Coroner's Finding: ANDERSON Rosemary Joy

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 2nd day of December 2010 and the 23rd day of September 2011, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Rosemary Joy Anderson.

The said Court finds that Rosemary Joy Anderson` aged 56 years, late of Woodbridge Retirement Village, 14/104 Westlakes Boulevard, West Lakes, South Australia died at the Queen Elizabeth Hospital, Woodville Road, Woodville South, South Australia on the 27th day of April 2009 as a result of multi-organ failure due to anorexia nervosa. The said Court finds that the circumstances of her death were as follows:

1. Introduction 1.1. Rosemary Joy Anderson was 56 years of age when she died on 27 April 2009. She had a long history of anorexia nervosa and other associated medical problems and was very thin in appearance at the time of her death with a body mass index of only 10.3.

2. Reason for Inquest 2.1. For most of her life Ms Anderson had lived with her mother. Shortly before her death she moved into independent accommodation because her mother had decided to move to Victoria to live with other family members. On 20 April 2009 Ms Anderson was found by staff of the residential village in which she lived, lying on her side on her bedroom floor. Ambulance officers were called and reported her condition as ‘very skinny, fragile and dehydrated’. She refused to accompany the ambulance officers to the hospital and refused to assist them when they attempted to assess her. The ambulance officers considered that Ms Anderson was suffering from paranoid delusions. Eventually she was taken to the Queen Elizabeth Hospital with the

assistance of police and was admitted and detained under the Mental Health Act 1993.

Treatment was commenced and continued until 27 April 2009 when Ms Anderson died. A detention order under the Mental Health Act 1993 was in place as at the date of her death and, accordingly, hers was a death in custody within the meaning of the Coroners Act 2003. This Inquest was held as required by section 21(1)(a) of that Act.

3. Cause and circumstances of death 3.1. A pathology review conducted by Dr Iain McIntyre of Forensic Science South Australia expressed the opinion that the cause of death was multi-organ failure due to anorexia nervosa1, and I so find.

3.2. While in the Queen Elizabeth Hospital Ms Anderson was provided with appropriate medical treatment. However, at approximately 11:30 on the morning prior to her death, she was found to have very low oxygen saturations. She was admitted to the Intensive Care Unit suffering from profound hypotension, hypoxia and severe mixed acidosis. She required ventilation and life support. During the early hours of 27 April 2009 she experienced a rapid decline in her condition and was declared deceased at 1:35am on that day.

4. Conclusions 4.1. Ms Anderson’s detention was lawful and appropriate. Her treatment in the Queen Elizabeth Hospital and at the hands of the staff of the South Australian Ambulance Service was appropriate and proper.

5. Recommendations 5.1. I have no recommendations to make in this matter.

1 Exhibit C2a

Key Words: Death in Custody; Anorexia Nervosa In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 23rd day of September, 2011.

State Coroner Inquest Number 33/2010 (0698/2009)