Coroner's Finding: SGAMBATO Raffaele

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 12th day of September 2013 and the 19th day of May 2014, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Raffaele Sgambato.

The said Court finds that Raffaele Sgambato aged 84 years, late of 42 Liberman Road, Para Hills, South Australia died at the Royal Adelaide Hospital, North Terrace, South Australia on the 8th day of October 2011 as a result of malnutrition in conjunction with heart, liver and kidney failure. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Mr Sgambato, aged 84 years, died on 8 October 2011. He suffered from severe dilated cardiomyopathy, atrial fibrillation, chronic renal failure, congestive cardiac failure, previous cardiac arrest, osteoarthritis, depression and post-traumatic stress disorder and behavioural disturbance.

1.2. At the time of his death Mr Sgambato was detained pursuant to the Mental Health Act 2009. His death was therefore a death in custody within the meaning of that expression in the Coroners Act 2003 and this Inquest was held as required by section 21(1)(a) of that Act.

2. Background 2.1. In late August 2011 Mr Sgambato had a fall at home and was admitted to the Modbury Hospital. He had been vomiting and had blood in his stool. Shortly after

admission he discharged himself from the hospital, despite being so ill he could hardly walk.

2.2. The following day Mr Sgambato's physical health was still poor and he was being abusive to his wife. He told his wife and daughter that he was going to wake up in the night, kill everyone and burn the house down. This was not in keeping with Mr Sgambato's usual behaviour.

2.3. A few days later a RDNS nurse attended at the home and advised that Mr Sgambato had a severely distended bowel and required Xrays. Over the next few days he was resisting all assistance and continuing to be very abusive including making threats to kill people. Eventually his family called an ambulance. Ambulance officers attended with police and took him to the Royal Adelaide Hospital.

3. Mr Sgambato’s admission at the Royal Adelaide Hospital 3.1. Admission notes for Mr Sgambato indicate significant abdominal distension and an abdominal Xray performed shortly after admission showed dilated loops of small bowel and large bowel. He presented to medical staff as very verbal, verging on aggressive.

3.2. On 3 September 2011 discussions were had between medical staff and Mr Sgambato's family about his condition, both physical and mental. It became very clear that he would not be able to return home as his frail wife was not able to manage his aggression and physical violence. It was also decided that he was not for CPR, intubation, defibrillation or ICU, that he would be currently for MET calls, but he had multiple comorbidities and if he deteriorated then it would be reasonable to reconsider that. His condition did continue to deteriorate and he would often call and cry out loudly stating that he wanted to die or wanted to kill his family.

3.3. On 6 September 2011 Mr Sgambato began demanding discharge and indicated that he was going to leave the hospital. He told staff that he would try and kill himself by jumping out of a window. Further, he continued to indicate a desire to kill his family and burn his house down and declared that he would not eat, drink or take medication until he died there.

4. Mr Sgambato’s detention 4.1. At 1430 hours on 6 September 2011 Mr Sgambato was detained on a level 1 detention and treatment order. At 1000 hours on 7 September 2011 that order was reviewed by psychiatrist, Dr Paul Davis, and confirmed until 9 September 2011. Dr Davis again reviewed Mr Sgambato on 9 September and a level 2 detention and treatment order was made with an expiration of 21 October 2011.

4.2. Through the duration of his admission Mr Sgambato was generally difficult to manage with intermittent episodes of compliance. His family maintained their position that they did not consider it appropriate for him to be discharged home due to his aggression and violence. Nursing home placement was considered, however he refused to move into a nursing home demanding that he be discharged to his own home.

4.3. On the morning of 23 September 2011 a MET call was made due to Mr Sgambato being unresponsive after pulling out his Jelco. This act followed several days of refusal of oral intake. A discussion between medical staff and the Sgambato family later that day resulted in a decision that medical treatment would not be forced upon him and that he should simply be kept as comfortable as possible, on occasion with the administration of morphine.

4.4. On 27 September 2011 a Guardianship Board hearing was conducted and full guardianship orders including section 32 powers were granted to Mr Sgambato's daughter, Ms Agnes Spago. As Ms Spago was advocating for Mr Sgambato to enter residential care upon discharge, an ACAT assessment was booked for 6 October 2011.

4.5. By 3 October 2011 Mr Sgambato was reported in the case notes to have been bed bound and refusing most oral intake. His blood pressure was low and his care focus was on comfort.

4.6. On 4 October 2011 the ACAT team attempted to assess Mr Sgambato, however he was sleeping during their visit. They did have discussions with Ms Spago and her husband and it was decided that ACAT would recommend placement. Mr Sgambato's admission was thereafter changed to a maintenance care type whilst awaiting placement or discharge.

4.7. He continued to deteriorate and died at 0730 hours on 8 October 2011.

5. Cause of death 5.1. The report of death provided by the Royal Adelaide Hospital indicated the cause to be malnutrition in combination with heart, liver and kidney failure1, and I so find.

6. Conclusion 6.1. I find that Mr Sgambato had a mental illness at all material times and that the orders for detention under the Mental Health Act 2009 were lawful and appropriate.

6.2. I am further satisfied that the medical treatment that was administered to Mr Sgambato during the period of his hospitalisation at the Royal Adelaide Hospital was lawful, appropriate, humane and necessary.

7. Recommendations 7.1. 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 May, 2014.

State Coroner Inquest Number 31/2013 (1620/2011) 1 Exhibit C10