Coroner's Finding: HOLLENS Christopher

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 9th day of March and the 5th day of April 2005, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Christopher Hollens.

I, the said Coroner, find that Christopher Hollens aged 44 years, late of the Glenside Campus of the Royal Adelaide Hospital died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 26th day of November 2002 as a result of aspiration pneumonia. I find that the circumstances of his death were as follows:

1. Reason for inquest 1.1. On 30 October 2002 the Guardianship Board of South Australia made an order Section 13 of the Mental Health Act 1993 detaining Mr Hollens at the Glenside Campus of the Royal Adelaide Hospital for a period up to and including 30 October 2003 (see Exhibit C8c).

1.2. Accordingly, at the time he died on 26 November 2002, Mr Hollens 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. Mr Hollens was a long-term patient at the Glenside Campus of the Royal Adelaide Hospital. He had been an inpatient at that campus on many occasions, and had been permanently detained there since about 1995. As is required by the Mental Health

Act 1993, his detention was reviewed annually by the Guardianship Board and, as I have mentioned, was last renewed on 30 October 2002.

2.2. Personal background Mr Paul Williams, the brother-in-law of the deceased, has provided a long and very helpful statement concerning his background (Exhibit C1a).

2.3. Christopher Hollens was born on 2 June 1958. His childhood was relatively uneventful. His parents separated in the 1970’s, and were later divorced. Mr Williams described how Mr Hollens drove to Darwin in 1977 to seek a reconciliation with his father but this was unsuccessful. He said: 'I believe that Christopher located his father, who rejected him. Christopher became very depressed over this and turned around to head back to Adelaide. On his return, he passed back through Tennant Creek, where he stopped. Christopher was travelling alone in his vehicle and he met up with a group of young people. We believe that Christopher attended a party where he tried some LSD. As a result of the LSD, he suffered a bad ‘trip’, and began hallucinating. The bad experience from the LSD, coupled with the trauma of the rejection from his father triggered something in him, which we believed unleashed his later schizophrenia, which developed from this time on. Christopher was transported to Alice Springs where he was admitted to a hospital for treatment for the physical effects of the LSD. He was treated for a day or two, and was then released.

Upon his release, Christopher drove back to Adelaide. On his return, the family noted that he was extremely morbid, depressed, and disturbed. From this point onwards, and certainly by the time Christopher was aged in his 20’s, it became apparent that he was suffering from a mental illness. He was delusional, and although rarely violent, he could put fear into his family members, due to his aggressive, hostile, verbal manner. It made him unpleasant to be around.' (Exhibit C1a, pp2-3)

2.4. Following these events, Mr Hollens was regularly admitted to as both a voluntary patient and as a detainee at psychiatric hospitals.

2.5. In late 1983 or early 1984 Mr Hollens fell, or jumped, from a train as a result of which he sustained massive head injuries which resulted in profound disabilities. He was initially admitted to the Julia Farr Centre for rehabilitation after which he was transferred to the Glenside Hospital, as it was then called, where he remained for at least twelve months as an inpatient.

2.6. In 1985, the first of many orders were made pursuant to the Guardianship and Administration Act, 1995 for his care and control.

2.7. I received the transcript of an interview with Dr Georgette Michail, a Medical Practitioner who cares for long-term patients in Karingai Ward at Glenside Campus.

Dr Michail summarised his conditions as follows: 'The principal diagnosis of his psychiatric condition was chronic schizophrenia. He suffered from a multiple number of physical dysphasi and spastic paraparesis. Also was subject to epilepsy. He had problems with reflex oesophagitis and also sustained a number of multiple fractures whilst he was a resident of Karingai - mainly fractured shoulder and bilateral fractured neck of femur. He was aged forty-four with, as I mentioned, a longstanding history of unremitting psychotic illness with the traumatic brain damage and the psychotic disease. He was a very, very difficult patient to manage.' (Exhibit C6a, p5)

2.8. Mr Williams described Mr Hollens’ progress at Glenside Hospital as follows: 'Following his rehabilitation at Julia Farr Centre, Christopher could hold only a basic level of conversation, which was reasonably good under the circumstances. He could walk, but had severe problems with balance, coordination, and strength. As time went on, Christopher’s ability to converse and move physically decreased from year to year.

Within the past twelve months, Christopher basically lost the ability to walk and was eventually confined to a wheelchair.

Robyn and I last visited Christopher at Glenside Hospital in February 2002. At this time, I saw that he was on his feet, but walking with a frame, and supporting his weight and elbows. As this year progressed, Christopher reached the point where he couldn’t stand, and became totally dependent on the wheelchair. He couldn’t feet, dress or toilet himself.

… As a result of Christopher’s physical condition, and as he became more frail through many years of restricted movement, the long term effects were very strong. I have spoken with his treating doctors and they informed me that the years of medication being administered to Christopher were taking their toll, having an effect on his kidneys and liver, and also caused his teeth to rot and fall out.

Medical staff at Glenside also told me that Christopher’s swallowing reflex became increasingly more difficult for him over the past twelve months, and he was unable to cough properly and clear mucus from this throat.

… Christopher also suffered from regular seizures throughout his stay at Glenside. Some of the seizures were quite serious, lasting up to half an hour. The occurrence of seizures would increase whenever there was a interruption to his regime of medication. For example, whenever Christopher suffered from other illnesses or injuries. Following each seizure, it appeared to Robyn and I that it left a little bit less of him …' (Exhibit C1a, pp5-6)

3. Admission to Royal Adelaide Hospital On 11 November 2002, Dr Michail was asked to review Mr Hollens because his breathing had become noisy and he was showing signs of a chest infection. She examined him and then made arrangements for him to be transferred to the Royal

Adelaide Hospital for assessment. She said that Mr Hollens had been progressively deteriorating to the extent that they were considering nursing home placement just prior to these events. In her referral letter, she said: 'Chris has deteriorated physically and has now become chair fast with severe flexion of his neck forwards hence his difficulty with swallowing and also a problem with uncooperative behaviour which makes it very hard to do an appropriate physical examination.

I could elicit some generalised expiratory wheeze with some fine creps on his left side, his pulse is 80 bpm. BP 120/80. He is apyrexic, however he continues to cough every time he is being offered any fluids and hence his refusal to eat or drink.

I would appreciate his review and advice with respect to what is going on with him.

?Inhalational ?Infective Lower (respiratory) tract problem ...' (Exhibit C8e)

3.1. Dr Sophia Kennedy was the Consultant Physician at the Royal Adelaide Hospital who was in charge of Mr Hollens’ treatment upon admission. She said that on admission Mr Hollens’ conscious state was depressed, he had abnormal chest symptoms and a reduced white cell count consistent with a chest infection. She remarked upon the difficulties they experienced in conducting an appropriate chest examination. She said a chest X-ray also indicated some abnormalities. Because Mr Hollens may have contracted pneumonia, antibiotic treatment was commenced.

3.2. The following morning Mr Hollens’ condition deteriorated further. His oxygen saturation level had fallen, and he was given oxygen in increased concentrations. He also developed seizures, and so intravenous phenytoin, an anti-convulsant medication, was administered. He was transferred to the Intensive Care Unit and remained there until 15 November 2002.

3.3. Mr Hollens’ condition had improved somewhat by 15 November 2002, to the extent that although still hypoxic, his seizures had stabilised and he no longer required mechanical ventilation. He was still required assistance with respiration.

3.4. Mr Hollens remained in Ward S8 with ongoing pneumonia requiring high-flow oxygen and naso-enteric feeding. He became increasingly hypoxic, uncooperative and agitated. By 23 November 2002 his oxygen levels had dropped to 65%. He had ongoing seizures for which he was given diazepam and phenytoin.

3.5. Eventually, on 26 November 2002, Mr Hollens’ breathing became more difficult and large quantities of discharge were removed from his airways. His breathing eventually ceased at around 11:25am on the morning of 26 November 2002 when he

was visited by Dr D'Silva, the Medical Registrar, who pronounced his life extinct at that time.

3.6. Dr D'Silva attributed Mr Hollens’ death to aspiration pneumonia (Exhibit C2a, p3). I accept his opinion about that, and find that Mr Hollens died as a result of aspiration pneumonia.

4. Issues arising at inquest 4.1. Mr Hollens’ death was the subject of a very thorough and helpful investigation by Detective Senior Constable Simon Keane of the Adelaide Criminal Investigation Branch of South Australia Police.

4.2. After a very careful analysis of the issues, Detective Senior Constable Keane concluded: '6.1 The evidence indicates that Christopher Hollens was lawfully detained pursuant to S13 Mental Health Act (1993).

6.2 The evidence indicates that Christopher Hollens’ assessment at Glenside Hospital and subsequent transfer to Royal Adelaide Hospital was not unduly delayed so as to contribute to his death.

6.3 The evidence indicates that Christopher Hollens was diagnosed correctly and treated appropriately at Royal Adelaide Hospital.' (Exhibit C8a, p15)

4.3. I agree with those conclusions and adopt them for the purpose of these findings.

5. Recommendations 5.1. In view of the conclusions expressed above, it is not necessary for me to make recommendations pursuant to Section 25(2) of the Coroners Act 1975.

Key Words: Death in Custody; Psychiatric/Mental Illness In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 5th day of April, 2005.

Coroner Inquest Number 10/2005 (3291/2002)