Coroner's Finding: O'REILLY Raymond John

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 Raymond John O'Reilly.

The said Court finds that Raymond John O'Reilly aged 91 years, late of 3 Lorna Street, Salisbury, South Australia died at the Lyell McEwin Health Service, Haydown Road, Elizabeth Vale, South Australia on the 20th day of December 2014 as a result of pneumonia on a background of chronic congestive cardiac failure and chronic obstructive lung disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Raymond John O'Reilly was 91 years of age when he died on 20 December 2014 at the Lyell McEwin Hospital in Elizabeth Vale.

1.2. Following his death a pathology review was undertaken by Dr Iain McIntyre from Forensic Science South Australia. I accept Dr McIntyre’s opinion and find that the cause of death was pneumonia on a background of chronic congestive cardiac failure and chronic obstructive lung disease.

2. Reason for Inquest 2.1. At the time of his death Mr O'Reilly was the subject of a Level 1 Inpatient Treatment Order under the Mental Health Act 2009 that had been instituted by his treating doctor, Dr Phillipa Baker of the Lyell McEwin Health Service. Mr O’Reilly’s 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.

3. Mr O’Reilly’s admission to the Lyell McEwin Hospital 3.1. Mr O'Reilly lived with his wife, Sally O'Reilly, in their private residence at Salisbury.

His relevant medical history included atrial fibrillation, chronic obstructive lung disease, chronic congestive cardiac failure, hypertension and pulmonary hypertension.

3.2. On 8 December 2014 Mr O'Reilly was noted by his wife to be confused, agitated and short of breath. She called an ambulance and he was conveyed to the Lyell McEwin Hospital. Whilst in the Emergency Department a code black was called due to Mr O’Reilly being combative with medical staff. As a result of the medical assessment of Mr O'Reilly it was decided that he be admitted to the hospital geriatric ward for further treatment. He remained there until his death on 20 December 2014.

3.3. During his admission Mr O'Reilly was assessed as having pneumonia, cardiac failure, exacerbation of chronic lung disease and delirium. Whilst on the ward Mr O'Reilly received treatment including a course of antibiotics and other prescription medications including, but not limited to, furosemide for his cardiac failure, prednisolone for the chronic lung disease, movicol for constipation and warfarin for chronic atrial fibrillation. A head CT was also undertaken with respect to the delirium he was exhibiting, however nothing untoward was found. Mr O'Reilly did not respond to treatment and he continued to display symptoms of shortness of breath, confusion, agitation and reduction in his oxygen saturation levels.

3.4. The issue concerning Mr O'Reilly's oxygen saturations was considered to be critical as his levels were dangerously low, however he would be combative with medical staff and resist treatment with oxygen. He displayed aggressive behaviour towards staff on numerous occasions. Mr O’Reilly’s lack of oxygen was thought to be contributing to his behaviour, but attempts to resolve the issue by giving him oxygen were met with resistance.

3.5. On 18 December 2014 at approximately 11pm Mr O'Reilly began exhibiting behaviour thought to be dangerous to both himself and others. He was calling out, acting in an aggressive manner towards nursing staff, trying to leave the hospital, refusing treatment and acting in a generally confused state. A code black was called.

3.6. The night resident medical officer (RMO) authorised the use of olanzapine to calm Mr O'Reilly and the night registrar contacted the Office of the Public Advocate to seek advice in relation to the management of Mr O'Reilly. It was felt that some form of restraint would be required to ensure he received his proper treatment, primarily the oxygen therapy. The Office of the Public Advocate discussed Guardianship and Administration Act and Mental Health Act powers. The registrar believed the Mental Health Act powers were most suited as they could be enacted immediately and revoked at a later date if suitable. Mr O’Reilly was subsequently detained on a Level 1 Inpatient Treatment Order.

3.7. Mr O'Reilly was administered further doses of olanzapine at 7pm on 19 December 2014 and 4:30am on 20 December 2014 due to his ongoing agitation and confusion. At 5:10pm on 20 December 2014 a code blue was called due to Mr O’Reilly’s deteriorating state, low GCS and decreased blood oxygen levels. His wife was present and, in consultation with medical staff, it was decided that a 'do not resuscitate' order would be placed into effect. Later that evening Mr O'Reilly passed away peacefully with his wife present. At 9:40pm his life was declared extinct.

4. Conclusion 4.1. I find that the order for detention under the Mental Health Act 2009 was lawful and appropriate and instigated in order to ensure the best possible treatment for Mr O’Reilly in the circumstances.

4.2. I find that the care that was given to Mr O'Reilly was appropriate and adequate.

5. Recommendations 5.1. 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 50/2016 (2205/2014)