Coroner's Finding: KENNEDY Brian

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 14th day of April 2016 and the 25th day of August 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Brian Kennedy.

The said Court finds that Brian Kennedy aged 70 years, late of 28 Chambers Court, Encounter Bay, South Australia died at Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 30th day of April 2014 as a result of general inanition on a background of advanced fronto-temporal dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mr Brian Kennedy was 70 years of age when he died at the Repatriation General Hospital on 30 April 2014. An opinion as to his cause of death was given by Dr Iain McIntyre of Forensic Science South Australia as being ‘general inanition on a background of advanced fronto-temporal dementia’1, and I so find.

2. Reason for Inquest 2.1. At the time of death Mr Kennedy was subject to a Level 3 Inpatient Treatment Order under the Mental Health Act 2009, and accordingly his 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.

1 Exhibit C2a

3. Background 3.1. Mr Kennedy was diagnosed with Alzheimer's dementia in 2011 by Dr Craig Whitehead, consultant geriatrician at the Repatriation General Hospital. Until January 2014 Mr Kennedy lived at Encounter Bay with his partner. On 31 January 2014 Mr Kennedy was admitted to the Flinders Medical Centre due to his worsening behaviour. He was not taking his medication and was becoming less tolerant of other people as a result.

This escalating behaviour included violent outbursts towards his partner. His family were hoping for some adjustments to his medications and perhaps some respite care during this admission.

3.2. On the day of Mr Kennedy’s admission to Flinders Medical Centre medical staff attempted to perform a CT scan, but Mr Kennedy became quite upset and angry. A code black was called in response to the aggression. Later that day a Level 1 Inpatient Treatment Order was imposed. He was moved to a ward and nurse specialled thereafter.

3.3. Mr Kennedy settled over the course of the night until an attempt was made to take blood from him, at which point he again became aggressive and non-compliant. The inpatient treatment order was confirmed the following day by psychiatrist, Dr Mohan. Dr Mohan reported that no meaningful conversation could be had with Mr Kennedy to glean any history. Over the following six days, six code blacks had to be called in response to Mr Kennedy becoming agitated and aggressive. Soft shackles were instituted from time to time.

4. The decline in Mr Kennedy’s health 4.1. Mr Kennedy began refusing food and medication and, despite numerous attempts in numerous different ways, he would not relent on these matters. His nursing special 24 hours a day continued. On 6 February 2014 discussions were held with Mr Kennedy's stepdaughter regarding his resuscitation status and it was updated to not include CPR, ICU admission, intubation or defibrillation. Over the ensuing three weeks, a further 11 code blacks were called in relation to Mr Kennedy and his behaviour. Towards the end of that period his health declined.

4.2. On 24 February 2014 Mr Kennedy was transferred to Ward 5 at the Repatriation General Hospital. Mr Kennedy continued to decline both with his general behaviours and his physical health and he continued to exhibit problematic behaviours including

wandering, refusing to eat, refusing to take medications, restlessness and agitation. On 24 April 2014 after discussions with family, care was changed to palliation only and it was considered that death was imminent.

4.3. On 30 April 2014 Mr Kennedy died peacefully.

5. Conclusions 5.1. A review of the material gathered in this inquiry raises no issues with regard to the care that was provided to Mr Kennedy. He was given very good care, in both the Flinders Medical Centre and then the Repatriation General Hospital and as much as could be done for him was done.

6. Recommendations 6.1. I have no recommendations to make in this matter.

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 25th day of August, 2016.

State Coroner Inquest Number 14/0216 (0703/2014)