Coroner's Finding: MCATEER John Desmond

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 10th day of July 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 John Desmond McAteer.

The said Court finds that John Desmond McAteer aged 84 years, late of 24 Challenge Drive, Noarlunga Downs, South Australia died at the Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 9th day of March 2013 as a result of ischaemic heart disease on a background of advanced Lewy body dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction, reason for Inquest and cause of death 1.1. John Desmond McAteer died on 9 March 2013. He was aged 84 years of age. He died as a detained patient at the Repatriation General Hospital. At the time of his death, Mr McAteer was the subject of a Level 2 inpatient treatment order pursuant to the Mental Health Act 2009. For those reasons this was a death in custody for which an Inquest was mandatory.

1.2. The cause of death was established by way of a pathology review of Mr McAteer’s clinical records that was conducted by a medical practitioner at Forensic Science South Australia, Dr Iain McIntyre. In his report Dr McIntyre expresses the cause of death as ischaemic heart disease in a man with advanced Lewy body dementia1. I accept that this in substance was the cause of Mr McAteer’s death. However, in my view the cause is more appropriately expressed as ischaemic heart disease on a 1 Exhibit C2a

background of advanced Lewy body dementia. I find that to have been the cause of Mr McAteer’s death.

2. Background 2.1. Mr McAteer had been a patient at the Beach Road Medical Centre general practice in Christies Beach (the Beach Road practice) since 1989. The records of this practice describe a past medical history of carcinoma of the thyroid, ischaemic heart disease with angioplasty in 1994, gastrectromy for gastric ulcer and glaucoma for which surgery was conducted on 12 March 2013.

2.2. The statement of Dr Francesco Maldari of the Beach Road practice2 asserts that in about July 2012 it became apparent that Mr McAteer was demonstrating signs of dementia. Dr Maldari indicates that he referred Mr McAteer to the Memory Disorders Clinic at the Repatriation General Hospital where, in October 2012, he was diagnosed with Lewy body dementia which is a progressive degenerative dementia primarily affecting older adults and which can be characterised by cognitive decline and hallucinations. Dr Maldari was aware of Mr McAteer's increasingly aggressive behaviour due to this particular type of dementia. Mr McAteer's wife had been caring for him at home and had indicated a desire to continue to care for him in that environment for as long as she possibly could. In his statement Dr Maldari acknowledges that this would have been a very difficult situation for Mrs McAteer to deal with. The statement of Mr McAteer’s daughter, Ms Kathleen Augustin3, confirms that Mr McAteer was experiencing hallucinations which made him difficult to care for.

2.3. Dr Maldari states that he continued to see Mr McAteer regularly to administer vitamin B injections and to check on his general health. The last time Mr McAteer presented was on 4 February 2013. At this time Dr Maldari noticed that Mr McAteer's movement was slow and unsteady and that he appeared clearly to be confused.

2.4. Mr McAteer was admitted to the Noarlunga Hospital on 15 February 2013. The statement of Tsung Han Woo4, who in February of 2013 was a medical registrar at that hospital, states that on 15 February 2013 Mr McAteer was brought to the Collins 2 Exhibit C8a 3 Exhibit C1b 4 Exhibit C6a

Ward due to increased aggression and violent behaviours towards his wife and other family members. A family decision was made to admit Mr McAteer to the hospital in order for him to receive treatment and to provide his wife with respite. Dr Woo indicates in his statement that he admitted Mr McAteer to the Collins Ward for care and treatment of dementia. He states that Mr McAteer was ‘pleasantly confused’ and displayed little appreciation of time and place. He was not at that time aggressive.

Mr McAteer was physically well at that point. Dr Woo prescribed Mr McAteer olanzapine, an antipsychotic that was to be given on a PRN basis should Mr McAteer become aggressive.

2.5. The following day a code black was called after Mr McAteer's behaviour deteriorated.

He was initially given lorazepam, 1mg, which did not appear to have any positive effect. After a second code black was called he was given clonazepam which did appear to have effect. A number of other code blacks were called in the following days; the medication used to calm him was increased, with an olanzapine dosage of 5mg. Dr Woo's statement5 reveals that on 19 February 2013 Mr McAteer started to refuse to eat and drink. At this time a decision was made to move Mr McAteer to another hospital as the Noarlunga Hospital was not equipped to deal with his particular condition.

2.6. Between 19 and 25 February 2013, while Mr McAteer was waiting for a bed to become available elsewhere, he was prescribed a further anti-psychotic, quetiapine, at 12.5mg, in addition to the 5mg of olanzapine. This was to manage Mr McAteer's deteriorating behaviour. Mr McAteer continued to refuse food and drink, which according to Dr Woo amounted to a sign of decline in his general health. The casenotes reflect that Mr McAteer was transferred to the Repatriation General Hospital at approximately 12pm on 25 February 2013 with the view to him being housed in Ward 18 which is a ward specifically designed to cater for older patients, 65 years and over, with psychiatric difficulties.

2.7. On Ward 18 Mr McAteer was initially assessed by Dr Tracey Landon. Dr Landon described the Mr McAteer as being a dishevelled, cachexic gentleman who was both agitated and aggressive and who was kicking out and grabbing staff. The notes indicated that it was Dr Landon's impression that Mr McAteer was reacting to visual hallucinations, a side effect of Lewy body dementia. It was because of this behaviour 5 Exhibit C6a

and Mr McAteer's general condition that he was placed under a Level 1 inpatient treatment order under the Mental Health Act and was transferred to the high dependency unit for fluid resuscitation. The detention order was confirmed the following day by Dr Jacqueline Symon, a consultant psychiatrist at the Repatriation General Hospital. Dr Symon has provided a statement6 to the Court which confirms this. Dr Symon slightly altered Mr McAteer's medications by reducing the antidementia patch from 10mg to 5mg as he was now experiencing diarrhoea. Two days later Dr Symon was notified that Mr McAteer's level of agitation had increased. In response to this Mr McAteer's nursing care was changed to nurse special care.

2.8. On 2 March 2013 Mr McAteer experienced a period of hypotension and a loss of consciousness. A MET call was made. Mr McAteer was stabilised in the Intensive Care Unit (ICU). The assessment made by ICU staff was that Mr McAteer had hyponatraemia secondary to dehydration.

2.9. Mr McAteer's condition deteriorated. During periods of responsiveness, he displayed unpredictable and aggressive behaviours towards staff and to family members that would visit him daily. On 4 March 2013 consultant psychiatrist Dr Deborah Blood imposed a Level 2 inpatient treatment order on Mr McAteer. This was the order that pertained at the time of Mr McAteer’s death. Dr Blood noted on the order the following: 'This man has known Lewy Body dementia with superimposed delirium. He is confused & combative at times. He requires ongoing detention to allow him to be treated appropriately. Currently receiving palliative care.' 7

2.10. Mr McAteer was returned to a general ward at the Repatriation General Hospital.

Consultant physician Dr Patrick Russell8 established that Mr McAteer was suffering from hypovolaemia and hypernatremia. His troponin levels were also raised at 144 which signified that Mr McAteer may have suffered a myocardial infarction. At this point Dr Russell spoke with Mr McAteer's daughter about the option of palliative care. She agreed that this was the family's wish.

2.11. On 5 March 2013 Mr McAteer was assessed by Dr Tony Arman who confirmed the diagnosis of Lewy body dementia. Dr Arman recorded his observations in the case 6 Exhibit C5a 7 Exhibit C11 8 Exhibit C4a

notes during this assessment. He noted aggressive behaviour, incoherent speech, traversed sleep and wake cycles, cachexia, poor eyesight and incontinence. It was also noted that Mr McAteer was refusing to eat or drink. He was attempting to hit staff and to kick and bite. It was the recommendation of Dr Arman, which supported that of previous doctors, that Mr McAteer should receive palliative care from that point in time. The integrated care pathway, or end of life pathway, was put in place.

This was a new system that the Repatriation General Hospital was trialling at that time. It consisted of a structured assessment and management of patients who were at the end of their life. Dr Jessica Selley was the clinician who handled this pathway in consultation with the family.

2.12. Mr McAteer was prescribed Fentanyl and clonazepam. By 7 March 2013 he had become more settled with the institution of that infusion. By 8 March 2013 Mr McAteer was unresponsive but appeared comfortable. The Fentanyl infusion had been increased slightly. It was the view of the family, as communicated to Dr Selley, that by late on 8 March 2013 Mr McAteer was as comfortable as he could be in the circumstances.

2.13. At approximately 7:45pm on 9 March 2013 members of Mr McAteer's family, who had been present with him for the duration of the palliative pathway, called Nurse Gorman into his room as it was believed that he was near the end of his life. Nurse Gorman observed that Mr McAteer was breathing very shallowly. She left the room to provide the family with privacy. Nurse Gorman returned after five minutes and established that Mr McAteer had died. She notified the doctor, who certified Mr McAteer's life extinct at 2035 hours on 9 March 2013.

3. Conclusions 3.1. The circumstances of Mr McAteer’s death were the subject of a detailed investigation by Senior Constable First Class Neil Ollerenshaw of the SAPOL Sturt Criminal Investigation Branch. Mr Ollerenshaw has provided an investigation report9 that can be described as one of conspicuous excellence. Mr Ollerenshaw has expressed a number of conclusions based on the evidence that he gathered. The conclusions that he expresses include an assessment that Mr McAteer’s inpatient treatment orders pursuant to the Mental Health Act 2009 had been appropriately imposed and that his 9 Exhibit C10a

care at both the Noarlunga Hospital and the Repatriation General Hospital was appropriate. The Court agrees with those conclusions.

3.2. The orders imposed pursuant to the Mental Health Act 2009 were imposed for humane reasons. Mr McAteer’s custodial circumstances had no adverse consequences as far as his end of life care was concerned.

4. Recommendations 4.1. The Court does not see a need to make any recommendations arising from 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 10/2015 (0373/2015)