Coroner's Finding: BLAKE Elizabeth Mathilda

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 27th day of April 2007, and the 28th day of June 2007, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Elizabeth Mathilda Blake.

The said Court finds that Elizabeth Mathilda Blake aged 76 years, late of Marten Residential Care Centre, 110 Strathfield Terrace, Largs North died at Marten Residential Care Centre, 110 Strathfield Terrace, Largs North, South Australia on the 14th day of October 2006 as a result of lower limb ischaemia due to diabetes and peripheral vascular disease. The said Court finds that the circumstances of her death were as follows:

1. Introduction and reason for Inquest 1.1. Elizabeth Mathilda Blake was born on 13 March 1930. She died on 14 October 2006 while a resident of the Marten Residential Care Centre at 110 Strathfield Terrace, Largs North. She was therefore 76 years old at the date of her death.

1.2. Mrs Blake was the subject of an order on 4 May 2006 made pursuant to section 32 of the Guardianship and Administration Act 1993 by the Guardianship Board of South Australia. That order stated that the Public Advocate be appointed full guardian of Mrs Blake and further authorised the detention of Mrs Blake in such place as the Public Advocate might determine. A copy of that order was admitted as Exhibit C7c in these proceedings. The Public Advocate made a direction in pursuance of that order, a copy of which was admitted as Exhibit C7d in these proceedings. That direction required that Mrs Blake reside at Marten Residential Care Centre and that she not leave that facility without the permission of the Public Advocate.

Furthermore, the direction authorised Mrs Blake’s detention in the Marten Residential Care Centre and permitted the use of pharmacological and physical restraint so far as was necessary to ensure the proper medical treatment and care of Mrs Blake. The order of the Guardianship Board, and the direction of the Public Advocate, were in force at the time of Mrs Blake’s death. Accordingly, she died in custody within the meaning of the Coroners Act 2003, and this Inquest was held as required by section 21(1)(a) of that Act.

1.3. Mrs Blake’s treating doctor, Dr Peter Gill was of the opinion that the cause of her death was lower limb ischaemia due to diabetes and peripheral vascular disease 1.

Dr John Gilbert, Forensic Pathologist, concurred in that cause of death having reviewed Mrs Blake’s medical notes and although no post mortem examination was carried out, I find that her cause of death was as described by Dr Gill.

1.4. According to an affidavit of Dr Gill, admitted as Exhibit C3a in these proceedings, Mrs Blake had a long psychiatric history which eventually developed into dementia.

She also suffered a number of medical problems including diabetes, peripheral vascular disease and ischaemia of her lower legs which developed to necrosis and ulceration. During the last three months of her life her medical condition declined dramatically.

1.5. While detained at the Marten Residential Care Centre, Mrs Blake received medication on a regular basis for her diabetes, anti-psychotic tranquillisers and analgesia for her vascular pain. She was under palliative care at the time of death and was receiving morphine for pain management2. I am satisfied that Mrs Blake received appropriate care while detained at the Marten Residential Care Centre. I have had regard to the affidavits of Kelly Sheehan, Care Manager of Marten Residential Care Centre3, Dr Peter Gill4 and Mrs Blake’s son, Michael Blake5 in forming that opinion. Indeed, Mr Blake stated that he was satisfied with the level of care that his mother received and was most appreciative of the support offered by the staff of the centre to his mother.

1 Exhibit C3b 2 Exhibit C6a 3 Exhibit C6a 4 Exhibit C3a 5 Exhibit C1a

1.6. In my opinion, Mrs Blake died of natural causes and there was nothing suspicious or untoward in relation to her death. It is unnecessary for me to make any recommendations pursuant to section 25 of the Act in this matter.

Key Words: Death in custody; Detention Order; Guardianship Board.

In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 28th day of June, 2007.

State Coroner Inquest Number 11/2007 (1545/06)