Coroner's Finding: GAVA Mario

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 day of November 2002 and the 28th day of March 2003, before Anthony Ernest Schapel, a Coroner for the said State, concerning the death of Mario Gava.

I, the said Coroner, find that, Mario Gava aged 80 years, late of 16 Laston Street, Pooraka, South Australia, died at Hillcrest Hospital, Oakden, South Australia on the 29th day of July 2000 as a result of bilateral pulmonary thrombo-embolism.

1. Background 1.1. On 29 July 2000 the deceased Mario Gava, aged 80 years, died at Howard House at Oakden. He had been detained pursuant to the provisions of the Mental Health Act 1995 (the Act). The deceased was therefore a person detained in custody and it was therefore mandatory for an inquest to be held into the cause and circumstances of his death pursuant to sections 12(1)(da) and 14(1a) of the Coroners Act 1975. I held that inquest on 19 November, 2002.

1.2. The deceased had exhibited signs of multi-infarct dementia. He had spent time in the Adelaide Clinic as a patient. A post-mortem examination revealed the existence of Alzheimers disease in the deceased’s brain. In July 2000, the deceased was a patient at the St Andrew’s Hospital. While in that hospital, an order for the admission and detention of the deceased in an approved treatment centre was made pursuant to section 12(1) of the Act on 23 July 2000 by a Dr Vetri. The reason for that detention was said to be his confusion and aggressive behaviour, giving rise to the opinion that he suffered from a mental illness and required immediate treatment. He was also said

to be a threat to patients and others at St Andrew’s. As a result of this order, the deceased was transferred to the Royal Adelaide Hospital (the RAH).

1.3. The original order was confirmed pursuant to section 12(4) of the Act by Dr Paul Davis, a psychiatrist at the RAH, on 24 July, 2000. Dr Davis expressed the view that the deceased suffered from dementia, was confused, restless and agitated.

1.4. On 26 July 2000 a Dr Mukherjee-Gray authorised the transfer of the deceased to Howard House at the Hillcrest Hospital pursuant to section 16 of the Act. This transfer order was based on the assessment of Dr Davis that the deceased required management in a specialised unit for the elderly as he was unable to be managed at the RAH.

1.5. On 26 July, a Dr Harvey executed a further order for the deceased’s detention while at Howard House pursuant to section 12(5) of the Act and recorded that there was evidence of a significant dementia with an escalated level of aggression to the point where the deceased injured staff and was a threat so as to require physical restraint.

Dr Harvey recommended a secure ward environment. The deceased died at Howard House 3 days later on 29 July 2000.

2. The cause of the deceased’s death 2.1. Dr Nicola Robinson, whose statement verified by affidavit I received in evidence, was the deceased’s doctor at Howard House. She understood that the deceased suffered form petit mal seizures as well as a number of physical maladies. She observed that the deceased was usually oriented but plainly had a mental impairment.

2.2. The evidence before me reveals that on the morning of 29 July 2000 nursing staff at Howard House observed the deceased to be drowsy, pale and unable to support his own weight. It was at first thought that the deceased was suffering from a petit mal seizure, but he was soon observed to have gone into cardiac arrest. First aid in the form of CPR was applied by nursing staff and an ambulance was called. Efforts to resuscitate the deceased, which can be described as very thorough, were unsuccessful.

2.3. The post-mortem examination of the deceased’s body showed that he had died of bilateral pulmonary thrombo-embolism which is represented by a blockage of both main pulmonary arteries. This was associated with a thrombotic occlusion of a

peripheral vein in the left calf. This occlusion of the calf vein may in turn have been associated with immobility. During the post-mortem examination, a bruise was observed to the left side of the deceased’s chest. This lesion was originally thought by some to have been a bite mark. Professor Byard, who conducted the post-mortem examination, was of the view that it was not a bite mark, although its aetiology remained uncertain. There was no significant underlying bruising and no rib fractures. There is no evidence as to how and in what circumstances this bruise was sustained. Professor Byard describes the bruise as an incidental finding. In my view, no conclusion of any kind can be drawn form the existence of this bruising, particularly when it is borne in mind that the deceased had exhibited agitation and aggressive behaviour.

3. Findings 3.1. The deceased was at all material times detained pursuant to the provisions of the Act.

I find that he was lawfully so detained.

3.2. The deceased died while he was a detained patient at Howard House.

3.3. I find the cause of the deceased’s death to be bilateral pulmonary thrombo-embolism.

4. Recommendations 4.1. I make no 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 28th day of March, 2003.

Coroner Inquest Number 32/2002 (1926/2000)