Coroner's Finding: ANNS William James

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 September 2016 and the 19th day of April 2017, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of William James Anns.

The said Court finds that William James Anns aged 69 years, late of 15 Armstrong Street, Sellicks Beach, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 23rd day of February 2015 as a result of end-stage interstitial lung disease and chronic congestive cardiac failure. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. William James Anns was 69 years of age when he passed away at the Flinders Medical Centre on 23 February 2015. At the time of his death Mr Anns was the subject of a Level 1 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.

2. Cause of death 2.1. On 25 February 2015 Dr Iain McIntyre of Forensic Science South Australia undertook a pathology review in relation to Mr Anns. In his report Dr McIntyre gave the cause of death as end-stage interstitial lung disease and chronic congestive cardiac failure, and I so find.

3. Background and medical history 3.1. Mr Anns was a Vietnam veteran and had been married for some 36 years. Mrs Anns had been fully involved during Mr Anns admission to the Flinders Medical Centre.

3.2. Mr Anns was in the end stage of interstitial lung disease and was on oxygen at home.

He had biventricular heart failure, ischaemic heart disease with previous stents and a coronary artery bypass graft. He was an insulin-dependent Type 2 diabetic with hypertension, chronic renal impairment, some cognitive impairment and had suffered from post-traumatic stress disorder and depression since returning from his military service.

3.3. He had suffered long-term from both his lung and heart complaints. Mr Anns had numerous admissions to the Repatriation General Hospital and the Flinders Medical Centre. Mr Anns was often non-compliant with medications which led to hospital presentations with acute symptoms in the context of his chronic ongoing illnesses. He would be treated for the acute symptoms which would be resolved prior to discharge, however Mr Anns would fall into non-compliance and acute illness would set in requiring his readmission to hospital.

3.4. Mr Anns was readmitted to the Flinders Medical Centre via Noarlunga Hospital on 13 February 2015. Due to the gravity of Mr Anns condition, consultation was had with Mrs Anns at the commencement of this admission and it was decided that Mr Anns would not be for cardiopulmonary resuscitation in the event he deteriorated.

3.5. On 22 February 2015 Mr Anns’ condition further deteriorated and, following consultation with Mrs Anns, he was classified not for cardiopulmonary resuscitation, nor MET calls, essentially indicating that he was at the end stage of his life.

3.6. On 22 February 2015 at 11:15am the Level 1 Inpatient Treatment Order was placed upon Mr Anns due to worsening delirium, agitation, aggression and non-compliance with his oxygen. Without this order Mr Anns could not be restrained to prevent the removal of his oxygen mask. At this time Mr Anns was regularly thrashing about in his bed as he could not breathe properly and would remove his oxygen mask. By this stage he was having trouble recognising his own wife. There were great concerns at

trying to administer oxygen to ensure that he could breathe as best as possible in order to keep him calm and give him the best possible quality of life through to the end stages.

3.7. Mr Anns died on 23 February 2015 at 6:04am.

4. Conclusion 4.1. I find that the order for detention under the Mental Health Act 2009 was lawful and appropriate. I also find the level of care and medical treatment provided to Mr Anns to be appropriate.

5. Recommendations 5.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 19th day of April, 2017.

State Coroner Inquest Number 52/2016 (0328/2015)