Coroner's Finding: HAYDEN Phillip Maxwell

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 Phillip Maxwell Hayden.

The said Court finds that Phillip Maxwell Hayden aged 80 years, late of Makk and McLeay Nursing Home, 200 Fosters Road, Oakden, South Australia died at Oakden, South Australia on the 27th day of February 2015 as a result of general inanition due to advanced Alzheimer's dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Phillip Maxwell Hayden was 80 years of age when he died on 27 February 2015 at the Makk and McLeay Nursing Home in Oakden. A pathology review was conducted by Dr Iain McIntyre from Forensic Science South Australia in relation to Mr Hayden's death. In his report Dr McIntyre provided a cause of death of general inanition due to advanced Alzheimer's dementia1, and I so find.

2. Reason for Inquest 2.1. At the time of Mr Hayden’s death he was the subject of a Level 3 Inpatient Treatment Order under the Mental Health Act 2009. His death was therefore 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.

1 Exhibit C2a

3. Background 3.1. Mr Hayden had been married to his wife Roslyn for 54 years. They had three adult children and 10 grandchildren. Mr Hayden was diagnosed with dementia in June 2012 and further diagnosed with behavioural and psychological symptoms of dementia in June 2014. During the two year period between his initial diagnosis and June 2014 he had remained living with his wife and she had cared for him in the family home.

3.2. Mr Hayden’s relevant medical history includes Alzheimer's disease, the behavioural and psychological symptoms of dementia or BPSD, a hiatus hernia, non-insulin dependent diabetes, ischaemic heart disease with coronary artery bypass grafting triple vessel, diverticulitis and hypercholesterolemia.

3.3. In June 2014 Mr Hayden was admitted to the Repatriation General Hospital and quickly transferred to geriatric evaluation and management unit or the GEM ward. Whilst on the GEM ward his behaviour worsened with increased aggression and sexually inappropriate behaviour, he also exhibited highly intrusive behaviour. He would throw his food and drink and required assistance with all meals. Multiple code blacks were called. Mr Hayden would make personal threats against staff. Multiple medications were trialled with Mr Hayden, however he showed sensitivity to these and they needed to be titrated cautiously. Due to this continued deterioration a Level 1 Inpatient Treatment Order was invoked.

3.4. On 15 September 2014 a Level 2 Inpatient Treatment Order was invoked due to Mr Hayden’s continued aggressive behaviour requiring physical restraint. On 21 October 2014 a Level 3 Inpatient Treatment Order was applied for and obtained and this order was in place when Mr Hayden was ultimately transferred from the Repatriation General Hospital to the Makk and McLeay Nursing Home. Mr Hayden moved to the nursing home on 1 November 2014.

3.5. During his time at the Makk and McLeay Nursing Home Mr Hayden continued to be physically aggressive towards staff members. He would often wander the ward in a state of confusion and constantly needed redirection. He was intrusive with staff and other residents. He was unsteady on his feet and suffered many falls.

4. Mr Hayden’s decline 4.1. On 11 February 2015 Mr Hayden was conveyed by ambulance to the Royal Adelaide Hospital with pain in his right hip. It was discovered that he had a possible greater trochanter undisplaced fracture. He was given morphine for pain management and his family were involved in the decision the following day to commence him on a palliative care plan only. All oral medication was ceased at that time other than pain relief.

4.2. On 24 February 2015 Mr Hayden had ongoing chronic deterioration and his family declined any further medical investigation, but reiterated their desire for a good palliative care pathway for him. On 26 February 2015 his general condition was deteriorating, he had irregular breathing and rapid respirations. He appeared to be in pain and was grimacing and wincing. On 27 February 2015 his respirations were still laboured. He was reviewed by a doctor at 9:50am who advised that Mr Hayden was in the final stages of his life and at 10:30am on 27 February 2015 he passed away in the presence of his wife and one of his daughters.

5. Conclusions 5.1. I find Mr Hayden’s detention was lawful and appropriate and had no bearing on his death. I find that all that could be done for him to ensure good treatment in very difficult circumstances, was done.

6. Recommendations 6.1. 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 53/2016 (0354/2015)