Coroner's Finding: THOMPSON Kym Joseph Paul

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 9th day of September 2009 and the 7th day of June 2010, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Kym Joseph Paul Thompson.

The said Court finds that Kym Joseph Paul Thompson aged 45 years, late of Unit 1, 11 Fleet Avenue, Hillcrest, South Australia died at Modbury Hospital, Smart Road, Modbury, South Australia on the 23 day of September 2007 as a result of sepsis with infective endocarditis, right lobar pneumonia (with abscess formation and pleural involvement) on a background of ischaemic and hypertensive heart disease and non insulin dependant diabetes mellitus. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mr Thompson was 45 years of age when he died on 23 September 2007. A postmortem examination was conducted by Dr Cheryl Charlwood, forensic pathologist, who found the cause of death to be sepsis with infective endocarditis, right lobar pneumonia (with abscess formation and pleural involvement) on a background of ischaemic and hypertensive heart disease and non insulin dependant diabetes mellitus, and I so find.

2. Reason for Inquest 2.1. Immediately preceding, and at the time of his death, Mr Thompson was involved in an incident with members of SAPOL. Mr Thompson had been behaving in an erratic

fashion on his electric wheelchair on Sudholz Road at Holden Hill near the Holden Hill Police Station. Police officers were in attendance and were attempting to prevent Mr Thompson from harming himself by riding his wheelchair into traffic. It appears that a decision had been made by one of the officers to detain Mr Thompson pursuant to the Mental Health Act 1993 although this decision had not been conveyed to Mr Thompson. In any event, it is appropriate that his death be treated as a death in custody under section 21(1)(a) of the Coroners Act 2003 and this Inquest was held accordingly.

3. Background 3.1. Mr Thompson was born in 1962 and was offered for adoption immediately by his birth mother. He had a troubled childhood and, at the age of 13, he made his first attempt at self-harm. At the age of 14 he retaliated with violence when other children teased him about being overweight. He also began glue sniffing at that age and at the age of 15 was expelled from high school. He began drinking alcohol very heavily and was from then on in regular contact with police for assaults and other behaviour related offences. He had a particular habit of spitting at people.

3.2. His adoptive mother, Mrs Kerslake, made a statement to police in which she said that psychiatrists had informed her that Mr Thompson had a borderline personality disorder1.

3.3. Mr Thompson resided with his adoptive parents until he was 30 when they divorced due to pressures that arose out of Mr Thompson’s behaviour. He moved into a unit at that time and lived independently until April 1999 when his unit caught fire and he was severely burned. His injuries left him severely disabled and confined to a wheelchair. He had a permanent tracheotomy in his throat to aid his breathing and was in constant pain. He was medicated for pain with the slow release pain killer, Kapanol.

3.4. Mr Thompson’s criminal history included offences of disorderly behaviour, failing to cease loiter, unlawful wounding, numerous assaults, assault and resist police, property damage, demanding money with menace and larceny. He served short periods of imprisonment in 1987, 1988, 1989, 1995 and 1998. Prior to his death on 23 1 Exhibit C6a

September 2007 he had been arrested on 7 August 2007 for spitting in the face of a police officer who was arresting him under the Public Intoxication Act. Mr Thompson was then medically assessed at the Royal Adelaide Hospital and was reported to have spat in the face of a treating doctor and a second police officer.

3.5. At the time of his death Mr Thompson had several criminal charges pending against him including charges for carrying an offensive weapon, driving under the influence and assault and arson.

4. Events surrounding Mr Thompson’s death 4.1. On the day prior to his death he was admitted to Modbury Hospital having been diagnosed with pneumonia. He remained in hospital overnight but discharged himself at approximately 12pm on the day of his death, 23 September 2007. Prior to his discharge he engaged in abusive and threatening behaviour towards staff and caused disruption to other patients. In particular, he threw faeces at a member of the nursing staff and spat at staff. He also set fire to paper in his hospital cubical. Doctors at the hospital considered whether at that time Mr Thompson was detainable but concluded that he was not threatening to harm himself or anyone else at the time and elected not to detain him. Dr Beare attempted to persuade Mr Thompson to remain in hospital and pointed out to him the danger to his health of being discharged. Mr Thompson left the hospital but returned shortly afterwards for treatment for a foot injury. A nurse was called to assist with this and he assaulted her while she was attempting to treat him. Police were called and they arrested him at the hospital. He was conveyed to the Holden Hill Police Station where he was charged and released on bail. This occurred at 2:23pm.

4.2. At about 2:59pm that day Mr Thompson called for an ambulance to attend his home saying that he had been diagnosed with pneumonia and was having trouble breathing.

The attending paramedics had had previous dealings with Mr Thompson and requested police assistance. When the paramedics arrived at Mr Thompson’s home they had a discussion with him about his condition. He was smoking throughout the conversation and they noted that his breathing appeared to be satisfactory apart from the obvious issues associated with his tracheotomy. They suggested that Mr Thompson see his general practitioner and at that point Mr Thompson became agitated and abusive. The ambulance officers returned to their vehicle and shortly

after Mr Thompson rammed the ambulance with his wheelchair whilst yelling obscenities and spitting at the ambulance. With the assistance of the police officers who had attended the ambulance departed as did the police shortly afterwards.

4.3. Nothing is known about Mr Thompson’s movements between then and approximately 3:55pm when he attended at the Coles Express service station on Sudholz Road. At that time he appeared to be intoxicated and was carrying a plastic bladder, apparently filled with red wine. Toxicological tests undertaken on post-mortem blood showed a blood alcohol level of 0.139% which supports the proposition that he had been drinking on the afternoon of his death, although it is not known from where he obtained the alcohol.

4.4. While at the service station he drank from the bladder of red wine and harassed the service station attendant and various customers within the station. After some time he left the service station and, at approximately 4:25pm, was seen by motorists to be riding his wheelchair amongst the vehicles on Sudholz Road opposite the Holden Hill Police Station in a manner suggesting that he seemed to want to be hit by a car. In particular, he drove into several of the cars whilst they were stationary, banging his wheelchair into them. He held up traffic by parking his wheelchair in front of vehicles until eventually an off-duty police officer approached him and persuaded him to move to the footpath. Other police then attended from the Holden Hill Police Station and Mr Thompson made threats to the officers about killing himself. He continued to attempt to ride his wheelchair into the path of oncoming traffic on Sudholz Road and the police constantly had to prevent him from doing so. This behaviour continued for some time until, at approximately 4:39pm, the officers at the scene contacted the Mobile Assistance Patrol service2. A representative of the Mobile Assistance Patrol service arrived but did not have a wheelchair access vehicle and was unable to assist the police any further.

4.5. The officers at the scene, in conjunction with police at the Communications Centre, discussed the possibility of taking Mr Thompson to the Salvation Army Sobering Up Centre in Whitmore Square. However, it was decided that this would not be appropriate as the sobering up unit cannot cater for persons who are unable to walk.

After some further attempts to cajole Mr Thompson into returning home and to refrain 2 A part of the Aboriginal Sobriety Group assistance program which assists in transporting people either to hospital or to their homes safely

from continuing with his erratic and dangerous behaviour, Constable Robertson conferred with Sergeant Brown and a decision was made to detain Mr Thompson under Section 23 of the Mental Health Act 1993. At 5:40pm a request was made for the ambulance service to attend to convey Mr Thompson to the Modbury Hospital.

4.6. At 5:53pm Constable Robertson was advised that the ambulance had been delayed.

Shortly after this Mr Thompson started to threaten to get out of his wheelchair which was now not working due to a flat battery. Mr Thompson succeeded in extricating himself from the wheelchair by using his arms and upper body and climbed out of the chair and onto the footpath. At this point he attempted to drag himself out towards the roadway. However, almost immediately he rolled over onto his left-hand side and covered his head with his right hand. He was talking but Constable Robertson could not hear what he was saying. Constable Robertson became concerned about his medical condition and lent over to ensure that Mr Thompson was breathing. He satisfied himself that Mr Thompson was breathing and then requested that he sit up.

However Mr Thompson did not respond and Constable Robertson bent down and shook Mr Thompson but again there was no response. Mr Thompson could be heard breathing or wheezing at this time. Constable Robertson became more concerned about Mr Thompson’s welfare, put some gloves on and pushed Mr Thompson onto his left side. He then checked Mr Thompson’s pulse and breathing and discovered that Mr Thompson seemed to have stopped breathing. Constable Robertson could find only a very weak pulse. He immediately called Police Communications and asked that the ambulance call-out be upgraded to urgent.

4.7. Constable Robertson was concerned that Mr Thompson’s breathing had stopped and, as he did not have a face mask with him, he ran into an adjacent McDonalds restaurant, grabbed some napkins from a customer inside, punctured a hole in the napkins using a pen and placed it over the Mr Thompson’s mouth and nose in an attempt to perform mouth to mouth resuscitation. However, the napkin was not properly sealing and the resuscitative methods were not effective. Constable Robertson thought that there may have been a problem associated with the tracheotomy tube and attempted to close that off in order to perform more effective mouth to mouth resuscitation. By this time other police officers had arrived and made a request over the police radio for a defibrillator to be provided from the Holden Hill Police Station. Detective Brevet Sergeant Zschorn was stationed at the Holden Hill

CIB at that time and, having heard this request, he took the defibrillator housed in the police station and ran across the road to the Mr Thompson’s location. He unpacked the defibrillator and followed the audible instructions provided by the defibrillator machine. The defibrillator went through a process of analysis before indicating that no shock was necessary. At about 6:13pm ambulance personnel arrived and commenced resuscitative efforts.

4.8. Despite all attempts by both police and ambulance officers, Mr Thompson could not be revived. He was conveyed to the Modbury Hospital and he was certified life extinct at 6:55pm that day.

5. Conclusions 5.1. In my opinion, the actions taken by police, hospital and ambulance personnel in the period leading up to Mr Thompson’s death were appropriate and no action, or inaction, of any of the persons involved played any part in Mr Thompson’s death.

6. Recommendations 6.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 7th day of June, 2010.

State Coroner Inquest Number 22/2009 (1386/2007)