Coroner's Finding: GREET Shirley Blanche

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 12th day of September 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Shirley Blanche Greet.

The said Court finds that Shirley Blanche Greet aged 87 years, late of 16a Lincoln Avenue, Sturt, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 13th day of October 2014 as a result of digoxin toxicity with hyperkalaemia. The said Court finds that the circumstances of her death were as follows:

1. Introduction and reason for Inquest 1.1. Mrs Shirley Blanche Greet was aged 87 years when she died on 13 October 2014 at the Flinders Medical Centre.

1.2. At the time of her death Mrs Greet was subject to a Level 1 Inpatient Treatment Order under the Mental Health Act 2009. By virtue of that order Mrs Greet’s death was 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) of that Act.

2. Cause of Death 2.1. An opinion as to her cause of death was given by Dr Iain McIntyre of Forensic Science South Australia as digoxin toxicity with hyperkalaemia1, and I so find.

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3. Background and the events leading to Mrs Greet’s death 3.1. On 13 October 2014 Mrs Greet called the South Australian Ambulance Service complaining of prolonged nausea and vomiting associated with an intentional overdose of digoxin tablets. Mrs Greet had been prescribed digoxin for many years to treat her atrial fibrillation. She had a number of comorbidities including irritable bowel syndrome, osteoarthritis, a right hip replacement in 2011, low grade renal failure, widespread pain and reduced mobility. She had been complaining to her general practitioner in the recent past of ongoing pain, especially in her legs, that could not be settled with medication. For her the pain was becoming unbearable.

3.2. Shortly prior to this event Mrs Greet had celebrated her 87th birthday with her family and by all reports she had enjoyed the day. She called the ambulance at approximately 5pm on Monday, 13 October 2014. She was able to communicate with the ambulance officers. Indeed, she told them what she had done and her reasons.

3.3. Upon her arrival at hospital they attempted to give her some activated charcoal, but her continued vomiting impeded their attempts.

3.4. Dr Anil Seshadri from the Emergency Department at Flinders Medical Centre provided a statement to the Court2. He said that there were immediate concerns about Mrs Greet’s continuing suicidal ideation, and that she might leave hospital prior to receiving the appropriate treatment. For these reasons Dr Seshadri placed Mrs Greet on a Level 1 Inpatient Treatment Order under the Mental Health Act 2009 to facilitate all possible treatment for her overdose. That treatment order had the effect of detaining Mrs Greet at the Flinders Medical Centre.

3.5. Mrs Greet’s admission toxicology showed a reading of 32.4 nmol/L of digoxin with the normal range considered to be between 0.6 nmol/L and 1 nmol/L. She was to be given the antidote DigiFab.

3.6. Mrs Greet was moved to the Intensive Care Unit. Whilst receiving her first dose of DigiFab Mrs Greet suffered a cardiac arrest. CPR was conducted and 26 vials (the recommended amount) of DigiFab was administered intravenously.

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3.7. Mrs Greet's son was contacted at that time and the situation explained. Following this discussion the decision was made to cease CPR. Mrs Greet died shortly afterwards.

3.8. Cardiac arrest is generally the effect of digoxin overdose. The overdose induces arrhythmia and cardiac arrest is the result.

3.9. The exact amount of digoxin taken by Mrs Greet remains unknown, but police investigations suggest that she might have taken approximately 79 tablets. That would have been sufficient to explain the levels found in her blood on admission.

3.10. Digoxin is a rapidly absorbed drug and it may well have been largely absorbed in Mrs Greet's system before she even called for help.

3.11. A handwritten note was later found at Mrs Greet’s house. It said that she had been in a lot of pain and did not want to go to hospital again. It said that she had been with her family over the weekend to celebrate her 87th birthday. She expressed her love for her family.

4. Conclusions 4.1. I find that Mrs Greet’s overdose was an intentional act and that in my opinion the staff at Flinders Medical Centre took all possible steps to prevent Mrs Greet’s death.

4.2. I have nothing further to add and no recommendations to make.

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 12th day of September, 2016.

State Coroner Inquest Number 26/2016 (1788/2014)