Coroner's Finding: FORGIONE Maria Eufemia

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 December 2016 and the 30th day of May 2017, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Maria Eufemia Forgione.

The said Court finds that Maria Eufemia Forgione aged 89 years, late of Salisbury Private Nursing Home, 147 Frost Road, Salisbury, South Australia died at Salisbury, South Australia on the 30th day of May 2015 as a result of multi-organ failure on a background of urinary sepsis. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Mrs Forgione was 89 years of age when she died at the Salisbury Private Nursing Home where she had been a resident. A pathology review was undertaken by Dr Iain McIntyre from Forensic Science South Australia. On the basis of Dr McIntyre’s report I find the cause of death to be multi-organ failure on a background of urinary sepsis.

2. Reason for Inquest 2.1. On 23 September 2013 the Guardianship Board granted a guardianship order pursuant to section 32 of the Guardianship and Administration Act. This included a power to direct where she lived and stayed. These orders were sought in light of Mrs Forgione's florid paranoid schizophrenia, advancing age and frailty of health. She was no longer able to care for herself in the community and her health and safety were considered at serious risk.

2.2. By virtue of the Guardianship Board’s orders Mrs Forgione 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

3. Background and the events leading to Mrs Forgione’s death 3.1. Mrs Forgione lived in Italy in the 1950s and there is evidence to indicate that during this time she had admissions to psychiatric hospitals for her schizophrenia. Following her arrival in Australia she had multiple admissions to the Hillcrest Hospital for similar issues. She spoke predominantly Italian and very little English.

3.2. In September 2011 she was admitted to the Northern Community Team for Older Persons who managed her in the community. She was regularly reviewed by her community care worker. Until 2013 she lived alone in her home with considerable family support to undertake basic tasks such as shopping, cleaning, laundry and bathing.

3.3. Mrs Forgione spent most of her time in her bed. During 2013 she began to become somewhat aggressive towards her family members as she did not believe she needed the help that they were providing. Her general health declined.

3.4. On 15 August 2013 Mrs Forgione was admitted to Ward 1H at the Lyell McEwin Health Service. She was interviewed in her native language and constantly asked to return home. She said that people were coming in through her roof and that her sister-in-law had the ‘evil eye’ on her. During this admission Mrs Forgione's family expressed concern about having to care for her in the community given her high care needs.

3.5. Following consultation with the staff at the hospital an application was made to the Guardianship Board for the orders referred to above.

3.6. On 23 October 2013 Mrs Forgione was discharged from Lyell McEwin Health Service to the Salisbury Private Nursing Home where she remained until her death. She continued to suffer ongoing delusions and auditory hallucinations. Her acute symptoms were dealt with by medication, however her chronic symptoms persisted. Mrs Forgione would not shower for fear that staff would steal her clothing, she regularly refused medications, she developed other health conditions that required ongoing treatment and suffered confusion. As a result she became verbally aggressive to those trying to assist

her. She refused to eat and would wander around the nursing home looking for a way to escape.

3.7. By 15 September 2014 Mrs Forgione's condition was deteriorating and her guardians, in conjunction with her general practitioner, prepared a palliative care plan.

3.8. In May 2015 Mrs Forgione developed a chest infection and a urinary tract infection.

She was given antibiotics and discussions were held between her family and medical staff resulting in the institution of palliative care measures only.

3.9. On 30 May 2015 Mrs Forgione died with her family present.

4. Conclusion 4.1. I find Mrs Forgione’s detention was lawful and that the care provided to her was appropriate.

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

Key Words: Death in Custody; Section 32 Powers In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 30th day of May, 2017.

State Coroner Inquest Number 67/2016 (0924/2015)