Coroner's Finding: WAY Dennis Martin

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 Dennis Martin Way.

The said Court finds that Dennis Martin Way aged 88 years, late of the Charles Young Residential Care Centre, 53 Austral Terrace, Morphettville, South Australia died at Morphettville, South Australia on the 15th day of December 2013 as a result of general inanition on a background of advanced dementia and a fractured patella (operated). The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Dennis Martin Way was 88 years of age when he died on 15 December 2013 at the Charles Young Residential Care Centre in Morphettville. A pathology review was undertaken by Dr Iain McIntyre of Forensic Science South Australia1. He was of the opinion that the cause of death was general inanition on a background of advanced dementia and a fractured patella (operated), and I so find.

2. Reason for Inquest 2.1. At the time of his death Mr Way was the subject of an order under the Guardianship and Administration Act 1993 which included powers under section 32 to make directions as to where Mr Way had to reside. Mr Way's son was appointed his guardian.

As Mr Way was, as a matter of law, regarded as being ‘detained’ at the time of his 1 Exhibit C2a

death, 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, and for no other reason.

3. Background 3.1. Up until June 2012 Mr Way had been living independently. In that month he was involved in a motor vehicle collision for which he was at fault. As a result of the collision he was hospitalised and had his driving licence revoked. Whilst in hospital Mr Way was diagnosed with progressive Alzheimer's dementia with behavioural and psychological symptoms. It was this diagnosis that led to the granting of the orders referred to above.

3.2. On 10 August 2012 Mr Way’s son made arrangements to have his father transferred into the care of Charles Young Residential Care Centre at Morphettville. From that date until his death, Mr Way was a resident of that facility and was obliged to live there by virtue of the order.

3.3. From 20 November 2012 the emphasis of management was on good palliative care and relief of symptoms and discomforts. No artificial measures designed to replace or support bodily function were to be undertaken.

3.4. On 25 November 2013 Mr Way suffered a fall and fractured his left patella. The fall was not witnessed by any staff or residents of the nursing home. He was conveyed to Flinders Medical Centre and X-rays confirmed a fracture to the left patella. The fracture was duly repaired and Mr Way was discharged back to the Charles Young Residential Care Centre on 30 November 2013 after an uneventful recovery.

4. Mr Way’s health declines 4.1. Mr Way’s health declined after the surgery with poor oral intake and drowsiness. This was probably caused by the analgesia required for postoperative pain.

4.2. Discussions were held with his family and it was decided that he was to receive only palliative care until his death in accordance with the good palliative plan that was in place.

4.3. Mr Way died peacefully in his sleep during the morning of 15 December 2013.

4.4. 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 5/2016 (2099/2013)