Coroner's Finding: McINERNEY Harold Leslie

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 30th day of March 2007, and the 12th day of April 2007, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Harold Leslie McInerney.

The said Court finds that Harold Leslie McInerney aged 84 years, late of 4 Tweed Avenue, Findon died at The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, South Australia on the 11th day of November 2005 as a result of lower respiratory tract infection complicating congestive cardiac failure. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Harold Leslie McInerney was born on 30 June 1921. He was 84 years of age as at the date of his death on 11 November 2005. His cause of death was given as lower respiratory tract infection complicating congestive cardiac failure by Dr John Gilbert, Forensic Pathologist. Dr Prudence Storer, a medical practitioner at the Queen Elizabeth Hospital also expressed the opinion that Mr McInerney’s cause of death was due to congestive cardiac failure and respiratory tract infection. No autopsy was carried out because Dr Gilbert did not consider that necessary. Accordingly, I adopt Dr Gilbert’s cause of death as lower respiratory tract infection complicating congestive cardiac failure and I so find.

1.2. Mr McInerney was at the date of his death subject to a detention order given under the Mental Health Act 1993. Accordingly, his was a death in custody within the meaning

of that expression in the Coroner’s Act 2003 and this Inquest was held as required by section 21(1)(a) of that Act.

2. Background 2.1. Prior to his last admission to hospital in September 2005, Mr McInerney lived alone at his home at 4 Tweed Avenue, Findon. He had lived alone since the death of his wife Dorothy Joan McInerney on 12 February 1985. According to a statement given by Mr McInerney’s daughter, Marlene Keane, which was admitted as Exhibit C1b in these proceedings, Mr McInerney was an independent man, maintaining his home in a neat and tidy way, and regularly preparing meals for himself. He was always fit. He had had two cataract operations, a hernia operation and a pacemaker.

2.2. On 23 September 2005 Ms Keane took her father to the Queen Elizabeth Hospital where he was diagnosed as having three bleeding ulcers in his stomach and one in his bowel. He was admitted to the hospital for treatment of this condition and remained there as a voluntary patient until he was detained on 28 October 2005. On that day, and on a number of previous occasions, Mr McInerney had left the hospital. He was located on Findon Road on 28 October 2005 attempting to return to his home. He refused to accompany nursing staff back to the hospital and police were called.

Eventually he was taken by nursing staff to his home, his daughter and son were called, and he was persuaded to return to the hospital. Later that day he was detained pursuant to the Mental Health Act 1993 by Dr Kym Duncliffe. The reasons for this detention as given by Dr Duncliffe included that Mr McInerney suffered from advanced dementia, that he was unable to manage at home and that he had absconded from the hospital on that date. This order was confirmed the following day (29 October 2005) by Dr Sue Waite, Psychiatrist. In confirming the order Dr Waite stated: ‘Mr McInerney was unable to provide a history of recent events and had clear short term memory deficits. He expressed his intention to leave hospital.’ She also stated: ‘case notes report a history of advanced dementia and absconding from hospital.’

2.3. On 31 October 2005 Dr Kate Jarvis detained Mr McInerney for a period of 21 days.

In her order she gave as grounds for detention the following:

‘Remains demented and confused, has tried to abscond and has hit out at staff. Seems to have had a rapid decline in cognition.’ She further noted: ‘Pleasant but confused (family present) shackled.’

2.4. Dr Jarvis recommended an increase in chemical sedation and assessment by the Aged Care Assessment Team with a view for a placement in a nursing home. According to a statement given by Dr Jarvis1 which was admitted as Exhibit C5a in these proceedings, Mr McInerney had a urinary infection which may have exacerbated his confusion and contributed to his cognitive impairment. Dr Jarvis stated that Mr McInerney was treated with Haloperidol and Oxazepam, both standard treatments for behaviour disturbances associated with dementia.

2.5. According the Queen Elizabeth Hospital medical notes, Mr McInerney’s health was deteriorating further in the days leading up to his death. On 9 October 2005 he was short of breath and on 10 November 2005 staff noted significant pitting oedema. This is indicative of cardiac illness.

2.6. At about 3:00am on 11 November 2005 Mr McInerney wished to go to the toilet. He was found shortly afterwards, unresponsive, having collapsed while sitting on the toilet. He was returned to his bed and responded to treatment becoming more alert and orientated. The next entry for that date indicates that he reported feeling comfortable and denied any breathing difficulty.

2.7. At 7:40pm that day he was found by a member of the nursing staff, Ms Rawson, Registered Nurse. Mr McInerney was not breathing and no pulse could be detected.

2.8. According an earlier note in his medical records, a decision had been made in discussion with his family on 23 September 2005 that in view of his dementia, in the event of cardiorespiratory arrest or significant illness needing prolonged intensive care admission, he would be not for resuscitation or prolonger treatment in the Intensive Care Unit, although in the event of a reversible event, resuscitation should be attempted. Clearly, the circumstances in which Mr McInerney was found are indicative that he had been pulseless for some little time. I am quite satisfied that the relevant staff correctly decided that this was not a reversible event such as to justify 1 Dr Jarvis is a psychiatrist

an attempt at resuscitation. Certainly Nurse Rawson was of the opinion that it would not have been possible to resuscitate Mr McInerney in any event.

3. Conclusions 3.1. In conclusion I consider that Mr McInerney’s care while in the Queen Elizabeth Hospital was of a very high standard and his status as a detained patient did not contribute in any way to his death.

3.2. I acknowledge the very thorough investigation which was conducted in this matter by Detective Brevet Sergeant Alex Tepavcevic of Port Adelaide CIB.

Key Words: Death in custody; Detention Order; Heart disease.

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

State Coroner Inquest Number 8/2007 (2924/05)