Coroner's Finding: PUTSEY Doreen Mary

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 24th day of June 2016 and the 5th day of September 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Doreen Mary Putsey.

The said Court finds that Doreen Mary Putsey aged 84 years, late of Helping Hand Aged Care, 437 Salisbury Highway, Parafield Gardens, South Australia died at Parafield Gardens, South Australia on the 11th day of August 2014 as a result of pneumonia with contributing Alzheimer's dementia. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Mrs Doreen Mary Putsey was 84 years of age when she died on 11 August 2014 at the Helping Hand Aged Care Facility at Parafield Gardens. An opinion as to her cause of death was provided by Dr Cheryl Charlwood of Forensic Science South Australia as pneumonia with contributing Alzheimer's disease1, and I so find.

2. Reason for Inquest 2.1. At the time of her death Mrs Putsey was the subject of orders under the Guardianship and Administration Act 1993. By virtue of these orders Mrs Putsey was regarded in the eyes of the law as being detained. Accordingly, hers 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 and for no other reason.

1 Exhibit C2a

3. Background 3.1. Mrs Putsey had lived with her husband Jack in Port Willunga prior to his passing in October 1997. Following his death Mrs Putsey stopped participating in social activities.

In 2005 Mrs Putsey made the decision to move to the Moana Mews Retirement Estate to allow her to improve her socialisation. At the time of this move Mrs Putsey was in good health both mentally and physically.

3.2. Mrs Putsey’s son began to notice a change in Mrs Putsey’s mental health in around 2010 when she was found to have wandered off on her own on at least two occasions.

She was noted to have become withdrawn and began to take meals alone in her unit. It is understood that Mrs Putsey suffered a mini stroke (TIA) whilst travelling in Queensland with other residents from Moana Mews.

3.3. In 2011 an Aged Care Assessment (ACAT) was undertaken on the advice of Mrs Putsey’s general practitioner, however her score was sufficient enough to allow her to remain in independent living.

3.4. A further ACAT assessment was undertaken on 19 March 2012 and Mrs Putsey was approved for high level residential respite care. She had become increasingly forgetful and neglectful of her personal needs. By this time Mrs Putsey had been diagnosed with dementia and suffered from TIAs and leg problems.

3.5. In May 2012 the Guardianship Board of South Australia made orders under the Guardianship and Administration Act 1993 appointing Mrs Putsey's granddaughter to be her guardian. The order included powers for the guardian to direct where Mrs Putsey was to remain and reside.

3.6. In June 2012 Mrs Putsey had a fall in her unit and injured herself requiring a hospital stay. Whilst in hospital her family were advised that a room had become available in the secure unit of the Helping Hand Aged Care facility in Parafield Gardens. Mrs Putsey was discharged to this location.

3.7. On 27 June 2012 a good palliative care plan was signed by Mrs Putsey's guardian. The emphasis of Mrs Putsey's management was to be on palliative care and the ongoing relief of symptoms and discomforts. The plan directed that no artificial measures designed to replace or support bodily functions were to be undertaken.

3.8. Her general condition and health remained relatively stable over the ensuing months.

4. Mrs Putsey’s decline in health 4.1. From mid-July 2014 Mrs Putsey suffered from a cough and general shortness of breath for which she was prescribed antibiotics. Her medical notes reflect a weight loss of 6.3 kilograms in a one month period because she was refusing to eat. Her lack of appetite and shortness of breath continued and on 1 August 2014 she became unresponsive.

4.2. On 6 August 2014 her condition worsened and she became very pale with laboured breathing. She was attended by a locum doctor who recommended that Mrs Putsey be transferred to the Lyell McEwin Hospital. A chest X-ray was undertaken at the hospital and revealed that she had pneumonia and concomitant heart failure. She was admitted for intravenous antibiotics.

4.3. A review the following day found her to be unresponsive. She was not responding to the antibiotics. Given her condition her family requested that she be moved back to Helping Hand to receive palliative care.

4.4. At 4:30am on 11 August 2014 Mrs Putsey stopped breathing in the presence of nursing staff who upon conducting observations could not find a pulse. Dr Charles Mayo attended the facility and declared life extinct.

4.5. I have nothing further to add.

Key Words: Death In Custody; Section 32 Powers; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 5th day of September, 2016.

State Coroner Inquest Number 32/2016 (1365/2014)