Coroner's Finding: WOZNIAKOWSKI Andrzej

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 6th and 19th days of May 2004, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Andrzej Wozniakowski.

I, the said Coroner, find that, Andrzej Wozniakowski aged 83 years, late of 147 Wattle Street, Malvern, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 28th day of March 2003 as a result of inanition with lobar pneumonia.

1. Reason for inquest 1.1. On 25 March 2003, Dr N K Brice, Medical Practitioner, made an order pursuant to Section 12(1) of the Mental Health Act 1993 immediately detaining Mr Wozniakowski to the Royal Adelaide Hospital, an approved treatment centre as defined in the Act. On 27 March 2003, Dr J N G Kent, Psychiatrist, confirmed Dr Brice’s order pursuant to Section 12(4) of the Act. Dr Kent stated that Mr Wozniakowski was suffering from ‘organic brain syndrome/malnutrition’ (see Exhibit

C7).

1.2. An order pursuant to Section 12(4) has effect for 21 days. Accordingly, at the time of his death on 28 March 2003, Mr Wozniakowski 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 1975, and an Inquest into his death was therefore mandatory by virtue of Section 14(1a) of the said Act.

2. Background 2.1. The statement of Mr N L Golding (Exhibit C5a) gives more information about the circumstances leading up to Mr Wozniakowski’s detention. Mr Golding was Mr Wozniakowski’s next-door neighbour. He said: 'We tried to help him out as much as possible, we would offer to do his shopping and pay his bills, however he always declined. I have been in the front part of his house, as I have stated it is in a state of disrepair, basically falling down around him. The house is large, but he lives in the front three bedrooms. I don’t believe that there is a shower or toilet in the house. The rooms that he lives in are full of rubbish and old furniture.

Andre was independent until about the last two months. From about January I noticed changes in him, he lost weight and appeared dishevelled. He used to go to the local shops, but I hadn’t seen him there for a while.

On one occasion in February, I remember it was the weekend and was 44 degrees. I saw that his bin was put out, but was not put back onto his property. I was worried that something had happened and tried to raise him. When he didn’t answer the door I called the Police. They also could not raise him and they had to break in. They advised me that Andre was in the house, and that he was okay.

From then on I contacted the council, I have been liaising with Chris Murray and she has been organising a Doctor and translator to assist Andre.

Last weekend, 22/03/03-23/03/03 I saw that Andre was standing in the middle of Wattle Street. Andre appeared disorientated and he stank of body odour and urine. He was ranting and gibbering on, he told me that he was waiting from some locks to be delivered from South America via Poland. He also stated that there were some people living in his house, this was the first time that I had fully entered the house. I was appalled by what I saw, it stank of body odour and urine, dirty clothes were piled up on the floor and rat droppings were everywhere, it was disgusting. No other person was living in the house.

I contacted the council that Monday morning and told Chris Murray of what I had seen.

On Tuesday morning, about 11:00am or 11:30am, the translator came to my door asking if she could use the phone. She told me that Andre had collapsed on the floor and needed the Doctor. After she made the call I went back to Andre’s house with her.

When I entered the house I saw that Andre had collapsed in the doorway of his bedroom.

The Doctor arrived about 30 minutes later and organised an ambulance. Andre was conscious, but was not lucid, he was talking about the Nazis and bandits. When the ambulance arrived Andre refused to leave the house, he grabbed onto anything he could so that he could not be carried out. The Police were called and Andre was removed from the house and taken to the Royal Adelaide Hospital. The Doctor gave me the keys to Andre’s house for safe-keeping.

I am now aware that Andre has passed on, I am glad that he was comfortable when he passed away, however it is very sad.' (Exhibit C5a, pp1-3)

2.2. Ms Barbara Wozniakowski, the sister of the deceased, states that she last saw her brother on 7 March 2003. She said that she was ‘very shocked’ at his appearance, that he was ‘very thin and drawn-looking’ (Exhibit C1a, p1).

2.3. Ms Wozniakowski visited her brother again on 14 March and 15 March 2003, but he did not answer the door. The bag she had left for him the day before had gone, so she did not worry about him.

2.4. Tragically, by the time Ms Wozniakowski found out that her brother was in the Royal Adelaide Hospital, and was able to get in there to see him, he had died.

2.5. Admission to hospital Mr Wozniakowski was admitted to the Royal Adelaide Hospital at about 2:30pm on 25 March 2003, having been conveyed there by ambulance after being detained by Dr Brice. He was seen in the Emergency Department by Dr Dwyer, who noted an extensive medical history, increasing cachexia (thinness from malnutrition) and increasing confusion and disorientation.

2.6. Mr Wozniakowski was seen by the Medical Registrar, Dr Dundon, who performed a very thorough examination, and made an extensive note in the medical record (Exhibit C7). Dr Dundon outlined an extensive treatment plan, including a variety of tests.

2.7. Mr Wozniakowski’s condition gradually deteriorated over the next several days, despite extensive medical, nursing, physiotherapy, dietary, speech pathology and psychiatric evaluation and care.

2.8. Mr Wozniakowski’s blood pressure dropped substantially, to the extent that by the early morning of 28 March 2003 it was 60/40. There were also signs that he was developing an infection.

2.9. During the morning of 28 March 2003 Mr Wozniakowski’s breathing was noted to have ceased. Dr Joanna Ghali was notified, and she attended and certified Mr Wozniakowski’s life extinct at 10:30am.

3. Cause of death 3.1. A post-mortem examination of the body of the deceased was performed by Professor R W Byard, Forensic Pathologist, on 1 April 2003 at Forensic Science SA, Divett Place, Adelaide.

3.2. Professor Byard concluded that the cause of Mr Wozniakowski’s death was ‘inanition with lobar pneumonia’. He commented: 'Death was due to marked cachexia with superimposed lobar pneumonia. The deceased had a history of difficulty with swallowing and poor nutrition for some time. While pneumonia was not present on the admission X-ray (25/3/03), it can develop quite rapidly as a terminal event. No other underlying organic diseases or malignancies were identified which would have caused or contributed to death. There was no evidence of trauma.' (Exhibit C3a, p2)

3.3. I accept Professor Byard’s conclusions, and find that the cause of Mr Wozniakowski’s death was inanition with lobar pneumonia.

4. Conclusions 4.1. Mr Wozniakowski was detained by Dr Brice pursuant to the Mental Health Act due to his mental state and inability to care for himself. I have read Dr Brice’s clinical records, and they describe a rather difficult patient with longstanding medical problems who was often reluctant to accept advice.

4.2. On the evidence before me, Dr Brice acted appropriately. Once he decided that Mr Wozniakowski was suffering a mental illness (which was not always clear), and that he was a danger to himself, he exercised his powers under the Mental Health Act.

4.3. Unfortunately, Mr Wozniakowski’s condition was such that, despite the best endeavours of Dr Brice and the clinicians at the Royal Adelaide Hospital, the natural progression of his disease had reached the stage where he could not be effectively treated.

4.4. On that basis, Mr Wozniakowski died from natural causes, and there are no grounds for criticism of anybody involved in his treatment. In particular, the fact that Mr Wozniakowski was in custody was an incident of his illness, and not causatively relevant to his death.

5. Recommendations 5.1. There are no recommendations pursuant to Section 25(2) of the Coroners Act.

Key Words: Death in custody; Mental/Psychiatric Illness In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 19th day of May, 2004.

Coroner Inquest Number 13/2004 (0771/2003)