Coroner's Finding: BAUMANIS Bronislawa Sonia

CORONERS ACT, 2003 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 26th day of June 2007, and the 12th day of December 2007, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Bronislawa Sonia Baumanis.

The said Court finds that Bronislawa Sonia Baumanis aged 84 years, late of 6 Burns Avenue, Hazelwood Park died at Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 3rd day of November 2006 as a result of ischaemic heart disease. The said Court finds that the circumstances of her death were as follows:

1. Introduction 1.1. Mrs Bronislawa Sonia Baumanis was 84 years old at the time of her death on 3 November 2006. A post mortem examination was carried out by Dr Barbara Koszyca, Forensic Pathologist, who gave the cause of death as ischaemic heart disease and I so find.

1.2. Mrs Baumanis had been detained under the Mental Health Act shortly before suffering a cardiac arrest on the day of her death. This meant that she died in custody within the meaning of the Coroner’s Act 2003. This Inquest was held in compliance with section 21(1)(a) of that Act.

2. Background 2.1. The facts may be shortly stated. On the morning of Friday, 3 November 2006 Mrs Baumanis was at her home address when her long time friend and cleaner Dina Ujigaeva arrived at about 10:00 am to assist Mrs Baumanis and do some cleaning.

Mrs Ujigaeva noticed that Mrs Baumanis was confused and did not seem to be well.

One of Mrs Baumanis’ daughters arrived at approximately 11:00 am and was informed by Mrs Ujigaeva that her mother was not well. Mrs Baumanis had been complaining about pain in her back and chest and had difficulty walking.

Mrs Baumanis’ daughter then contacted Dr Patrick Elton, her treating general practitioner, and asked him to attend the home address to assess her mother. He arrived at approximately 11:50 am and examined Mrs Baumanis. He found that she was suffering from dehydration, a high temperature and needed to be admitted to hospital immediately.

2.2. Mrs Baumanis refused to go to hospital and said that she wanted to remain at home and be looked after there. It seems that she was concerned that she might be put in a nursing home and was very resistant to that idea. However, Dr Elton contacted Dr Natesan Lakshmanan who was a consultant physician who had first treated Mrs Baumanis at the Parkwynd Hospital in October 2005, to arrange an admission to the hospital. Unfortunately, Dr Lakshmanan was on leave so Dr Elton made arrangements with a Dr Wong for Mrs Baumanis to be admitted to the Wakefield Hospital. Dr Elton then contacted the South Australian Ambulance Service to arrange that transfer.

2.3. In the meantime, despite the best efforts of her daughter, Mrs Baumanis was still refusing to go to hospital. When the ambulance officers arrived at the house they too were unable to convince Mrs Baumanis that she needed to go with them to the hospital. Mrs Baumanis was maintaining her position that she feared being placed in a nursing home. The ambulance officers reassured her and explained that they simply wanted to take her to hospital for treatment but she still refused to go. One of the ambulance officers then attended at Dr Elton’s surgery and informed him that Mrs Baumanis was refusing to go to hospital and that they could not persuade her otherwise.

2.4. Dr Elton then returned to Mrs Baumanis’ house and again, together with the other ambulance officer and Mrs Baumanis’ daughter, attempted to convince her to go to the hospital. Mrs Baumanis steadfastly refused. Dr Elton felt that it was unsafe for Mrs Baumanis to remain at home and that she required immediate medical treatment.

He therefore decided that he would detain her under the Mental Health Act for her treatment in the Royal Adelaide Hospital. He had to return to his surgery to obtain

the relevant forms. At 2:18 pm he completed a Form 1 Detention Order in the presence of Mrs Baumanis. The grounds for his opinion as written on that form are: ‘Patient is dehydrated and confused. Self neglect.’

2.5. In my opinion, having regard to the various efforts made by Dr Elton, the South Australian Ambulance Service officers and Mrs Baumanis’ daughter, and in the circumstances which faced Dr Elton, the detention order was lawful and appropriate.

I note that in the Form 1 completed by Dr Elton, a copy of which was admitted as Exhibit C17b in these proceedings, he has not included the Royal Adelaide Hospital in the appropriate place in that form, although he refers to it in another part of the form in such a way that his intention that Mrs Baumanis be admitted and detained at the Royal Adelaide Hospital is quite plain. In my view nothing turns on this and the detention order was appropriately made.

2.6. The detention order having been made, Mrs Baumanis was placed in a wheelchair with a restraining belt by the ambulance officers. She was still resistant to being taken from her house and was protesting verbally and appeared to be trying to get out of the chair. According to one of the statements she attempted to grab a doorframe as the wheelchair was being wheeled through the house and bit one of the ambulance officers on the finger. Just as the ambulance officers were about to attempt to get Mrs Baumanis out of the chair and onto a stretcher she was seen by Dr Elton and the ambulance officers to suddenly cease her resistance, then stiffen and become unresponsive. She was immediately placed on the stretcher, put into the ambulance and cardiopulmonary resuscitation commenced. The defibrillator was used and cardiac massage started. Dr Elton inserted an intravenous line and she was given adrenaline. Police officers arrived at the house as did another ambulance crew to assist and ultimately Mrs Baumanis was taken to the Royal Adelaide Hospital, leaving her house at approximately 2:47 pm and arriving at the Royal Adelaide Hospital at 2:58 pm.

2.7. Despite continuous resuscitative efforts from the time of her collapse to her arrival at the Royal Adelaide Hospital, Mrs Baumanis did not respond. Dr Jarrod Koh was on duty at the Royal Adelaide Hospital. He made a statement which was admitted as Exhibit C2a in which he described Mrs Baumanis’ state on her arrival at the hospital and the treatment that was given to her. He said that at about 3:20 pm a pulse was palpable and cardiopulmonary resuscitation was stopped. At 3:26 pm her blood

pressure was so low that she was pulseless and she had ventricular tachycardia. She was again defibrillated and some rhythm did return. Additional pacing was instituted to keep the rate up to sixty beats per minute.

2.8. Following discussion with Mrs Baumanis’ daughters, a decision was made that there would be no further invasive therapy and the pacing and other active measures were withdrawn. Mrs Baumanis was certified deceased at the Royal Adelaide Hospital at about 4:00 pm that day.

2.9. As I have already said it is my belief that there was a clear basis for Dr Elton to make a detention order. Furthermore, all treatment instituted after Mrs Baumanis’ collapse was appropriate and extremely timely.

2.10. This matter was investigated on my behalf by Senior Constable Stan Tsoulos of Adelaide CIB and his investigating officer’s statement was admitted as Exhibit C17 in these proceedings. The investigation was thorough and I have found it very useful. It includes information about Mrs Baumanis’ health history and her personal circumstances, drawn from statements obtained from her daughters Silvia Brown and Ilona Howard, her friend Dina Ujigaeva, a person by the name of Gianni Ricci and the medical practitioners Dr Lakshmanan, Dr Elton and a locum doctor who had attended on Mrs Baumanis some days before by the name of Dr Kamal Wellalagodage.

Statements were also obtained from the paramedics and the attending police officers.

2.11. According to Dr Koszyca’s autopsy report, Exhibit C3a, Mrs Baumanis’ cause of death was ischaemic heart disease. The findings included severe atherosclerosis of the right coronary and left anterior descending coronary arteries. There were features suggestive of focal acute ischaemic injury and cardiomegaly was found post mortem.

In view of those findings it clear that Mrs Baumanis’ death was from natural causes and that there was no deficiency in her treatment on 3 November 2006. Of course, the events of that day would have been very distressing for Mrs Baumanis and they may have precipitated her cardiac arrest. However she clearly required medical treatment at a hospital and in my opinion Dr Elton and Mrs Baumanis’ daughters and all others involved acted appropriately and in her best interests on 3 November 2006. I make no recommendations in relation to this matter.

Key Words: Death in custody; Detention Order; Ischaemic heart disease.

In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 12th day of December, 2007.

State Coroner Inquest Number 19/2007 (1627/06)