Coroner's Finding: PERTZ Zvonka

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 11th March 2016 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 Zvonka Pertz.

The said Court finds that Zvonka Pertz aged 81 years, late of Sandringham Private Residential Care, 150 Adams Road, Craigmore, South Australia died at the Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, South Australia on the 2nd day of February 2014 as a result of aspiration pneumonia on a background of severe dysphagia and a right hemiplegia. The said Court finds that the circumstances of her death were as follows:

1. Introduction and reason for Inquest 1.1. Zvonka Pertz, aged 81 years, died at the Lyell McEwin Hospital on 2 February 2014.

At the time of her death Ms Pertz was the subject of a guardianship and administration order with special powers, including powers of detention, under section 32 of the the Guardianship and Administration Act 1993 (the Act). This was a death in custody for which an Inquest was mandatory. These are the findings of that Inquest.

2. Cause of Death 2.1. Subsequent to Ms Pertz’s death a pathology review was carried out by Dr Iain McIntyre of Forensic Science South Australia. In that review Dr McIntyre asserts that the cause of death can be ascertained from Ms Pertz’s clinical circumstances and that an autopsy was not required. He suggested that the cause of death was aspiration pneumonia in a

woman with severe dysphagia and a right hemiplegia1. I find that the cause of death was aspiration pneumonia on a background of severe dysphagia and a right hemiplegia.

3. Background 3.1. In early 2011 Ms Pertz suffered a stroke with right hemiplegia, severe oropharyngeal dysphagia, gastroesophageal reflux disease, hypertension, vision impairment and right homonymous hemianopia. She was entirely paralysed down her left side and was unable to walk or speak. Given her condition she was no longer able to take care of herself or to make legal decisions concerning her care. As Ms Pertz had no family members able to take on the role of her legal guardian, two of her friends applied to the Guardianship Board for guardianship orders with special powers under section 32 of the Act. They were granted that application jointly on 1 March 2011.

3.2. On 15 March 2011 Ms Pertz was admitted to full time residential care at Sandringham Nursing Home in Craigmore. She was detained within that facility by virtue of the special powers granted pursuant to the Act. She remained a resident there until her ultimate demise in early 2014. On admission to that facility Ms Pertz had a PEG feeding tube surgically inserted. Her daily diet consisted of liquid feeding through the PEG feeding tube. She was immobile and bedfast.

3.3. On 11 September 2011 a good palliative care plan was executed by Ms Pertz’s guardians. The plan stipulated that in the event of further deterioration in her condition, the emphasis within her management would be on good palliative care, highlighting relief of symptoms and discomfort, with no artificial measures designed to supplant or support bodily function to be be undertaken. Her condition remained generally stable and consistent throughout her admission.

4. The events leading to Ms Pertz’s death 4.1. In April 2012 Ms Pertz’s PEG feeding tube was removed in an effort to enable her to feed orally. However, she continually refused this. After a number of weeks, and an obvious decline in Ms Pertz’s health, it was decided by her guardians that the PEG feeding tube should be reinserted. The Guardianship Board ratified this decision. The 1 Exhibit C2a

Board ordered that such force as was reasonably necessary for the purposes of ensuring the proper medical treatment and daily care and wellbeing of Ms Pertz may be administered.

4.2. On 1 February 2014 Ms Pertz’s PEG feeding site was flushed and cleaned by nursing staff as per normal protocols. At 10:30pm 700ml of jevity feeding was administered while Ms Pertz slept. At about 5:30 the following morning the registered nurse on duty located Ms Pertz lying supine in her room in a distressed state. Ms Pertz had experienced a large vomit. Ms Pertz was noted to be breathing rapidly. Attempts to undertake oral suction were prevented by her having a tightly clenched jaw. An ambulance was called and oxygen was administered while waiting for it to arrive.

Throughout this time it was noted that Ms Pertz maintained a low blood pressure and had a rapid heart rate. She was conveyed to the Lyell McEwin Hospital Emergency Department and was assessed. Examination revealed that she was unconscious with a high pulse rate, no recordable blood pressure and a high oxygen demand.

4.3. Ms Pertz exhibited breathing sounds that were suggestive of pneumonia. Septic shock was suspected. Blood tests revealed a gross derangement of her system including metabolic acidosis, raised sodium suggesting dehydration and high blood glucose levels. She was diagnosed as having aspiration pneumonia, septic shock and dehydration.

4.4. The dehydration component could likely have been attributed to her vomiting episode earlier that day. Her prognosis was considered poor. Given the good palliative care plan in place Ms Pertz was conservatively treated with IV fluids, antibiotics and nebulisers. She died the following morning, 2 February 2014. Life was declared extinct at 7:10am.

5. Conclusion 5.1. The circumstances surrounding Ms Pertz’s death were extensively investigated by SAPOL. The conclusions reached were that the level of care both at the Sandringham Nursing Home and at the Lyell McEwin Hospital was appropriate. The Court agrees.

No deficiency in care at either place has been identified. The fact of detention did not contribute to Ms Pertz’s death

6. Recommendations 6.1. There are no recommendations in this matter.

Key Words: Death in Custody; Section 32; 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 7/2016 (0205/2014)