Coroner's Finding: CALLAGHAN Brian Francis

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 September 2016, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Brian Francis Callaghan.

The said Court finds that Brian Francis Callaghan aged 79 years, late of 7 Laurie Avenue, Encounter Bay, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 11th day of September 2014 as a result of multi-organ failure due to pneumonia and bleeding duodenal ulcer complicating surgery for left hip fracture on a background of ischaemic heart disease and dementia. The said Court finds that the circumstances of his death were as follows:

1. Cause of death and reason for Inquest 1.1. Brian Francis Callaghan, aged 79 years, died on 11 September 2014 at the Flinders Medical Centre (FMC). His cause of death was determined by a pathology review of his clinical history to be multi-organ failure due to pneumonia and bleeding duodenal ulcer complicating surgery for a left hip fracture on a background of ischaemic heart disease and dementia1. I find that to have been the cause of Mr Callaghan’s death.

1.2. At the time of his death Mr Callaghan was the subject of a Level 2 Inpatient Treatment Order pursuant to the Mental Health Act 2009. He was in essence detained at the FMC pursuant to that order. Therefore, Mr Callaghan’s death was a death in custody for which an Inquest was mandatory. These are the findings of that Inquest.

1 Exhibit C2a

2. Background and circumstances of death 2.1. Mr Callaghan had a past medical history of ischaemic heart disease, type 2 diabetes, hypertension, chronic kidney disease, obstructive sleep apnoea and acute on chronic subdural haematoma that had resolved. He suffered visual impairment, falls, alcohol abuse and possible chronic obstructive airways disease from a lengthy history of smoking.

2.2. Since the death of his wife in 2010, Mr Callaghan had lived alone in his home at Encounter Bay. His daughter lived in the United States. He had two close friends whom he saw regularly. They were Mr Stanley Spink and Ms Marjorie Penn.

2.3. In August 2012 Mr Callaghan's daughter, Teresa, and Mr Spink and Ms Penn signed an enduring power of guardianship in relation to Mr Callaghan. They were all also made aware at that time of Mr Callaghan's wishes for a ‘do not resuscitate’ order should circumstances arise where his resuscitation became an issue.

2.4. On 6 August 2014 Mr Callaghan sustained a fall at his home address and seriously injured his hip. He was admitted to the FMC on 7 August 2014. As a result of the fall he suffered a fracture of the left femoral neck. He was also noted at presentation to have an acute kidney injury with hyponatremia and metabolic acidosis, possibly related to dehydration.

2.5. On 8 August 2014 Mr Callaghan underwent left hip hemiarthroplasty surgery for the broken hip, after which he was transferred to Ward 5A to recover. While in hospital Mr Callaghan experienced a number of complications as outlined in the statement of Dr Christopher Nirmal2, who is a member of the general medicine team at the FMC.

He experienced post-operative anaemia, which was managed with blood transfusions, as well as severe hospital acquired bilateral pneumonia, with hypoxia and a pleural effusion. It was possible that he had recurrent aspiration pneumonia. The pneumonia failed to improve despite appropriate and aggressive antibiotic therapy.

2.6. Mr Callaghan was seen by the respiratory team who concluded that drainage of the pleural effusion was not indicated. The aetiology of the pleural effusion was likely hypoalbuminemia with a possible component of heart failure. Malnutrition, due to poor oral intake, resulted in nasogastric feeding. Mr Callaghan pulled the tube out on several 2 Exhibit C4

occasions. Parenteral feeding was deemed not appropriate for him as there was a significant chance that he would try to remove the tube with adverse consequences.

Providing appropriate nutrition to Mr Callaghan remained an ongoing issue. He was noted to have acute kidney injury on a background of chronic kidney disease, likely secondary to dehydration. To some extent this improved with the administration of fluids.

2.7. During his admission Mr Callaghan was noted to have severe mixed delirium. From 9 August 2014 he was found to have an agitated delirium and was unable to co-operate with medical care.

2.8. On 10 August 2014 a code black was called in relation to Mr Callaghan's behaviour.

As a result he was placed on a Level 1 Inpatient Treatment Order pursuant to the Mental Health Act 2009. This order was confirmed on the same day.

2.9. The aetiology of Mr Callaghan's delirium was considered likely to be multifactorial, with components of alcohol withdrawal combined with post-operative delirium, severe pneumonia and an electrolyte imbalance. The possibility of an underlying cognitive impairment such as dementia was also considered.

2.10. On 15 August 2014 the Level 1 Inpatient Treatment Order lapsed. On 16 August 2014 Mr Callaghan was placed on a fresh Level 1 order, again due to mental illness and delirium. This order was confirmed on the same day.

2.11. On 22 August 2014 Mr Callaghan was placed on a Level 2 Inpatient Treatment Order as he was still delirious. The order was considered necessary to ensure his own safety.

2.12. During his admission Mr Callaghan also had an upper gastro intestinal bleed with significant drop in his haemoglobin. He was transfused blood and underwent an upper gastro intestinal endoscopy conducted by the gastro luminal team. He was noted to have a bleeding duodenal ulcer. Haemostasis was achieved. He was also initiated on a proton pump inhibiters at that time.

2.13. Throughout his admission in hospital it was documented that he was not for resuscitation. Up until 5 September 2014 he was for MET calls if required, but after 5 September 2014 this was removed from his resuscitation status. Mr Callaghan deteriorated gradually.

2.14. By noon on 11 September 2014 Mr Callaghan was placed on palliative care only measures. Between 4pm and 4:15pm on 11 September 2014 a nurse attending upon Mr Callaghan noticed him to be pasty and lacking colour. She checked his vital signs and determined that he had died.

3. Conclusion 3.1. This death in custody was extensively investigated by SAPOL. The investigating officer has not identified any deficiency in Mr Callaghan’s care. Neither has this Court.

3.2. Mr Callaghan’s detention was at all times lawful and appropriate. His detention could arguably have been lifted earlier, but in any event his status as a detained patient had no bearing on his death. Mr Callaghan was a sick man who died of natural causes.

4. Recommendations 4.1. There are no recommendations.

Key Words: Death in Custody; Inpatient Treatment Order; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 1st day of September, 2016.

Deputy State Coroner Inquest Number 38/2016 (1606/2014)