Coroner's Finding: RICHARDSON Margaret Joan

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 3rd day of November 2010 and the 19th day of September 2011, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Margaret Joan Richardson.

The said Court finds that Margaret Joan Richardson aged 63 years, late of the Salisbury Private Nursing Home, 147 Frost Road, Salisbury, South Australia died at the Salisbury Private Nursing Home, Salisbury, South Australia on the 31st day of January 2009 as a result of ischaemic heart disease. The said Court finds that the circumstances of her death were as follows:

1. Introduction and reason for Inquest 1.1. Mrs Margaret Joan Richardson was 63 years of age when she died on 31 January 2009 at the Salisbury Private Nursing Home. At that time she was subject to an order of the Guardianship Board made under section 32 of the Guardianship and Administration Act 1993 which provided for her to be detained at the Salisbury Private Nursing Home. Her death was therefore a death in custody within the meaning of section 21(1)(a) of the Coroners Act 2003 and this Inquest was held as required by that section.

2. Cause of death 2.1. An autopsy was conducted by Dr Neil Langlois, forensic pathologist. He gave the cause of death as ischaemic heart disease1 and I so find. An investigation was carried out by Senior Constable Sutherland of Elizabeth CIB. Senior Constable Sutherland 1 Exhibit C2a

prepared a report as a result of his investigation and found no evidence of a lack of care at the Salisbury Private Nursing Home, nor at the Lyell McEwin Hospital2. Mrs Richardson’s death was a result of natural processes.

3. Background and events leading to Mrs Richardson’s death 3.1. Mrs Richardson had lived in her Housing Trust unit at Elizabeth Park for approximately 20 years. She was a chronic alcohol abuser and presented at the Lyell McEwin Hospital on many occasions for alcohol intoxication. She lived in that unit with her only son who had a substantial intellectual deficit. Three years prior to her death her son was moved by Housing SA due to family violence.

3.2. In October 2008 Mrs Richardson became unwell while shopping at the Elizabeth City Centre. She was transported by ambulance to the Lyell McEwin Hospital where she was found to be in a very poor state of health. A full dementia workup was carried out and she was found to have persistent and significant cognitive impairments. Mrs Richardson was fortunate to come under the pastoral care of social worker, Mr Peter Zanker, while at the Lyell McEwin Hospital3. Mrs Richardson told Mr Zanker that her son would assault her if she did not give him money. Mr Zanker witnessed an incident where Mrs Richardson’s son had attended at the hospital ward and demanded money. Furthermore, she told him that her son had attended her home address whilst she was in hospital and had taken belongings which he had exchanged for cash at Cash Converters.

3.3. Mr Zanker then wrote a report for presentation to the Guardianship Board which ultimately resulted in the Guardianship Board making the order, to which I have already referred, on 5 December 2008. Mrs Richardson entered the Salisbury Private Nursing Home on 6 January 2009 and during that month she had two admissions to the Lyell McEwin Hospital for respiratory tract infections. She was returned from the second of those admission to the Salisbury Private Nursing Home on 31 January

2009. At approximately 3pm that afternoon she was found by a carer in her bed.

There were no signs of life.

2 Exhibits C17a and C17b 3 Exhibit C12a, Statement of Mr Zanker

4. Conclusions 4.1. I have read the relevant material in this matter and I am satisfied that during her detention Mrs Richardson was appropriately cared for. Her death was a result of a natural disease process which was probably contributed to by her lifestyle choices over a very long time.

5. Recommendations 5.1. 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 19th day of September, 2011.

State Coroner Inquest Number 31/2010 (0175/2009)