Coroner's Finding: NOCKOLDS Dorothy Ellen

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 Dorothy Ellen Nockolds.

The said Court finds that Dorothy Ellen Nockolds aged 93 years, late of Olive Grove Aged Care, 67 Porter Street, Salisbury, South Australia died at the Lyell McEwin Health Service, Haydown Road, Elizabeth Vale, South Australia on the 27th day of July 2015 as a result of dehydration with hypernatremia and acute renal failure with metabolic acidosis.

The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Dorothy Ellen Nockolds was 93 years of age when she died on 27 July 2015 at the Lyell McEwin Health Service. A cause of death was given by the treating doctor at the Lyell McEwin Health Service. Mrs Nockolds’ cause of death was given afps dehydration with hypernatremia and acute renal failure with metabolic acidosis, and I so find.

2. Reason for Inquest 2.1. On 8 April 2010 a guardianship and administration order with provisions as to where Mrs Nockolds had to be and remain was made by the Guardianship Board. These orders were sought by Mrs Nockolds' relatives in light of her advancing dementia and prolonged hospitalisation for the condition.

2.2. In view of these orders Mrs Nockolds was regarded, in the eyes of the law, as 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.

3. Background and the events leading to Mrs Nockolds’ death 3.1. Mrs Nockolds was hospitalised from 27 January 2010 to 28 June 2010 in the context of her advancing dementia. On 28 June 2010 she was admitted to the Olive Grove Aged Care facility in a high care ward. Her medical history included vascular dementia with increased confusion and aggression resulting in decreased personal care and medication compliance. She was prone to falls and hypertension and experienced recurrent bladder infections.

3.2. On 8 July 2015 Mrs Nockolds suffered a transient ischaemic attack. There was a brief loss of consciousness but this was managed at Olive Grove. She was given 24 hours of neurological observations and there was no permanent deficit noted.

3.3. On 11 July 2015 a fractured right arm was detected. This was managed with a sling and pain relief.

3.4. On 14 July 2015 Mrs Nockolds was noted to be generally unwell. Fluid was detected in her injured arm and she was transferred to the Lyell McEwin Health Service. She was assessed and returned to Olive Grove on the same day. She was determined to be dehydrated and subcutaneous fluids were administered.

3.5. On 17 July 2015 Mrs Nockolds’ condition had not improved and she attended the Lyell McEwin Health Service outpatients service for a review of her arm. She was considered to be dehydrated and subcutaneous fluids were administered.

3.6. On 22 July 2015 she began to experience breathing difficulties and, in consultation with her family, it was decided that Mrs Nockolds would be transferred to the Lyell McEwin Health Service.

3.7. From 22 July to 27 July 2015 Mrs Nockolds remained an inpatient at the Lyell McEwin Health Service. She was diagnosed with dehydration and a urinary tract infection.

Mrs Nockolds died in the early hours of 27 July 2015.

4. Conclusion 4.1. I find Mrs Nockolds’ detention was lawful. The care provided during her admission to the Lyell McEwin Health Service was appropriate. Her family expressed some concerns about her treatment at the nursing home, but I have no reason to believe that this contributed to her death. I suggested that the family may wish to take their concerns up with the relevant Commonwealth agency.

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 70/2016 (1311/2015)