Coroner's Finding: HODGINS William Albert

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 18th day of November 2016 and the 12th day of December 2017, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of William Albert Hodgins.

The said Court finds that William Albert Hodgins aged 95 years, late of 17 Callington Road, Callington, South Australia died at the Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 28th day of February 2015 as a result of multi-organ failure due to sepsis and general inanition on a background of advanced vascular dementia and ischaemic heart disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. William Albert Hodgins was 95 years of age when he died on 28 February 2015 at the Repatriation General Hospital at Daw Park (the RGH).

1.2. Mr Hodgins’ cause of death was reviewed by Dr Iain McIntyre of Forensic Science South Australia. In his pathological review Dr McIntyre has opined that Mr Hodgins’ cause of death was multi-organ failure due to sepsis and general inanition on a background of advanced vascular dementia and ischaemic heart disease. This opinion was based upon the circumstances surrounding Mr Hodgins’ and his medical history. I have accepted Dr McIntyre’s opinion and find that the cause of death is as stated by Dr McIntyre.

2. Reason for Inquest 2.1. At the time of his death Mr Hodgins was the subject of a Level 2 Inpatient Treatment Order (ITO) which had been imposed pursuant to the Mental Health Act 2009. The order was imposed on 17 February 2015 by Dr Christopher Veale who is a psychiatrist at the RGH. The order had a duration of 42 days. The effect of the order was that Mr Hodgins was detained at the RGH. Mr Hodgins died during the currency of the order. As a result, Mr Hodgins’ death was a death in custody in respect of which this Inquest was mandatory. These are the findings of that Inquest.

3. Background 3.1. Mr Hodgins had a medical history that included peripheral vascular disease, gastrooesophageal reflux disease and ischaemic heart disease for which he had undergone coronary bypass surgery. He had also undergone an aortic aneurysm repair. In December 2014 he had been diagnosed with herpes zoster (shingles) in his eye and face and had then experienced post-herpetic neuralgia.

3.2. Mr Hodgins had previously resided at Callington with his wife. He had four adult children. He had been a motor trimmer by trade. Upon his retirement Mr Hodgins bought the Callington property and converted it into a horse stud.

3.3. Mr Hodgins’ diagnosis of shingles occurred on 23 December 2014. On 24 December 2014 he was admitted to hospital overnight for nausea, vomiting, dehydration and persistent headache. He was admitted overnight. On 7 January 2015 he saw his general practitioner and indicated that he felt he had been ‘knocked flat’ by his shingles. At the same attendance there was also mention of a few months of history of short-term memory loss and irritability.

3.4. On 9 January 2015 Mr Hodgins was admitted to Mount Barker Hospital with lethargy, confusion and a history of falls at home. He complained of ongoing headaches, was verbally abusive to staff, would refuse medication and became resistive to care.

3.5. On 16 January 2015 Mr Hodgins’ family started to look for post discharge accommodation for Mr Hodgins. It was felt that his wife would not be able to look after him in the family home. On 23 January 2015 Mr Hodgins was discharged to Estia Health at Strathalbyn.

3.6. On 2 February 2015 Mr Hodgins became verbally and physically abusive and aggressive towards Estia staff. As a result he was transferred by ambulance to Strathalbyn Hospital where he was admitted. Mr Hodgins’ condition there deteriorated.

He showed aggression towards hospital staff and tried to leave the hospital. On 10 February 2015, following an incident involving a fire extinguisher, a Level 1 ITO was imposed upon him and he was transferred to the Flinders Medical Centre (the FMC) where he was admitted.

3.7. On 11 February 2015 the Level 1 ITO was confirmed. Mr Hodgins was diagnosed with post-herpetic neuralgia, vascular dementia and delirium. His aggressive behaviour unfortunately continued. As a result, on 12 February 2015 he was transferred under the ITO to the RGH where he would remain until his death on 28 February 2015.

3.8. The Level 2 ITO which was in force on the day of Mr Hodgins’ death was imposed by the psychiatrist Dr Veale on 17 February 2015.

3.9. Dr Veale is a senior staff specialist at the RGH. At the time with which this Inquest is concerned he was the Director of the RGH Consultation Liaison Service and provided psychiatric review and treatment for patients in the RGH on medical wards. Dr Veale provided a statement to the Inquest1. Dr Veale’s statement reveals that he was asked to assess Mr Hodgins for a Level 2 ITO on 17 February 2015. On that occasion Mr Hodgins was delirious and agitated. A review by Dr Veale of Mr Hodgins’ notes indicated that he had been aggressive towards staff and non-compliant with treatment.

Dr Veale was concerned about Mr Hodgins’ age, physical frailty, delirium, lack of orientation to the situation and his inability to make treatment decisions for himself. It was also clear that he had developed sepsis which is a severe infection that can often cause confusion in elderly people. Dr Veale therefore imposed the Level 2 ITO so that Mr Hodgins could undergo an adequate assessment and treatment. Due to Mr Hodgins’ background and behaviour Dr Veale was satisfied that the Level 2 ITO was appropriate in the circumstances and was necessary for his continued treatment. It was clear that Mr Hodgins was not able to make decisions for himself, in particular about his healthcare. Nursing staff would need to provide him with medication and to attend to 1 Exhibit C4

his care needs by observing, toileting, showering and cleaning him. In short, Dr Veale states that the order was needed to allow nursing staff to do what they needed to do in order to ‘provide him with good, sensible care’. Dr Veale’s statement asserts that he believed that there was no less restrictive means other than the Level 2 ITO.

3.10. On 19 February 2015 Mr Hodgins exhibited profound confusion. He suffered a fall which resulted in a laceration to his left elbow requiring sutures.

3.11. On 24 February 2015 swabs of the elbow revealed a staphylococcus aureus infection.

Discussions were held with Mr Hodgins’ family. A decision was made by family and medical staff together that there would be a switch to a palliative care focus.

3.12. On 25 February 2015 the elbow was slightly improved but by then his right elbow was also very hot, very swollen, obviously painful and a likely source of infection.

Mr Hodgins was no longer able to mobilise and was refusing oral intake. His death was thought to be imminent.

3.13. Between 3pm and 6pm on 28 February 2015 regular observations were conducted with respect to Mr Hodgins. He was sedated due to palliation. His breathing became very slow and shallow and he exhibited an irregular pulse. He was declared life extinct at 7:05pm that day.

4. Conclusions 4.1. Mr Hodgins’ death was thoroughly investigated by Detective Sergeant Andrew Bissell of the Mount Barker CIB. Detective Bissell has expressed the conclusions in his helpful report2 that the Level 2 ITO imposed by Dr Veale was an appropriate and valid order.

Having regard to the circumstances surrounding Mr Hodgins’ during his admission at the RGH, and to Dr Veale’s clear explanation for the imposition of the order, I am compelled to agree with Detective Bissell’s conclusion that the order was appropriate.

4.2. The further conclusion arrived at by Detective Bissell was that Mr Hodgins’ care at the RGH was appropriate. I also agree with that conclusion. Mr Hodgins’ custodial circumstances had no bearing on his death. On the contrary, the ITO had been imposed 2 Exhibit C8a

with Mr Hodgins’ best interests as the paramount consideration. The statement of Mr Hodgins’ son, Mr Rex Hodgins3, contains the following: 'At no stage could I complain about the medical treatment that Dad received from the time he got sick at Christmas until the time he died. The medical staff kept us updated with Dad’s condition and treatment he was undertaking.'

5. Recommendations 5.1. The Court does not make any recommendations in this matter.

Key Words: Death in Custody; Inpatient Treatment Order; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 12th day of December, 2017.

Deputy State Coroner Inquest Number 63/2016 (0361/2015) 3 Exhibit C1b