Coroner's Finding: TILBROOK James Henry

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 James Henry Tilbrook.

I, the said Coroner, do find that James Henry Tilbrook, aged 76 years, late of Acacia Ward, Glenside Hospital, died at Glenside Hospital on the 4th day of November, 1999 as a result of pneumonia.

1. Reason for inquest 1.1 On 5 August 1999 the Guardianship Board of South Australia made an order pursuant to Section 13 of the Mental Health Act 1993 that James Henry Tilbrook be detained in Glenside Hospital for the period up to and including 5 August 2000. Accordingly, at the time of his death Mr. Tilbrook 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 The Clinical Nurse Consultant at Acacia Ward at Glenside Hospital, Ms. L.K Sander, states that Mr. Tilbrook had been a patient there since 14 September 1999. He was treated for a number of illnesses, including dementia, irregular pulse, right adrenal adenoma, mild anaemia, bursitis/cellulitis (right elbow), pneumonia, and congestive cardiac failure.

2.2 On occasions he became highly agitated and required heavy dosage of medication to control his behaviour. He was disoriented, had no short term memory, and required

full assistance with daily tasks. He was detained in the closed ward as “he was prone to wandering off” (Exhibit C.3a, p2).

2.3 Dr. V.A. Nicholls, medical practitioner, states that on 3 November 1999, the condition of his pneumonia required palliative care. She expected him to die within 24 hours.

The use of morphine was authorised if required (Exhibit C.1a, p2).

2.4 Registered Mental Health Nurse G.R. Lee states that on 4 November 1999 at 5.00a.m.

he noticed that Mr. Tilbrook’s breathing was rapid and shallow, and by 6.00a.m. he had ceased breathing. Dr. Bosnich was called and certified life extinct at 6.30a.m.

The family were then notified (Exhibit C.2a, p2).

3. Cause of death 3.1 Dr. Rhett Bosnich reported that the cause of Mr. Tilbrook’s death was pneumonia.

Dr. Nicholls agreed (see Exhibit C.1a, p2). I accept this diagnosis and find accordingly.

4. Recommendations 4.1 There are no recommendations pursuant to Section 25(2) of the Coroners Act.

Key Words: death in custody; pneumonia.

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

……………………………..……… Coroner Inq.No.30/2000