensive Care Unit. The Modbury Hospital casenotes (Exhibit C.7) disclose that by this time heart output had been restored but her pupils were fixed and dilated, she was cyanosed (blue) and she was not breathing spontaneously. She was artificially ventilated. Her condition failed to improve and by 24 September 1998 her prognosis was poor.

Treatment was withdrawn. Her death was certified at 6.45p.m. on 24 September 1998 by Dr. Newman.

2. Cause of death 2.1 A post mortem examination was performed by Dr. R.A. James, forensic pathologist, on 25 September 1998. Dr. James diagnosed the cause of death as hypoxic brain damage complicating fresh water drowning (see Exhibit C.2a, p1).

2.2 An analysis of the blood sample taken from Ms. McTye upon admission to Modbury Hospital was performed by Ms. Janice Gardiner, forensic scientist. Her report is Exhibit C.3a. The analysis revealed that the blood contained:-

• carbamazepine - 9.5mg/L (therapeutic concentration);

• diazepam - approximately 0.02mg/L (sub-therapeutic concentration);

• nordiazepam - 0.04mg/L (therapeutic concentration);

• clonazepam - 0.03mg/L (therapeutic concentration);

• 7-aminoclonazepam - 0.02mg/L (therapeutic concentration).

2.3 The most significant matter to arise from the toxicology analysis was that the concentrations of clonazepam and its metabolite were at therapeutic levels.

Clonazepam is an anti-convulsant medication given to people suffering from epilepsy.

Dr. Michael Harbord, the visiting neurologist at the Strathmont Centre who was treating Ms. McTye, told me that such medication gave no guarantee of preventing seizures, even if the medication was at therapeutic levels (T.54).

2.4 Although Dr. James found no objective signs that Ms. McTye had suffered a seizure at the time she drowned in the bath, Dr. Harbord said that, in his opinion, in the absence of any other explanation, it was “quite likely” that she suffered a seizure which prevented her from saving herself when she slipped under the water (T.58).

3. Issues arising at the inquest 3.1 Medication An issue of some concern is that Ms. McTye did not receive her morning dose of Clonazepam on either 21 or 22 September 1998. This omission was due to a mix-up between the night and day staff, as to who was responsible for administering it.

3.2 On 9 September 1998, Dr. Harbord had ordered that the dose of Clonazepam be increased to 4mg twice a day, and he directed that the morning dose should be given at 7.00a.m. rather than 6.00a.m. His intention was to give her greater coverage in the afternoon, when most of her convulsions tended to occur (T.48).

3.3 This, however, created confusion as a change of shifts occurred at around 7.00a.m.

Ms. McTye usually had a breakfast before that time, so that she could be ready for the 7.30a.m. bus to take her to the sheltered workshop.

3.4 The morning dose of Clonazepam for 23 September 1998 is also not recorded in the casenotes as having been given. Mr. Felix Ng, in a letter to Mr. Dale Hassam, Director, IDSC Accommodation Services, dated 26 September 1998 (part of Exhibit C.9), was certain that he gave her the medication while she was still in bed at about 6.15a.m. or thereabouts that morning.

3.5 I accept that assurance, since the level of Clonazepam in the anti-mortem blood sample was acceptable, as I have already discussed. Dr. Harbord explained that Clonazepam would have remained at therapeutic levels only for twelve hours or so, so that Mr. Ng must have given Ms. McTye the medication as he said. However, it is unsatisfactory that he failed to record that fact in the casenotes, since Mr. Brown did

not know whether she had received her dose of medication or not when he commenced his shift at 7.00a.m. (T.70).

3.6 The intercom It is not clear why the intercom in Kangaroo Villa was not working on 23 September 1998 when Mr. Brown went to use it to call for assistance. The villa had only been opened for a week or so prior to this incident, and Mr. Hassam told me that the intercoms are used on a daily basis, and any faults are quickly noticed (T.36).

3.7 In this particular case, I very much doubt that the problem with the intercom affected the tragic outcome. Mr. Hassam told me that the intercom has now been repaired, and hopefully the problem will not re-occur.

3.8 Briefing of staff Mr. Brown told me that he was unfamiliar with Ms. McTye and her needs, having only met her once before. He had not received a briefing following his transfer from another villa, before assuming responsibility for her care. He told me that on the day the briefing was to occur there had been a motor vehicle accident in the Barossa Valley involving some Strathmont residents, and this disrupted the day’s activities to the extent that the briefing did not go ahead (T.67).

3.9 Mr. Brown said that he received a verbal hand-over from the night carer, Mr. Ng, who told him that Ms. McTye had suffered a convulsion the night before and that she did not want to go to work that day (T.68).

3.10 Another problem was that Ms. McTye’s casenotes were not in the villa on the morning of 23 September 1998. If they had been, Mr. Brown would have been able to see the note in the “Profile” section, which reads:- “Alice is an epileptic. Do not leave her unattended in the bathroom”. (Exhibit C.8).

3.11 Mr Brown is an experienced and, on the evidence of Mr Hassam, which I accept, competent and diligent officer (T36). Knowing that Ms McTye was an epileptic, he said he was aware of the care she needed, and would not have acted any differently had he had the opportunity to read the casenotes before Ms McTye had her bath

(T77).

3.12 Mr. Hassam argued that Mr. Brown did not leave Ms. McTye “unattended” in the bathroom (T.38). However, Dr. Harbord said that a person with epilepsy taking a bath is a “potentially dangerous” activity (Exhibit C.13, p2), and that the client should not be left unobserved for more than a minute or so (T.56). If this is not possible, Dr.

Harbord argued that bathing should be avoided altogether, or the bath should only be filled to a slight extent so that it is too shallow to drown in.

3.13 Dr. Harbord pointed out that a person suffering a seizure does not necessarily make a noise, and does not always get an “aura” or warning that it is about to happen. A person with a degree of intellectual retardation suffered by Ms. McTye would probably not be capable of communicating that she was receiving an “aura” anyway.

As this case demonstrates, Ms. McTye drowned quickly and silently.

3.14 Mr. Brown said that he thought he would hear something if Ms. McTye was in trouble (T.77). He said that he left her alone in the bath, with the curtain pulled across, to give her some privacy. This was a thoughtful and sensitive thing to do, but, having regard to Dr. Harbord’s evidence, it was ill-advised.

4. Remedial action 4.1 Mr. Hassam told me that the IDSC has conducted a careful inquiry into what occurred in this case, and has taken remedial action. I accept this. Indeed, I think the IDSC in general, and Mr. Hassam in particular, should be commended for the thorough and self-critical way in which the inquiry was carried out. They have correctly taken the view that it is more important to analyse what went wrong so that it can be avoided in future, than it is to seek to avoid criticism.

4.2 Mr. Hassam told me that the following remedial action has been taken:-

• policies and procedures in relation to medication have been changed so that medication is not required to be given at around the time of shift change-overs, and it is now to be made clear whether the medication is to be given at a particular meal time or at another time;

• the policies and procedures in relation to the transfer of clients between units have been changed so that check lists which deal with such issues as the briefing of carers, and the transfer of casenotes, must be signed off by the managers of both the unit departed from and the unit to which the client has been transferred;

• the intercom has been repaired;

• Mr. Hassam has written to all staff pointing out that extra care must be taken when people suffering from epilepsy are taking a bath.

5. Recommendations 5.1 Mr. Hassam was reluctant to accept that a blanket rule should be made in relation to epileptics taking a bath. He said that the need for such rules varied widely, having regard to the nature and severity of the client’s illness (T.63). He suggested that the handling of such clients should be left to the judgment of carers in individual cases.

5.2 But Dr. Harbord has given clear evidence that people suffering from epilepsy, even if they are well controlled with medication, can still suffer a seizure without warning at any time. If they are in “at risk” situation, such as in contact with water, they may suddenly and silently die.

5.3 In those circumstances, pursuant to Section 25(2) of the Coroners Act, I recommend that the IDSC issue guidelines to staff that if a person suffering from epilepsy is to be permitted to take a bath, such a person should not be left unobserved for more than one minute. If this cannot be assured, then bathing should be avoided, or alternatively the bath water should be so shallow that the client is not at risk of drowning should they suffer a seizure.

Key Words: intellectual disability; epilepsy; drowning In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 14th day of April, 2000.

……………………………..……… Coroner Inq.No.17/2000