Coroner's Finding: DANIELSON Jens Thomas

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 18th day of November 2015 and the 5th day of May 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Jens Thomas Danielsen.

The said Court finds that Jens Thomas Danielsen aged 82 years, late of the Salisbury Private Nursing Home, 147 Frost Road, Salisbury, South Australia died at Salisbury, South Australia on the 3rd day of July 2013 as a result of pneumonia on a background of ischaemic and hypertensive heart disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Jens Thomas Danielsen was aged 82 years when he died on 3 July 2013 at the Salisbury Private Nursing Home where he was a resident. At the time of his death Mr Danielsen was the subject of orders pursuant to section 32 of the Guardianship and Administration Act 1993 that included a provision for detention. Mr Danielsen’s death is therefore a death in custody within the meaning of that expression in the Coroners Act 2003, and this Inquest was held as required by section 21(1)(a).

2. Background and the events leading to Mr Danielsen’s death 2.1. Mr Danielsen had a medical history that included a severe hearing impairment, hypocholesterolemia, hypertension, chronic obstructive pulmonary disease, gastroesophageal reflux disorder, vitamin D deficiency, right MCA infarction and nonST segment elevation, myocardial infarction. His primary medical concern leading up to his death was a worsening dementia with inappropriate behaviour.

2.2. On 24 December 2010 Mr Danielsen was admitted to the Lyell McEwin Health Service upon referral from the low-level aged care facility at Park Village Hostel in Elizabeth Park, due to inappropriate behaviour in the facility and also other health issues. He was discharged into the care of Salisbury Private Nursing Home on 21 January 2011.

2.3. On 17 February 2011 Ms Kerry McCann, who was a social worker working with Mr Danielsen, made an application to the Guardianship Board for orders concerning Mr Danielsen. A hearing was convened on 3 March 2011 and guardianship and administration orders, including section 32 powers regarding residence, were granted.

The Public Advocate was made Mr Danielsen’s guardian. The orders made on 3 March 2011 were to remain in effect until 2 March 2014, with the exception of the section 32 powers which were to be reviewed on or about 2 September 2011. Those powers were reviewed on 20 September 2011 and were further granted until 19 September 2012.

The special powers were again reviewed and granted on 25 September 2012.

2.4. By the time of Mr Danielsen’s admission to the Salisbury Private Nursing Home he was already in a state of advanced dementia and unable to make decisions for himself.

There were no family or friends available to him that were either willing or capable of looking after him or assisting him with his affairs. Due to a combination of his dementia and hearing difficulties Mr Danielsen was almost non-communicative from the time of his admission to Salisbury Nursing Home.

2.5. On Saturday 29 June 2013 a locum doctor attended upon Mr Danielsen regarding an unresolved chest infection that he developed some six days prior. Antibiotics had been instituted and were continued from this point and he was prescribed cephalexin 500mg three times per day. Mr Danielsen had a valid palliative care order in place which had been prepared in August 2011 and directed that: 'The emphasis of management will be on Good Palliative Care, and directed at the continuing relief of symptoms and discomforts. For that reason no artificial measures designed to replace or support bodily function will be undertaken.'

2.6. On Wednesday, 3 July 2013 the clinical nurse for the Salisbury Nursing Home, Kiran Dhillon, contacted the Office of the Public Advocate to advise them that Mr Danielsen’s health had deteriorated such that they had instituted the palliative care provisions for him. Mr Danielsen spent the majority of that day on a lounge chair in the common area of the secure dementia unit. He did not want to eat and was eventually

bathed and taken to bed at about 10pm. He was checked at about 10:30pm and seemed to be still in bed and breathing. He was checked again at approximately 11:30pm and was found to be in his bed but no longer breathing. As a result of this discovery a locum doctor was called to the facility and life was declared extinct.

3. Cause of death 3.1. I find that the cause of Mr Danielsen’s death is that identified in the pathology review undertaken by Dr Iain McIntyre of Forensic Science South Australia1, namely pneumonia on a background of ischaemic and hypertensive heart disease.

4. Recommendations 4.1. I have no recommendations to make in this matter.

Key Words: Death in custody; natural causes; Section 32 Powers In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 5th day of May, 2016.

State Coroner Inquest Number 32/2015 (1103/2013) 1 Exhibit C3a