Coroner's Finding: GRAETZ Clifford Ralph

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 25 November 2015 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 Clifford Ralph Graetz.

The said Court finds that Clifford Ralph Graetz aged 82 years, late of Makk & McLeay Nursing Home, Older Persons Mental Health Services, 200 Fosters Road, Oakden, South Australia died at Oakden, South Australia on the 16th day of September 2013 as a result of pneumonia on a background of severe mixed Alzheimer’s and vascular dementia.

The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Clifford Ralph Graetz, aged 82 years, died at the Older Persons Mental Health Services at Oakden, otherwise known as the Makk & McLeay Nursing Home (the Oakden facility), on 16 September 2013.

1.2. At the time of his death Mr Graetz was the subject of a Level 2 Inpatient Treatment Order pursuant to the Mental Health Act 2009. As such, he died while detained pursuant to a law of the State. His death was therefore a death in custody for which an Inquest was mandatory. These are the findings of that Inquest.

2. Cause of death 2.1. Dr Iain McIntyre of Forensic Science South Australia conducted a pathology review in relation to Mr Graetz’s death. Dr McIntyre advised that the cause of death could be established from his medical history and that no autopsy was required. Dr McIntyre

reported that the cause of death was pneumonia in a man with severe mixed Alzheimer's and vascular dementia1. I find that the cause of Mr Graetz’s death was pneumonia on a background of severe mixed Alzheimer’s and vascular dementia.

3. Background and the circumstances leading to Mr Graetz’s death 3.1. Mr Graetz had a medical history including ankylosing spondylitis, asthma, vitamin B12 deficiency, vitamin D deficiency, benign prostatic hypertrophy and postural hypotension.

3.2. Approximately five years prior to his death Mr Graetz started experiencing the effects of dementia. Mr Graetz suffered from mixed Alzheimer's and vascular dementia, communication problems, agitation and depression.

3.3. On 22 April 2013 Mr Graetz was admitted to the Lerwin Nursing Home in Murray Bridge. This is a high care facility that has a secure dementia ward. Mr Graetz was restless, agitated and non-compliant with almost all care. He exhibited physical and verbal aggression towards staff and other residents. He was treated with Risperidone to manage his behavioural issues. On 2 June 2013 Mr Graetz was transferred to the Murray Bridge Hospital as the nursing home felt they could not adequately manage his behaviour. As it transpired, Murray Bridge Hospital staff also felt they could not manage him due to similar ongoing behaviour.

3.4. On 5 June 2013 at the Murray Bridge Hospital, a Level 1 Inpatient Treatment Order was imposed in respect of Mr Graetz. He was then transferred to the Royal Adelaide Hospital Emergency Department. On 6 June 2013 the Level 1 order was confirmed at the Royal Adelaide Hospital. Mr Graetz was then transferred to Ward 18 of the Repatriation General Hospital (the RGH) for psychogeriatric admission. He was assessed at the RGH as experiencing behavioural and psychological symptoms of an advanced degree of underlying dementia.

3.5. On 12 June 2013 a Level 2 Inpatient Treatment Order was imposed at the RGH. On 11 July 2013 an application was made to the Guardianship Board for a Level 3 Inpatient Treatment Order. The application was granted. As a result changes were made to 1 Exhibit C2a

Mr Graetz’s medications. This resulted in some improvement in his behaviour. On 30 July 2013 the Level 3 order was revoked.

3.6. On 31 July 2013 Mr Graetz was discharged from Ward 18 and was returned to the Lerwin Nursing Home in Murray Bridge. However, his behaviour quickly declined.

He became constantly agitated and resistive upon his return. An opinion was formed by staff at the home that the living environment was unsuitable to meet his needs. As a result, a readmission to the RGH was negotiated.

3.7. On 1 August 2013 Mr Graetz was readmitted to the RGH where a fresh Level 1 Inpatient Treatment Order was imposed. It was considered that Mr Graetz would need a longer term placement in a specialised psychogeriatric facility. On 2 August 2013 the Level 1 order was confirmed by Dr Michael Page. On 8 August 2013 a Level 2 order, with an expiry of 19 September 2013, was imposed by Dr Page. Dr Page’s explanation for the imposition of the order was that Mr Graetz had dementia with significant behavioural and psychological symptoms of violence and aggression2. He had failed discharge to a mainstream residential care facility and needed intensive psychogeriatric care and management in a secure setting. It was assessed that Mr Graetz had no ability to consent to management which at times needed to be coercive.

3.8. On 12 August 2013 a bed became available at the Oakden facility. Mr Graetz was transferred to the facility. Appropriate transfer documents were completed under the Mental Health Act. This meant that Mr Graetz remained subject to the Level 2 order as a detained resident of the Oakden facility. At this time there was also an advanced care planning form completed.

3.9. On 19 August 2013 as a result of a telephone discussion with Mr Graetz's wife regarding Mr Graetz’s end of life wishes, palliative care was decided upon. On 24 August 2013 Mr Graetz’s wife and son visited him and reinforced that decision.

3.10. On 9 September 2013, due to a suspected respiratory tract infection, Mr Graetz was transferred by ambulance from the Oakden facility to the Royal Adelaide Hospital. A 2 Exhibit C10

chest X-ray showed a right lower lobe opacity. Mr Graetz was prescribed intravenous Ceftriaxone and Azithromycin. The case note of Dr Vaniyartaz states: 'There was discussion with wife and son. Patient is not for CPR, intubation, ICU admission. Patient has clearly stated before that he's not for MET calls either. Since we have given antibiotics already, give three days and transfer back to nursing home after that.

Family will inform the nursing home any further deterioration not to transfer patient to any hospital but to let him die in the nursing home.' 3

3.11. During this period Mr Graetz remained subject to the Level 2 order. The order would not have expired until 19 September 2013.

3.12. On 11 September 2013 Mr Graetz was discharged back to the Oakden facility where on 14 September 2013 he was reviewed by a locum. His health was deteriorating. The advanced care directive was noted. As Mr Graetz was for palliative care, he was commenced on morphine for symptomatic relief.

3.13. On 16 September 2013 Mr Graetz was noted to be sweating profusely, was breathing rapidly and had a poor response to all aspects of diet including fluid. He had extreme difficulty swallowing as it clearly interfered with his ability to breathe, thus causing him distress. At about 5:15pm Mr Graetz died. As indicated earlier, he was still subject to the Level 2 order.

4. Investigation and conclusion 4.1. A statement taken from Mr Graetz’s son, Stuart Graetz, reveals that he was initially ‘taken aback’, not in a good way, by the Oakden facility. He believed that his father was less content there than he had been at the RGH. Mr Stuart Graetz identified communication issues with Oakden facility staff. He noticed a significant decline in his father’s level of personal hygiene while at the facility. He also identified a marked deterioration in his father when in September 2013 he was transferred from the Oakden facility to the Royal Adelaide Hospital. When returned to the Oakden facility, Mr Stuart Graetz discovered on 16 September 2013 that his father had fallen out of bed and that his father exhibited an upsetting further cognitive deterioration. Mr Graetz died later that day.

3 Exhibit C19

4.2. The circumstances of Mr Graetz’s death were extensively investigated by SAPOL.

From that investigation it is apparent to the Court that attempts were made at the Oakden facility to maintain Mr Graetz’s hygiene, including the attempted cleaning of his teeth, but that he was resistive to staff. When properly considered there is no evidence that Mr Graetz’s deterioration was due to abuse or neglect. Investigating police were satisfied that the care of the deceased at the Oakden facility was appropriate. The Court has not identified any reason to depart from that conclusion.

Mr Graetz experienced a cognitive and accompanying physical decline with which this Court is very familiar. Mr Graetz’s custodial circumstances did not contribute to his death. His detention under the Mental Health Act 2009 was at all times lawful and appropriate.

5. Recommendations 5.1. 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 35/2015 (1566/2013)