Coroner's Finding: SMITH Arthur

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 Arthur Smith.

The said Court finds that Arthur Smith aged 80 years, late of Helping Hand, 7-31 Shackleton Avenue, Ingle Farm, South Australia died at Ingle Farm, South Australia on the 15th day of August 2015 as a result of aspiration pneumonia complicating inanition of dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Arthur Smith was 80 years of age when he died on 15 August 2015 at the Helping Hand Aged Care facility at Ingle Farm where he resided in a secure unit.

1.2. Following his death a pathology review was undertaken by Dr Neil Langlois from Forensic Science South Australia. Dr Langlois reported the cause of death as aspiration pneumonia complicating inanition of dementia, and I so find.

2. Reason for Inquest 2.1. On 12 August 2013 the Guardianship Board granted a guardianship and administration order with provision as to detention pursuant to section 32 of the Guardianship and Administration Act 1993. The Public Advocate was appointed as Mr Smith's guardian and Public Trustee as his administrator in relation to his finances.

2.2. In view of the provisions related to detention Mr Smith’s death 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 3.1. For 27 years prior to his death Mr Smith had a good friend, Ms Maria James, who had been a companion to him and also a great help in the later years, assisting with shopping, paying the bills, cooking and other odd chores. He had a medical history of a brain haemorrhage in 1984 which had caused him to stop working and he was no longer able to drive. He suffered from Alzheimer's dementia, hypertension, urinary and faecal incontinence, varicose veins and osteoarthritis.

3.2. In January 2011 he was seen by a consultant physician, Dr Brendon Daly, and diagnosed with early mild cognitive impairment.

4. Mr Smith’s cognitive decline and the events leading to his death 4.1. On 26 June 2011 Mr Smith was conveyed to the Lyell McEwin Health Service where he was admitted following an episode of upper gastrointestinal bleeding. He was given a blood transfusion and an endoscopy. He recovered and was discharged. Whilst an inpatient a cognitive assessment was completed due to the confusion he was exhibiting.

The assessment showed severe impairment in memory, moderate impairment in orientation, and a moderate impairment in reasoning.

4.2. On 18 July 2013 he was conveyed to the Lyell McEwin Health Service where he was admitted following a collapse at home. Mr Smith was unable to recall the event and was noted to have suffered a laceration to his head. During this admission a code black was called as Mr Smith had tried to climb out of the bed, over the bed rails, and was aggressive towards staff.

4.3. On 19 July 2013 it was decided that a Level 1 Inpatient Treatment Order under section 21 of the Mental Health Act 2009 was required due to ongoing difficult behaviours. Mr Smith was placed on the wait list for the Geriatric Evaluation and Management Unit (GEM) at the Modbury Hospital.

4.4. On 24 July 2013 Mr Smith was seen by a geriatrician and it was considered that his dementia had progressed to a point where he would require assistance and supervision

for all basic self-care needs, including the administering of medications. Mr Smith denied requiring this assistance and insisted he would be fine to manage on his own.

4.5. On 5 August 2013 he was transferred to the GEM Unit at Modbury. It was at this time that orders were sought from the Guardianship Board in light of Mr Smith's advancing Alzheimer's disease and his failure to recognise his frailties, along with the risk this posed to him. Mr Smith felt that he could return home without assistance. Mr Smith's friend, Ms Maria James, was also ageing and felt she could no longer assist him in the way he required, and did not wish to administer his finances.

4.6. On 12 August 2013 the Guardianship Board issued the guardianship and administration order previously referred to.

4.7. On 24 September 2013 permanent accommodation was found for Mr Smith at Helping Hand Ingle Farm. During his time there he was verbally uncooperative. He would refuse to participate in activities of daily living, including hygiene activities. He would hide and hoard items, including his incontinence pads, because he did not want to wear them.

4.8. During the period 29 May 2014 to 21 April 2015 Mr Smith had at least 12 falls. He had physiotherapy assessments and a four-wheeled walker was recommended for him.

Mr Smith required prompting to use the walker. Occasionally he would fall, even though it was next to him, due to his refusal to use it. He had hip protectors in place.

4.9. Mr Smith had several choking episodes and so a speech pathology review was recommended for him. In the meantime he was put on a varied soft diet. He was noted to be pocketing food in his mouth, so he required careful monitoring during all meal times.

4.10. On 10 August 2015 it was noted by nursing home staff that Mr Smith had a low mood, and had so for several days. He barely mobilised, choosing to stay in his bed for most of the time.

4.11. On 13 August 2015 he was showing signs of pain when he was being re-positioned in his bed and was noted to have what were coined ‘rattly respirations’.

4.12. On 15 August 2015 at 8:25pm Mr Smith died in his bed at the nursing home.

5. Conclusion 5.1. I find Mr Smith’s detention was lawful and that the care provided to him whilst under detention was appropriate.

6. Recommendations 6.1. 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 69/2016 (1445/2015)