Coroner's Finding: CRAFTER 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 15th day of July 2016 and the 4th day of August 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Lorraine Crafter.

The said Court finds that Lorraine Crafter aged 88 years, late of Boandik Lodge, 101 Lake Terrace East, Mount Gambier, South Australia died at Boandik Lodge, Mount Gambier, South Australia on the 15th day of October 2014 as a result of general inanition on a background of advanced dementia and chronic renal failure. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Mrs Crafter was 88 years of age when she died on 15 October 2014 at the Kessel Wing of Boandik Lodge in Mount Gambier. Having regard to the opinion given by Dr Iain McIntyre of Forensic Science South Australia, I find her cause of death to be general inanition on a background of advanced dementia and chronic renal failure1.

2. Background 2.1. Ms Crafter was admitted to the Mount Gambier Hospital on 19 September 2014 due to a significant decline in her health and an inability to care for herself.

1 Exhibit C2a

2.2. From there she was transferred to Boandik Lodge on 1 October 2014. She remained there until her death 14 days later.

2.3. She had been diagnosed with a number of conditions including dementia, ischaemic heart disease, lymphoedema, osteoarthritis and anaemia. Mrs Crafter had had contact with, and had been receiving in-home care assistance from, carers from the Boandik Lodge since 2005. They would attend at her home three times a day and assist her with all aspects of her personal care, including meal preparation and cleaning.

2.4. In consultation with staff at the Mount Gambier hospital, her brother and nephew made an application to the Guardianship Board for a guardianship order with special powers under section 32 of the Guardianship and Administration Act 1993. A preliminary order was granted and it included power for the brother and nephew to give directions as to her place of residence. These orders were to be in full force and effect until 18 March 2015.

2.5. In the exercise of that power Mr Crafter and Mr Ward had Mrs Crafter readmitted to the Mount Gambier Hospital until a place became available at Boandik Lodge.

3. Mrs Crafter’s decline in health 3.1. From the time of Mrs Crafter's admission to Boandik she showed a steady decline in health with reduced oral intake. From 11 October 2014 Mrs Crafter was regularly refusing to eat or take her medication. She had conversations with staff members and indicated that there was nothing that she particularly wanted eat. She also stated that she was not particularly unhappy and that she only had a small appetite.

3.2. On the evening on 15 October 2014 Mrs Crafter was found by staff in bed in her room.

She was unresponsive and had clearly died.

4. Reason for Inquest 4.1. Given the orders I have referred to as to her placement for residential purposes, Mrs Crafter’s death was a death in custody within the meaning of Coroners Act 2003, and this Inquest was held as required by section 21(1)(a) of that Act.

5. Recommendations 5.1. I have nothing further to add, and no recommendations to make.

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 4th day of August, 2016.

State Coroner Inquest Number 27/2016 (1803/2014)