Coroner's Finding: MIDDLETON Geraldine Ruth

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 19th and 20th days of September, and 20th day of November, 2000, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Geraldine Ruth Middleton.

I, the said Coroner, do find that Geraldine Ruth Middleton, aged 45 years, late of Unit 9, 24 Ponton Street, Salisbury, in the State of South Australia, died at Salisbury on the 14th day of February, 1999 as a result of haemorrhage due to traumatic rupture of the liver. I find that the circumstances of death were as follows:-

1. Circumstances of death 1.1 In the late evening of Sunday 14 February 1999 a pedestrian was killed by a train near the crossing with Park Terrace at Salisbury, not far from the Salisbury Interchange.

The pedestrian was later identified as Geraldine Ruth Middleton.

1.2 The circumstances of the collision are outlined in the statement of Mr. D.K.

Mackereth, the driver of the train (Exhibit C.5b) as follows:- “We departed the interchange at about 2226 hours or thereabouts. As I departed the interchange the lights and boomgates for Park Terrace were working normally. A young chap walked across the front of me on Park Terrace and I sounded the horn to warn him.

He was about 40 metres away when he walked in front. The train was moving slowly at this stage and there was no chance of any impact but I thought I would let him know that the train was moving now. I crossed over Park Terrace and cleared the crossing when I suddenly saw a person appear from my right about 20 feet away from the front of the railcar. This person I think it was a female seemed to appear from nowhere. She was a few feet to the right of my rail-line, and she appeared to dive onto the right hand rail in front of me. I say dive because she had her hands out-stretched in front of her in a diving position. She must have been squatting there waiting, because if she was standing, I’m sure I would have seen her earlier. I can’t remember what colour clothing she was wearing. As soon as I saw her dive onto the track, I thought shit and put the railcar in

full brake. I didn’t have time to put on the emergency brake. I didn’t have time to operate the horn. She was so close that as soon as she landed on the line, she was almost out of my view as you can’t see down for the last few metres in front of the railcar. It was only about 2 or 3 seconds and there was an impact. I felt the train bump something and I knew the railcar had hit her. The train stopped”. (Exhibit C.5b, p1-2) I accept Mr. Mackereth’s evidence, and find that he had no opportunity to avoid the collision.

1.3 After the collision Mrs Middleton was alive but unconscious. An ambulance was called, and she was conveyed to Lyell McEwin Hospital (‘LMH’). By the time she arrived, she was in cardio-pulmonary arrest. Attempts were made to resuscitate her for about an hour, but these were unsuccessful, and her life was declared extinct at 11.45pm.

2. Cause of death 2.1 A post mortem examination was conducted by Dr RA James, Forensic Pathologist, on 15 February 1999 at the Forensic Science Centre. Dr James diagnosed the cause of death as ‘haemorrhage due to traumatic rupture of the liver’ (Exhibit C3a, p1).

2.2 Apart from the recent injuries obviously caused by the collision with the train, Dr.

James also noted “on the lower left wrist were two recent sutured incisions held by black silk” (p.2).

3. Background 3.1 Mrs. Middleton had a long history of mental illness, with records dating back to 1982.

She had been diagnosed with a bipolar mood disorder (manic depression) and maladaptive personality disorder. She also suffered from hypothyroidism, which added to her lethargy and depression.

3.2 Since November 1997 Mrs. Middleton had been seeing Dr. N. Nambiar, a consultant psychiatrist. Dr. Nambiar said that this combination of illnesses led her to suffer from sustained periods of depression or mania, general instability and impulsivity, and led to a maladaptive response to stress, usually in the form of self-harming behaviour. He said that she was not responsive to treatment and she was complicated to manage. All that could be offered was a combination of medication and electro-convulsive therapy (ECT), together with psychotherapy and support.

3.3 In December 1998 Mrs. Middleton was detained pursuant to the Mental Health Act because of various family pressures. She remained in LMH until 22 January 1999, after having a course of ECT, which continued after her discharge.

3.4 Dr Nambiar saw Mrs Middleton several times after her discharge, the last time on 12 February 1999, when she had deteriorated again and was hearing voices. He decided to see her in five days, a little sooner than usual. He said that, although he was concerned about her, he did not think her condition warranted detention, nor did he think it necessary to telephone her caseworker to keep an eye on her over the weekend

(T111).

4. Events of 13-14 February 1999 4.1 During the evening of 13 February 1999 Mrs. Middleton and her ex-husband, Peter Gorczyca, visited her daughter at Salisbury. He said that she had been anxious during the evening, and had taken Valium which made her drowsy.

4.2 When they returned to Mrs. Middleton’s flat at Ponton Street, Salisbury, Mr.

Gorczyca noted that her mental state had deteriorated further. He said:- “She became very agitated and teary, and was losing control of her emotions”. (Exhibit C1b, p1).

4.3 While Mr. Gorczyca was on the telephone to the Acute Crisis Intervention Service (‘ACIS’), Mrs. Middleton went to the bathroom and cut her wrist with a carving knife.

She inflicted a deep wound and “there was quite a lot of blood” (Exhibit C1b, p2).

4.4 This was not the first time Mrs. Middleton had cut herself. Dr. James noted numerous scars on both her arms (Exhibit C.3a, p1). Dr. Nambiar said that this was the first time for eighteen months or so, however (T.113).

4.5 Mrs. Middleton was conveyed by ambulance to LMH, arriving just after midnight.

She was eventually seen by Dr. John Ceely, the Casualty Medical Officer, at 2.30a.m.

4.6 Treatment by Dr. Ceely Dr. Ceely noted a 7cm laceration to Mrs. Middleton’s left arm, the wound being so deep that it involved a tendon, and deeper muscle. He sutured the wound.

4.7 Dr. Ceely said that he was unable to recall whether he conducted a mental state examination. He said:- “As I said, I haven’t documented that I’ve done one but I - I imagine I would have assessed that in passing and talking to her”. (Exhibit C.19, p2-3).

4.8 Dr. Ceely described Mrs. Middleton as uncommunicative. She said that she cut her arm because she was “sick of herself”, but:- “She just didn’t want to talk. She was just - just lying there very quietly, just - just talking in general terms but didn’t really want to elaborate on the circumstances”.

(Exhibit C.19, p3).

4.9 Dr. Ceely certainly made no note about Mrs. Middleton’s mental state in the casenotes. His note reads in part:- “O/E Oriented x 3. No alcohol on breath. Pupils 4mm. ERTL. EOM CNS grossly intact”.

4.10 During his interview with the investigator, Senior Constable Elliott, Dr Ceely said that his plan was that Mrs Middleton would be reviewed by ACIS at home in the morning: “after she had a chance to sleep it off. She had actually been drinking at the time as well”. (Exhibit C.19, p4).

Dr. Ceely acknowledged in oral evidence that this was a mistaken recollection, and that there was no sign of intoxication (T.29).

4.11 Dr. Ceely telephoned Mr. Gorczyca and asked him to come and collect Mrs.

Middleton from the hospital. He refused. Dr. Ceely said:- “I think he was disturbed about her behaviour and was requesting a psychiatric review”.

(Exhibit C.19, p4).

4.12 Dr. Ceely said that he considered detaining Mrs. Middleton pursuant to the Mental Health Act, but decided that it was not necessary to do so. He said:- “At the time I didn’t, no. I thought she - she was in control of her - her faculties; she knew what she was doing and she was aware of the circumstances of her injuries”.

(Exhibit C.19, p3).

4.13 After Mr. Gorczyca refused to collect her from the hospital, Dr. Ceely was content for Mrs. Middleton to remain in Casualty overnight and be reviewed by ACIS there in the morning. He said that he expected this to take place by 9.30 - 10.00a.m.

4.14 Dr. Ceely clearly thought that ACIS was the appropriate body to assess Mrs.

Middleton psychiatrically. He said:- “Well ACIS does all the psychiatric consults. There’s nobody else available”. (Exhibit C.19, p5).

He also said that he could not have admitted her to the psychiatric ward, or indeed even discussed her case with a Psychiatric Registrar or Consultant, except through

ACIS (T.30).

4.15 This is a somewhat academic point, however, since Dr. Ceely did not think it necessary to resort to any of those measures.

4.16 Mrs. Middleton absconds from hospital At about 4.45a.m. on 14 February 1999 Mrs. Middleton was seen leaving the LMH in her hospital gown. Registered Nurse Patrick Millar tried to persuade her to return, but she refused. He reported this to RN Bromely and Dr. Ceely. Bromely then telephoned the police, on Dr. Ceely’s instructions.

4.17 Constables Atkinson and Sheehy located Mrs. Middleton walking East on Ponton Street, Salisbury, near her flat. She refused to go back to hospital. They continued to try and persuade her, and she eventually agreed to go.

4.18 In the meantime, the police communications (“ComCen”) operator had advised Bromely that Mrs. Middleton did not want to return to hospital. By the time she had changed her mind, ComCen was advised that no doctor was available to see her then, and that ACIS would follow-up in the morning (Exhibit C.18, p2).

4.19 Dr. Ceely confirmed that he instructed the staff to call the police because he was concerned for Mrs. Middleton’s welfare, in that she may have become lost. He did not think she was suicidal, and when he heard that she was safely home, he was happy to leave further action until ACIS had visited (T.32-34). He still did not think she should have been detained (T.32).

4.20 Follow-up by ACIS Mr Gorczyca said that Mrs Middleton arrived home at about 3.00am (it was more like 5.00am), saying that there “wasn’t much point in staying there” (Exhibit C1a, p2).

4.21 The ACIS casenotes (Exhibit C20a) reveal that at 1045hrs the next morning a telephone call was made to the house but there was no answer. At 1145hrs, the note records: “PC to Geraldine. Spoke to (husband). He remains concerned re Gerry’s depressed state. He feels that she is safe whilst he is with her, but is at risk of self-harm if he leaves or falls asleep. I have advised him that we would discuss at p.m. meeting and recontact with outcome”.

4.22 Mr. Gorczyca said that when he had not heard by 3.00p.m., he telephoned ACIS and spoke to “Rick”. As a result of this, two ACIS workers, Terence McGinn and Rebecca Morath (both experienced psychiatric nurses, although Mr. McGinn was quite new to ACIS), attended at Ponton Street.

4.23 Both workers said that a detailed psychiatric assessment of Mrs. Middleton occurred at the house. Ms. Morath (who is overseas and could not be called) explained her understanding of the purpose of the visit in her interview with Senior Constable Elliott as follows:- “So the doctor would have done, you know, a basic mental state and the plan would have been for ACIS to follow up as is generally done. I mean they would have requested an overnight assessment of Geraldine had they been concerned that she was immediately at risk. We have an overnight - we have an on-call worker, someone that’s rostered on to attend when requested to do so by - if A and E request an assessment overnight on somebody it goes through our combined regional triage and they would page the person from the appropriate service to attend, and in the northern area it would have been somebody from our service. So I guess summarising that, the doctor that assessed saw Geraldine at the A and E, did not request immediate ACIS assessment”. (Exhibit C.17a, p4).

4.24 Ms. Morath described Mrs. Middleton’s demeanour as giving minimal answers, a bit blunt, a little bit belligerent or sullen. She then gave a detailed account of her conversation with Mrs. Middleton (Exhibit C.17a, p7-8). She added:- “When Terry McGinn and myself saw her that afternoon although it’s not officially written up as a mental state in the casenotes, when we see anyone we do a mental state assessment and my assessment of Geraldine on that afternoon was that her affect was she was reactive, or she was moving around the room, she was smoking cigarettes. There was no sign of neurovegatative changes, there was no sign that she was psychomotor retarded so her, as I said, she was reactive, at one stage smiling although a little incongruently with what she was talking about but it was an implication - when I think I was talking about that she was implying that she might hurt herself the next day. So basically the mental the assessment of Geraldine was that her presentation on that day was of a behavioural disturbance but there didn’t seem to be any evidence of major depression when we saw her”. (Exhibit C.17a, p11).

4.25 Mr. McGinn’s evidence was to similar effect (Exhibit C.20). Unfortunately, very little of this assessment is recorded in the casenotes. The note made by Mr. McGinn reads:- “(Home Visit) follow up following her act of self-harm. Initially refused to talk to us.

Ex partner Peter is staying with her. She states she is not going to harm herself today but gave no promise not to self-harm when her partner leaves for work at 0730 15/2. She remains dressed in hospital gown, slumped in armchair smoking constantly. Will contact Geraldine this evening with (follow-up) phone call and check her safety. For referral to her case manager tomorrow”. (Exhibit C.20).

4.26 Ms. Morath interpreted those comments by Mrs. Middleton as an indication that she had no suicidal ideation that day (Exhibit C.17a, p8). For that reason she was content to leave the matter on the basis of a telephone check that night, and referral to her caseworker next day.

4.27 Mr Gorczyca said that soon after the ACIS workers left, Ms Morath ran into the bathroom and locked the door. When she refused to open it he called an ambulance.

He said: “A man and a woman came. The man said to Gerry to open the bathroom door, she wouldn’t, so he kicked it down. Gerry had only cut her finger, and he said she was only attention seeking. Ambulance rang ACIS, and ACIS told the Ambulance that she wasn’t detainable. I asked them what they were going to do and they said they couldn’t do anything, as her finger didn’t need medical attention.

The ambulance then left and she went into the spare bedroom and went to sleep for awhile”. (Exhibit C.1b, p3).

4.28 Mr. McGinn acknowledged that he received the call from the Ambulance Officer. His note at 1650 reads:- “P/C from ambulance service who are at the home treating superficial wounds. F/U phone call tonight”. (Exhibit C.20a).

4.29 It is surprising that the ACIS workers did not think it necessary to take further action in light of this further self-harming behaviour so soon after their visit. Mr. McGinn said that they thought that their visit may have “prompted the behaviour”. He then said they thought they would wait to see if Mr. Gorczyca contacted them (Exhibit C.20, p7-8).

4.30 It is apparent from Mr. Gorczyca’s statement that he took the advice given to the ambulance officer, that Mrs. Middleton was not detainable, at face value and did not ring ACIS again. One could hardly blame him for that. His attempts to get appropriate psychiatric help for Mrs. Middleton over the previous 24 hours had all been in vain.

4.31 Mr. Gorczyca noticed that Mrs. Middleton was missing from the flat at about 10.00p.m. on 14 February 1999. He said that the last he saw of her was when she was “running down the road towards the Salisbury shopping area”. He said:- “I called the police and told them she had previously talked about going to the railway station and throw herself in front of a train. This was in the past and she heard voices telling her to go there and harm herself ...”. (Exhibit C.1b, p4).

4.32 Nothing more is known of Mrs. Middleton’s movements until she was seen by Mr.

Mackereth in front of his train just after 10.24p.m.

5. Issues arising at the inquest 5.1 Professor R.D. Goldney provided an expert evaluation of the psychiatric issues in this inquest. Professor Goldney is widely experienced and eminent in this field, and has assisted me in many previous inquests when such issues were raised.

5.2 Professor Goldney said that he agreed with Dr. Nambiar’s diagnosis of Mrs.

Middleton’s condition. He also agreed with the treatment she received, including the

ECT.

5.3 Professor Goldney said that Mrs. Middleton had inflicted a serious wound on herself, indicating that she had a high-level intent to harm herself (T.143). Dr. Nambiar agreed (T.113). Professor Goldney noted that she was showing signs of psychosis, in that she was hearing voices (T.143), which makes her conduct even more significant.

5.4 Record-keeping Professor Goldney was critical of Dr Ceely for not recording the results of his mental state examination (assuming that he conducted one) in the casenotes. He likened it to a cardiologist not recording a patient’s blood pressure (T144). I have heard this criticism of doctors’ note-taking many times before (see Chandraratnam - 20/96, Hogarth - 31/96, Ciampi - 32/96, Proctor - 8/97, Lewin - 9/97, TenHoopen - 10/97).

5.5 Professor Goldney pointed out that it is particularly unhelpful to one’s colleagues if such information is not recorded, since they are unable to build up a longitudinal view of a patient’s symptoms (T.145). He described this as “undergraduate stuff” (T.146).

5.6 Another problem adverted to by Professor Goldney is the fact that the ACIS Team and LMH had separate casenotes, and “Having separate notes makes continuity of care very challenging”. (Exhibit C.22, p9).

Having considered the practicalities, however, it would seem that the only way of dealing with this problem would be by introducing an electronic database, with access shared between the two services, indeed by all relevant mental health services. I note that this is a topic which has been raised before (see Chandraratnam 20/96, etc, Recommendation 12).

5.7 Detention Professor Goldney said that, in his opinion, Mrs. Middleton’s presentation as uncommunicative and sullen, in the context of high intent self-harming behaviour, constituted “perfectly reasonable grounds to detain a person”, at least until a proper assessment of her psychiatric condition could be carried out. He described such a move as “playing safe” (T. 147, 158). He agreed that even the mere observation of the extensive scarring on Mrs. Middleton’s arm demonstrated in the photographs was enough to demonstrate an extensive history of such behaviour (T.150).

5.8 Professor Goldney said that, even if there was doubt about detention before that, Mrs.

Middleton’s absconce should have put the matter beyond doubt. He said:- “If she had been willing to stay at that stage, fair enough, she wouldn’t need to be detained because she would be cooperating with treatment. It seems to me that when she absconded the stakes went up. She definitely should have been detained at that point, and on the basis of Dr Ceely’s statement and the statement of others that the police were asked to bring her back - but I mean obviously they can’t unless the person is detained - I really cannot understand why she wasn’t detained at that stage. If there is concern enough to ask the police to bring the person back, there is concern enough to be detained.

Otherwise it is just that the police are impotent, they aren’t able to do anything”.

(T.150).

Had she been detained then, Mrs. Middleton could have been taken to a large institution where, hopefully, she could have been assessed by a specialist (T.164).

5.9 The ACIS Team Professor Goldney said that he was also critical of the ACIS Team for failing to record the findings of their mental state examination of the patient, something he described as “absolutely mandatory” (T.153).

5.10 In his report (Exhibit C.22), Professor Goldney said:- “If mental health nurses are to be used to triage patients, then the response needs to be prompt and there needs to be a well-documented mental status examination ... In my view this is a totally inadequate psychiatric assessment, whether it be made by a psychiatrist or a mental health nurse, particularly when it is being performed 15 hours after the initial presentation”. (p.9).

5.11 In view of Mrs. Middleton’s indicating to the ACIS Team that she could not guarantee her safety after Mr. Gorczyca went to work the next day, Professor Goldney said that there were sufficient grounds for the ACIS Team to take Mrs. Middleton for specialist assessment (T.155). When they received the further information that she had cut herself again, an indication of ongoing distress, this action was even more strongly indicated (T.156).

5.12 Checklists In terms of mental state examinations, Professor Goldney agreed with Mr. Harley, the Public Advocate, that a checklist of the type used by the Eastern Community Mental Health Service (Exhibit C.21a), was a good idea (T.158). It is surprising that one

Service has been well-organised enough to have designed such an aide-memoire, and others apparently had not. Such assistance is particularly important where, as Ms.

Cliff, counsel for the Lyell McEwin Health Service, pointed out, Dr. Ceely was working in the emergency department of a public hospital (T.171), and had many and varied challenges arising from that.

5.13 Dr. Ceely’s treatment I have already mentioned the fact that Dr. Ceely asserts that he performed a mental state examination of Mrs. Middleton while he was with her. I find it difficult to accept his evidence about that. I doubt that he could have done so while suturing her arm. I think he would have detained her at some stage that morning, or sought an urgent consultation with the ACIS Team, if he had reached an adequate appreciation of her mental state. I do not think that the ACIS team adequately appreciated the extent of her distress, either. However, they understandably assumed that Dr. Ceely had adequately assessed her the night before (T.175).

5.14 I agree with the comments of Ms. Cliff, his counsel, that Dr. Ceely did not appear to have a complete understanding of the options that were available to him at that time

(T.173).

5.15 In summary, I agree with Professor Goldney’s final comments:- “Having noted the above, I appreciate that some of these concerns could be allayed by further information being provided, and that Ms. Middleton had a severe psychiatric condition with a long history of suicidal behaviour. I am also aware of the constraints which have apparently been imposed on the provision of psychiatric services with assessment by mental health nurses rather than medically trained personnel.

Nevertheless, the fact remains that Ms. Middleton had a life threatening condition and, if one draws an analogy between her condition and other medical life threatening conditions, I consider that the response provided by the health services to adequately assess and provide care was not satisfactory”. (Exhibit C.22, p10).

6. Recommendations Pursuant to Section 25(2) of the Coroners Act, I make the following recommendations:-

• that protocols be developed for the use of medical staff in Emergency Departments which make clear the resources which are available to them, and their powers under the Mental Health Act, when dealing with such patients, and which will provide guidance as to appropriate interactions with the Acute Crisis Intervention Teams and other facets of the mental health system;

• that checklists be developed, along the lines discussed by Professor Goldney when giving evidence in this matter, to assist medical staff and ACIS Team members to perform an adequate mental state examination of patients who may be suffering from a mental illness;

• that medical practitioners and ACIS staff be reminded (yet again) of the need to properly document mental state examinations in the Medical Record;

• that Mental Health Services and public hospitals examine ways in which their staff can gain access to a combined Medical Record of a patient when both have been involved in treatment of that patient.

Key Words: mental illness; psychiatric treatment; hospitals; ACIS teams; suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the20th day of November, 2000.

……………………………..……… Coroner Inq.No.39/2000