Coroner's Finding: BOEHM Valma Mona

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 1st day of July 2016 and the 1st day of August 2016, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner into the death of Valma Mona Boehm.

The said Court finds that Valma Mona Boehm aged 92 years, late of Tanunda Lutheran Homes, 27 Bridge Street, Tanunda, South Australia died at Tanunda Lutheran Homes, 27 Bridge Street, Tanunda, South Australia on the 4th day of September 2014 as a result of bilateral pulmonary thromboembolism with contributing right temple lobe haemorrhage due to cerebrovascular amyloidosis. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. This was an Inquest into the cause and circumstances of the death of Valma Mona Boehm, aged 92 years, who died on 4 September 2014 at Tanunda Lutheran Homes in Tanunda. Her cause of death was determined at an autopsy undertaken by Dr Karen Heath of Forensic Science SA. Dr Heath described Miss Boehm’s cause of death as bilateral pulmonary thromboembolism with contributing right temple lobe haemorrhage due to cerebrovascular amyloidosis. I find that to have been the cause of Miss Boehm’s death.

2. Reason for Inquest 2.1. At the time of Miss Boehm’s death she was subject to a Guardianship Board order including special powers pursuant to section 32 of the Guardianship and Administration Act 1993. These powers authorised that she reside at, and be detained at, such place as

determined by her brother, Mr Dudley Boehm. As I understood the evidence, that place was Tanunda Lutheran Homes where Miss Boehm died. For those reasons this was a death in custody for which an Inquest was mandatory pursuant to the provisions of the Coroners Act 2003.

3. Background 3.1. Prior to August 2014 Miss Boehm had resided with and been cared for by her brother at their home address. Mr Boehm noted a sudden decline in Miss Boehm’s mental state and consequently sought the assistance of local health professionals. This led to Miss Boehm being admitted to Tanunda Lutheran Homes as a resident on 7 August 2014.

3.2. On 9 August 2014 Miss Boehm was transferred from Tanunda to the Lyell McEwin Health Service after it was found that her behaviour could not be adequately controlled by medication in the nursing home. Assessment at the Lyell McEwin Health Service determined that Miss Boehm was suffering delirium triggered by a urinary tract infection on a background of dementia. Oral antibiotics were instituted.

3.3. During her admission Miss Boehm displayed aggressive behaviours towards staff with numerous code blacks being called resulting in Miss Boehm being sedated medically.

Miss Boehm was occasionally restrained using soft shackles until such time as her behaviour resolved. The hospital documented that, as a consequence of her severe dementia, Miss Boehm was not oriented to time and place.

3.4. On 18 August 2014 a guardianship order with section 32 powers including a power of detention was sought in order to facilitate treatment. This was granted on 21 August 2014 with Mr Boehm appointed as the guardian. Miss Boehm was discharged back to Tanunda Lutheran Homes on 22 August 2014 after being medically cleared for the urinary tract infection.

4. Miss Boehm’s health decline 4.1. On 23 August 2014 at Tanunda Lutheran Homes Miss Boehm sustained a fall which resulted in a superficial abrasion to the right side of her head. She was medically assessed and was found to have suffered no injury. Her brother was contacted and advised about the incident. Mr Boehm suggested to staff that he believed she had also experienced an earlier fall at the Lyell McEwin Health Service. Preventative measures were discussed with Mr Boehm and it was agreed that sensors would be set in Miss Boehm’s room.

4.2. On 25 August 2014 Miss Boehm was again found on the floor of her room. This discovery was made in response to the activation of the sensor alarm. A medical examination determined that she had sustained no apparent injury on this occasion.

4.3. Miss Boehm regularly refused meals and medications. Her behaviour also deteriorated over time. There were a number of incidents involving physicality towards staff and other residents at Tanunda Lutheran Homes. Eventually Miss Boehm simply ceased responding to staff and to her brother when he visited. Miss Boehm spent most of her time sleeping in her bed.

4.4. At approximately 8:30am on 4 September 2014 staff detected that Miss Boehm had stopped breathing. Resuscitation was initially attempted, however Mr Boehm was contacted and, as a result of a discussion with him, CPR was understandably discontinued. Miss Boehm passed away shortly thereafter.

5. Conclusions 5.1. Following Miss Boehm’s death an extensive police investigation ensued. It established that Miss Boehm’s care both at the Lyell McEwin Health Service and at the Tanunda Lutheran Home was appropriate. I so find. I also find that Miss Boehm’s custodial circumstances did not contribute to her death. The cause of Miss Boehm’s death was entirely natural and the circumstances of her death were in accordance with a clinical course typically seen in these cases.

6. Recommendations 6.1. The Court does not make any recommendation consequent upon these findings.

Key Words: Death in Custody; Section 32 Powers; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 1st day of August, 2016.

Deputy State Coroner Inquest Number 37/2016 (1536/2014)