Coroner's Finding: HEWLETT Betty Lorraine

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 4th day of August 2015 and the 22nd day of September 2015, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Betty Lorraine Hewlett.

The said Court finds that Betty Lorraine Hewlett aged 92 years, late of 27 Wunderley Drive, Mount Barker, South Australia died at the Royal Adelaide Hospital, Nort Terrace, Adelaide, South Australia on the 22nd day of January 2013 as a result of community acquired pneumonia on a background of end stage chronic obstructive airways disease. The said Court finds that the circumstances of her death were as follows:

1. Introduction, reason for Inquest and cause of death 1.1. Betty Hewlett was 92 years of age when she died on 22 January 2013 at the Royal Adelaide Hospital (the RAH). At the time of her death Mrs Hewlett was detained pursuant to a Level 2 inpatient treatment order pursuant to the Mental Health Act

2. Thus her death was a death in custody for which an Inquest was mandatory pursuant to the Coroners Act 2003.

1.2. The medical deposition forwarded to the State Coroner from clinical staff at the RAH expresses the cause of death as community acquired pneumonia on a background of end stage chronic obstructive airways disease. As will be seen, that opinion as to cause of death is totally in keeping with Mrs Hewlett’s medical history and with the clinical course at the RAH prior to her death. I find that Mrs Hewlett’s cause of death was community acquired pneumonia on a background of end stage chronic obstructive airways disease.

2. Background 2.1. Mrs Hewlett had suffered from chronic obstructive airways disease (COAD) during her life. She had been prescribed prednisolone for this condition over a long period of time. She was also prescribed the use of an oxygen tank at home. Mrs Hewlett lived alone following her husband’s death in 1998. In late 2012, due to her experiencing depression and anxiety, Mrs Hewlett was commenced on antidepressant medication by her general practitioner.

2.2. On 28 December 2012 Mrs Hewlett called an ambulance for herself due to her health deteriorating. As a result she was admitted to the Mount Barker District Soldiers Memorial Hospital (the Mt Barker Hospital). There Mrs Hewlett was found to be extremely frail and was considered to be malnourished. She weighed only 38kg. She remained in the Mount Barker Hospital into January 2013.

2.3. During Mrs Hewlett’s admission at the Mt Barker Hospital she became increasingly paranoid, confused and agitated. For this reason on 3 January 2013 Mrs Hewlett was prescribed the antipsychotic medication, risperidone. On 4 January 2013 Mrs Hewlett's general practitioner, Dr Allison Ramsey, who was treating her while she was in hospital, attempted to arrange some investigations such as blood tests.

However, Mrs Hewlett had become quite delusional and had formed a belief that the hospital staff were trying to kill her. Mrs Hewlett refused to comply with any requests or offers of assistance from the staff at the hospital. On 4 January Mrs Hewlett tried to leave the hospital. She was physically aggressive to her daughter in the car park. Based on the behaviours Mrs Hewlett had exhibited that day, at about 5pm Dr Ramsey imposed a Level 1 inpatient treatment order under the Mental Health Act. Mrs Hewlett was subsequently transferred to the RAH.

2.4. On 5 January 2013 Mrs Hewlett was reviewed at the RAH by a psychiatrist, Dr Jon Symon, who confirmed the Level 1 inpatient treatment order. During her admission at the RAH Mrs Hewlett's health steadily declined. On 7 January 2013 she was suspected of having suffered a seizure.

2.5. On 11 January 2013 Mrs Hewlett was reviewed by psychiatrist, Dr Andrew Beckwith, for the purpose of determining whether or not she required ongoing detention.

Dr Beckwith noted that Mrs Hewlett was disoriented and experiencing paranoid delusions. Apart from being extremely physically frail, Mrs Hewlett’s mental state

was also poor. She experienced the delusional belief that she was not in the RAH but in Downing Street and that it was the year 1913. She was also refusing food, drink and medication in the ongoing belief that it had been poisoned by the hospital staff.

She had confronted one mental health nurse and accused him of being a witch.

Dr Beckwith concluded that Mrs Hewlett was a danger to her herself because of her mental state and that she needed to be in hospital where she could be adequately cared for. He concluded that she was clearly unable to care for herself in the circumstances.

As a result of his findings Dr Beckwith issued the Level 2 inpatient treatment order that, as seen earlier, was still in place at the time of Mrs Hewlett’s death.

2.6. By 12 January 2013 Mrs Hewlett had developed increasing shortness of breath and an increased respiratory rate. She was treated with antibiotics for a suspected chest infection. The shortness of breath worsened and by 14 January 2013 it was thought that Mrs Hewlett had most likely developed pulmonary oedema. By 16 January 2013 it was found that Mrs Hewlett had developed atrial fibrillation. Tests revealed an elevated troponin which indicated an acute coronary event. Mrs Hewlett's physical condition continued to decline over the ensuing days and ultimately comfort care was instituted for her.

2.7. Mrs Hewlett passed away peacefully at the Royal Adelaide Hospital at approximately 11:50am on 22 January 2013.

3. Conclusions 3.1. The circumstances surrounding Mrs Hewlett’s death were thoroughly investigated by Detective Brevet Sergeant Ryan McClean of SAPOL Mt Barker CIB. In his comprehensive report1 Mr McClean has expressed the conclusions that the detention of Mrs Hewlett under the Mental Health Act was necessary and appropriate and that the level of care, treatment and supervision she received while under that detention was also appropriate. Having examined the evidence I agree with those conclusions.

I would add that the imposition of orders pursuant to the Mental Health Act was undertaken for humane reasons and that Mrs Hewlett’s custodial circumstances had no bearing on her death.

1 Exhibit C7a

4. Recommendations 4.1. The Court does not see any need to make any recommendation in relation to this death in custody.

Key Words: Death in Custody; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 22nd day of September, 2015.

Deputy State Coroner Inquest Number 13/2015 (0124/2013)