Coroner's Finding: McCARTHY Nancy Clare

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 18th and 25th days of October 2001, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Nancy Clare McCarthy.

I, the said Coroner, find that, Nancy Clare McCarthy aged 67 years, late of Unit 7, 61 Bridge Street, Kensington, South Australia, died at the Royal Adelaide Hospital on the 17th day of December, 2000 as a result of bronchopneumonia complicating disseminated pulmonary large cell carcinoma. I find that the circumstances of the death were as follows:

1. Reason for Inquest 1.1. On 9 December 2000 Mrs McCarthy was admitted to the Royal Adelaide Hospital.

On 11 December, Dr Sarabjit Loyal made a Detention Order pursuant to Section 12 of the Mental Health Act. On 12 December that Order was confirmed by Dr Mary Frost, a psychiatrist, and on 14 December, Dr Frost extended that Order for a period of 21 days.

1.2. Accordingly when she died on 17 December 2000, Mrs McCarthy was ‘detained in custody pursuant to an Act or law of the State’ within the meaning of Section 12(1)(da) of the Coroner’s Act, and an inquest was therefore mandatory pursuant to Section 14(1a) of the said Act.

2. Background 2.1 Mrs McCarthy was born on 23 November 1933. She separated from her husband in the 1960’s and they never remarried. According to her son, Stephen, she smoked cigarettes regularly throughout her life.

2.2 Stephen McCarthy said that his mother went to Queensland in early 2000 and while there suffered a fall. She began complaining of lower back pain, and sought medical treatment.

Stephen said: “… she was complaining of constant pain about her lower back and front abdominal area. She seeming to think that this pain seemed to be moving around and she could offer no explanation for this” (Exhibit C6a, p2) 2.3 Mrs McCarthy consulted the Tranmere Village Medical Centre and her pain was investigated. An x-ray revealed a “mild compression fracture of the T12 vertebral body and other age-related changes” (see the Statement of Dr Kristina Bamford, Exhibit C7a, p3). The condition was managed conservatively, and Mrs McCarthy continued to consult Dr Bamford and her colleagues for pain relief.

2.4 Mrs McCarthy’s pain progressed to her sternum and anterior chest wall. Dr Bamford states that an x-ray revealed nothing of significance (Exhibit C7a, p3).

2.5 On 8 December 2000, Stephen McCarthy took his mother to see his own general practitioner, Dr Fenella Livesey. Dr Livesey noted that Mrs McCarthy seemed very anxious, and “easily distractible” (Exhibit C8, p2). Dr Livesey asked to see the xrays, and made a follow-up appointment.

2.6 That evening, Mrs McCarthy telephoned her son complaining of increasing pain and distress. He stayed the night with her, and at 5.00am the next morning , took her in to the Royal Adelaide Hospital, because she was complaining of shortness of breath.

2.7 Dr Robert Carroll treated Mrs McCarthy on admission. In his statement, Dr Carroll records that Mrs McCarthy was confused and disoriented, hypertensive and delirious to the extent that she required physical restraint. For these reasons, the Detention Orders I have already mentioned were made.

2.8 Further investigations with CT scans revealed that Mrs McCarthy had lung cancer, with a large mass in the lungs, and this had spread to the liver, the adrenal glands and to the brain and possibly to the bones.

2.9 Mrs McCarthy’s condition failed to improve, and she remained agitated and confused.

She developed a fever, and was prescribed broad-spectrum antibiotics. Her neurological status gradually worsened until her respiration ceased at 8.30pm, and her life was certified extinct at 9.15pm on 17 December 2000.

3. Cause of Death 3.1 A post-mortem examination of the body of the deceased was performed by Dr Yung Tran, on 19 December 2000. Dr Tran’s diagnosis of the cause of death was: “Bronchopneumonia complicating disseminated pulmonary large cell carcinoma in a woman with recent myocardial infarction.

He commented: “The cause of death was natural. The deceased’s respiratory decline (dyspnoea, reduced oxygen saturation) and fever were consistent with the pathological finding of bronchopneumonia. This was a complication of the disseminated pulmonary carcinoma.

Metastatic carcinoma was identified in the adrenal glands, liver and brain. An additional autopsy finding was a recent myocardial infarction.” 3.2 Having regard to the evidence before me, it is clear that Mrs McCarthy’s death was from natural causes and having regard to the extensive spread of her cancer to vital organs, the outcome was inevitable.

3.3 Although Mr Stephen McCarthy expressed some understandable concern to me that the medical investigations carried out prior to his mother’s death failed to reveal her cancer, and thus made her death unexpected, I find that there is no reason to think that there is any ground for criticism of the medical treatment she received.

3.4 There are no grounds for recommendations pursuant to Section 25(2) of the Coroners Act, 1975.

Key Words: Death in Custody In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 19 th day of October, 2001.

……………………………..……… Coroner Inq.No. 23/01 (3225/2000)