Coroner's Finding: SCHULZ Bertha Anna

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 16th day of February 2016 and the 22nd day of August 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Bertha Anna Schulz.

The said Court finds that Bertha Anna Schulz aged 89 years, late of Resthaven Nursing Home, 53 Swanport Road, Murray Bridge, South Australia died at Murray Bridge, South Australia on the 22nd day of October 2013 as a result of multiple organ failure with cachexia on a background of chronic lower limb ulceration, squamous cell carcinoma, lower intestinal haemorrhage, pulmonary thromboembolic disease and cardiac amyloidosis.

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

1. Introduction and cause of death 1.1. Bertha Anna Schulz was 89 years of age when she died on 22 October 2013 at the Resthaven Nursing Home in Murray Bridge. Her cause of death following autopsy1 was given as multiple organ failure with cachexia on a background of chronic lower limb ulceration, squamous cell carcinoma, lower intestinal haemorrhage, pulmonary thromboembolic disease and cardiac amyloidosis, and I so find.

2. Reason for Inquest 2.1. At the time of her death Ms Schulz was the subject of a guardianship order under the Guardianship and Administration Act 1993. The orders included powers for her guardians to direct where she remain and live. By virtue of these orders Ms Schulz was 1 Exhibit C2a

regarded in the eyes of the law as being subject to detention. 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.

3. Background and the period leading to Ms Schulz’s death 3.1. Ms Schulz had suffered from severe venous leg ulcers for many years. These ulcers had required treatment with intermittent hospitalisation. On 7 January 2013 she was admitted to the Murray Bridge Soldiers Memorial Hospital as her situation at home had become untenable.

3.2. Ms Schulz was refusing to allow visiting nurses to dress her ulcers and her living circumstances were extremely poor. Management of her condition was made more difficult by virtue of her eccentric personality, her hearing impairment and her noncompliant and aggressive behaviours.

3.3. Upon hospitalisation it was found that the condition of Ms Schulz's leg ulcers had deteriorated significantly. Biopsies demonstrated squamous cell carcinoma. Her behaviour deteriorated and attempts to examine and treat her were met with both verbal and physical resistance.

3.4. In light of this consideration was given to whether Ms Schulz had developed a dementia or whether it was a paranoid psychotic illness. An opinion was sought from a specialist geriatrician who attempted to interview Ms Schulz. She refused to engage with the specialist during this consultation and the specialist concluded from medical history and input from the nursing staff that there appeared to be a dementing process occurring.

3.5. On 17 January 2013 it was concluded that amputation of the right leg to above the knee may benefit her. Ms Schulz refused outright to consider this option and so treatment by way of cleaning and dressing the ulcers continued.

3.6. On 25 March 2013 Mrs Schulz was admitted to the Resthaven Nursing Home in Murray Bridge. She remained a resident there until her death in October 2013. Throughout her time at Resthaven Ms Schulz's resistance to wound care and pain relief continued.

Consideration was again given to amputating the right leg, but it was the opinion of clinicians that she would not likely survive the operation and that it would be best to continue with conservative management.

3.7. At approximately 6:50pm on Tuesday, 22 October 2013 Ms Schulz died at the Resthaven Nursing Home in Murray Bridge.

3.8. I have nothing further to add.

Key Words: Death in Custody; Natural Causes; Section 32 Powers In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 22nd day of August, 2016.

State Coroner Inquest Number 3/2016 (1766/2013)