Coroner's Finding: CAMERON George William

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 25th day of November 2015 and the 17th day of November 2017, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of George William Cameron.

The said Court finds that George William Cameron aged 76 years, late of 15 Warwick Grove, Morphett Vale, South Australia died at the Noarlunga Hospital, Alexander Kelly Drive, Noarlunga Centre, South Australia on the 29th day of September 2013 as a result of pneumonia and exacerbation of chronic obstructive airway disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for Inquest 1.1. George William Cameron was 76 years of age when he died at the Noarlunga Hospital on 29 September 2013.

1.2. At the time of his death, Mr Cameron was subject to a Level 1 inpatient treatment order that had been imposed pursuant to the Mental Health Act 2009. The order had been imposed on 25 September 2013 and had been confirmed on 26 September 2013. This meant that Mr Cameron’s death was a death in custody as defined by the Coroners Act

2003. Accordingly, this was a mandatory Inquest pursuant to the provisions of the Coroners Act. These are the findings of that Inquest.

1.3. This death was reported to the State Coroner by way of a deposition of a medical practitioner employed at the Noarlunga Hospital. That practitioner was Dr Tri Cao who declared life extinct. Dr Tri Cao’s deposition explains that Mr Cameron was admitted to the Whittaker Ward of the Noarlunga Hospital on 25 September 2013 for treatment

of alcohol withdrawal and an infective exacerbation of chronic obstructive airway disease. A chest X-ray revealed right lower lobe pneumonia. Dr Tri Cao expresses the cause of Mr Cameron’s death as pneumonia and exacerbation of chronic obstructive airway disease. I find that to have been the cause of Mr Cameron’s death.

2. Background and the events leading to Mr Cameron’s death 2.1. Mr Cameron had been a heavy drinker and smoker throughout his adult life. He retired in 2001 and his marriage then broke down. In 2005 he was diagnosed with prostate cancer and subsequently spent ten weeks at the Repatriation General Hospital for radiation therapy. He did not undergo any surgery for this complaint and remained in remission from the cancer up until the time of his death in 2013.

2.2. In 2001 he was diagnosed with chronic obstructive airway disease, most likely due to smoking. From about 2010 Mr Cameron began regularly calling the SA Ambulance Service complaining of shortness of breath. On a number of these occasions his calls resulted in him being taken to hospital where he would be admitted, only for him to then discharge himself contrary to medical advice.

2.3. In December 2011 Mr Cameron's daughters, Heather Kay and Karen Venables, applied for and were granted a guardianship order with respect to Mr Cameron's medical care.

This order also included a do not resuscitate clause as it was their father's wish not to be kept alive by machines should he be unable to make decisions for himself.

2.4. In May 2012 Mr Cameron lost his driver's licence due to drink driving. He acquired a gofer to mobilise. At around this time his drinking and smoking increased significantly and he was smoking at least a packet of cigarettes a day despite his lung disease. He became decreasingly self-reliant and started receiving in home care as well as visits from the Community Complex Care Team.

2.5. On 25 August 2013 Mr Cameron rang triple-O alleging that someone was attempting to break into his home. South Australia Police attended and inspected the premises.

They found no indication of anyone either on the premises or of anyone having attempted to gain entry to the premises. They did, however, locate Mr Cameron in very poor health. He was short of breath and appeared very confused. There was no evidence of a break in or other disturbance. The attending officers felt that in light of Mr Cameron’s condition he had most likely hallucinated.

2.6. On 29 August 2013 Mr Cameron again telephoned triple-O reporting that someone had broken into his house, that he had confronted and fought with the person and that he was now injured as a result of the fight. SAPOL attended. Again, there was no indication of a break-in. However, police did find Mr Cameron smelling very strongly of liquor, that he was slurring his speech and was in generally poor health. They observed Mr Cameron to be suffering from open bleeding sores on his arms, but on closer inspection felt that they were non-suspicious skin tears on delicate skin. SAPOL did call Mr Cameron's family on this occasion and a decision was made to convey him to Noarlunga Hospital. This occurred by way of the South Australia Ambulance Service (SAAS). Mr Cameron was ultimately discharged.

2.7. On 10 September 2013 Mr Cameron experienced a dizzy spell at home that resulted in a fall. He called an ambulance and was admitted to Noarlunga Hospital. He was discharged.

2.8. At 5:18pm on 23 September 2013 Mr Cameron was transferred to Noarlunga by SAAS seemingly for an episode of shortness of breath. He was admitted on this occasion. At about 9pm that evening Mr Cameron attempted to leave the hospital but once again became short of breath and a decision was made for him to be admitted. His treatment included salbutamol and ipratropium, prednisolone, oxygen, oral antibiotics, nicotine replacement, thiamine, diazepam and alcohol withdrawal measures. It was agreed that he was not for CPR or invasive ventilation.

2.9. On 24 September 2013 the primary concerns for Mr Cameron were his exacerbation of chronic obstructive airway disease and the risks associated with alcohol withdrawal.

2.10. On 25 September 2013 Mr Cameron was noted to be acutely confused and delirious on ward round. He was given diazepam for alcohol withdrawal. Due primarily to alcohol withdrawal Mr Cameron became increasingly agitated and began demanding to leave the hospital. At about 4pm a ‘code black’ was called in Whittaker Ward in respect of Mr Cameron’s attempting to leave the hospital. Dr Miriam Whitten persuaded Mr Cameron to return to his room. As explained by Dr Whitten in her statement1, she spoke to Mr Cameron and found him to be very confused and quite agitated, showing signs of acute alcohol withdrawal. He required large doses to treat his withdrawal.

Mr Cameron was not able to comprehend his need to stay in hospital to continue his 1 Exhibit C2

treatment and he was not in a position to make sound judgments about his medical condition and the seriousness of it. At first Mr Cameron agreed to stay but soon changed his mind and wanted to leave again. It was clear to Dr Whitten that Mr Cameron was not going to respond and would attempt to leave the hospital.

Mr Cameron’s daughter was present. As a result of considering his poor medical state plus his desire and attempts to leave the hospital, as well as his own daughters' concerns about the behaviour he would engage in if he was discharged home, primarily smoking and drinking, a Level 1 Inpatient Treatment Order was invoked by Dr Whitten with effect from 4:20pm. This order required confirmation with 24 hours.

2.11. The following day, 26 September 2013, Mr Cameron was noted to be slightly less confused, but was still lacking insight into his condition and as to why he required hospitalisation. He continued his demands to leave the hospital. At 11:28am Dr Angelos Giannakoureas, a psychiatrist, confirmed the Level 1 Inpatient Treatment Order.

2.12. A ward round review the following day indicated that Mr Cameron's withdrawal struggles were subsiding and that he was more settled. The plan was to continue assessment of him and of his mental state over the ensuing weekend and to determine whether his delirium and confusion was ongoing or whether it was entirely related to the alcohol withdrawal. Ward round notes from Saturday 28 September 2013 indicate he was more settled.

2.13. At 11pm on 28 September 2013 a code blue was called for Mr Cameron due to his experiencing a rapid deterioration in his condition. He had experienced a significant drop in oxygen saturations and exhibited a worsening mental state. He was agitated and uncooperative. He was diagnosed at this time with right lower lobe pneumonia and type 2 respiratory failure on a background of severe chronic obstructive pulmonary disease.

2.14. Discussions with Mr Cameron's daughter, Ms Heather Kay, resulted in the decision that he should be treated with comfort care measures only. He was administered midazolam for his agitation. Mr Cameron ultimately died at approximately 3:35am on 29 September 2013.

3. Conclusions 3.1. Mr Cameron’s detention under the Mental Health Act 2009 was at all times lawful and appropriate having regard to his mental condition.

3.2. Mr Cameron’s treatment within the Noarlunga Hospital was appropriate. Ms Heather Kay, a daughter of Mr Cameron, provided two statements to the Inquest2. In those statements Ms Kay indicates that after her father was admitted to hospital in September 2013, she noticed that her father’s health drastically deteriorated both mentally and physically. Ms Kay indicates that she did not actually discover that her father had been admitted to hospital until 25 September 2013 when the hospital called to say that he had been admitted, was very confused and was trying to leave. Ms Kay had then made her way to the hospital. Ms Kay confirms that her father was very confused, weak and frail and that he did not realise that he was in hospital. He spoke as if he was still in his house. Ms Kay describes him as delusional. Ms Kay confirms that she discussed the matter with Dr Whitten and in particular about her concerns for her father should he be allowed to go home. Sometime later that afternoon while Mr Cameron was still in the hospital, he tried to leave and was prevented from doing so by medical staff. Ms Kay describes the discussion between Dr Whitten and her father at length. Ms Kays says that despite Dr Whitten’s best efforts her father was not responding and could not comprehend the seriousness of his medical condition. She was present when Dr Whitten imposed the Level 1 Inpatient Treatment Order. Her father reacted belligerently. Ms Kay acknowledges that her father needed to be heavily sedated to keep him calm.

3.3. Ms Kay’s second statement concludes as follows: 'In my opinion invoking the Treatment Order was the only option left to the medical staff to ensure my dad's treatment. In fact I would have been very upset had they allowed him to leave.

Dr Whitten and all the medical staff were actually very good in handling my dad and his behaviour and I am very grateful he was in their care and I would like to thank them for all their efforts trying to help him and look after him.' 3

3.4. I agree with Ms Kay’s observations.

2 Exhibits C1b and C1c 3 Exhibit C1c

3.5. Mr Cameron’s death was investigated by Detective Brevet Sergeant Libor Hlavnicka4 of the South Coast Criminal Investigation Branch. In his final report Mr Hlavnicka expresses the view that the care of the deceased at Noarlunga Hospital was more than appropriate. This Court agrees and has nothing further to add.

4. Recommendations 4.1. There are no recommendations in this matter.

Key Words: Death in Custody; Natural Causes; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 17th day of November, 2017.

Deputy State Coroner Inquest Number 37/2015 (1635/2013) 4 Exhibit C9a