Coroner's Finding: WEIR Maureen Mary

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 1st day of July 2016 and the 25th day of August 2017, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Maureen Mary Weir.

The said Court finds that Maureen Mary Weir aged 79 years, late of Kapara Nursing Home, 80 Moseley Street, Glenelg, South Australia died at Kapara Nursing Home, 80 Moseley Street, Glenelg, South Australia on the 3rd day of October 2014 as a result of general inanition due to advanced vascular dementia on a background of ischaemic heart disease and chronic lymphatic leukaemia. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for Inquest 1.1. Maureen Mary Weir died on 3 October 2014 at the Kapara Nursing Home in Glenelg South. She was 79 years of age at the time of her death. A pathology review1 based upon Mrs Weir’s recent and longitudinal medical history and conducted by Dr Iain McIntyre of Forensic Science South Australia determined that her cause of death was general inanition due to advanced vascular dementia on a background of ischaemic heart disease and chronic lymphatic leukaemia. I find that to have been Mrs Weir’s cause of death.

1.2. In March 2011 Mrs Weir’s sons, Gregory Weir and Anthony Weir, applied to the Guardianship Board for joint guardianship and powers pursuant to section 32 of the Guardianship and Administration Act 1993. This application was made due to the 1 Exhibit C2a

ongoing deterioration in Mrs Weir's cognitive abilities, her progression of advanced dementia and out of concern for her safety. On 31 March 2011 the guardianship order with section 32 powers that involved residential detention was granted. Reviews of those orders occurred on 19 October 2011, 17 October 2012, and 16 December 2013, and on each occasion the orders were confirmed and renewed for a further term.

1.3. In April 2011 Mrs Weir was accepted into the Kapara Nursing Home in Glenelg South.

She would remain there until her death. The primary concern at the time of her admission to this facility was Mrs Weir's declining mental health due to Alzheimer's dementia and her need for 24-hour care. By virtue of the order of the Guardianship Board Mrs Weir was at all material times detained in this facility. Therefore her death was a death in custody as defined within the Coroners Act 2003. Accordingly, this Inquest was mandatory. These are the findings of that Inquest.

2. Medical history 2.1. In 2012 Mrs Weir suffered a heart attack requiring hospitalisation. She also experienced a number of falls. In 2013 she was diagnosed with lymphatic leukaemia.

In 2014 she was hospitalised for malnutrition due to her general deterioration.

2.2. During a period of hospitalisation in 2013 discussions were undertaken with Mrs Weir's family concerning her resuscitation status and it was mutually agreed that a ‘do not resuscitate’ directive would be put in place. This was confirmed in July 2014 when tests revealed that an aggressive transformation of her leukaemia was occurring. By this time Mrs Weir was chair and bed bound requiring significant assistance in order to mobilise. Mrs Weir was also suffering from vascular dementia and heart disease. In consultation with her family, on 2 July 2014 she was placed on a Palliative Care Order after showing no optimistic progress for nearly two years.

2.3. The plan developed for the deceased was for good palliative care measures directed at the continuing relief of symptoms and discomfort and for no artificial measures designed to replace or support bodily function to be undertaken. Mrs Weir’s clinical management was handed over to a general practitioner, Dr Sheree Cross, who has expertise in aged and palliative care. Dr Cross’ statement2 reveals that Dr Cross looked 2 Exhibit C5

after Mrs Weir in the four months before her death. In that period Dr Cross saw Mrs Weir on eight occasions. Dr Cross describes Mrs Weir as follows: 'With her Alzheimer/dementia, Mrs Weir was usually alert but not communicative. She was not able to help herself and suffered from tardive dyskinesia resulting in her confinement to a chair.'

3. Mrs Weir’s decline 3.1. On 1 October 2014 Dr Cross observed that Mrs Weir was becoming increasingly unable to eat or drink and so it was becoming unsafe for her to continue with oral medication.

Dr Cross assessed that she was entering the terminal phase of life and so she made a decision to implement a ‘terminal phase plan’ for Mrs Weir. On 2 October 2014 Dr Cross spoke with Mr Tony Weir and advised him of his mother’s decline in health and of her decision to implement the terminal phase plan and of her clinical reasoning in relation to that plan. Mr Weir indicated that he was content with that plan of management and said that he would travel from Melbourne the following day. I observe from the statement of Mr Gregory Weir3 that one week prior to his mother’s death he was notified by staff at the Kapara facility that his mother’s death was imminent. In that week he saw his mother every day.

3.2. Between 5pm and 6pm on 3 October 2014 Mrs Weir was given some medication for her pain reduction as she was showing signs of being in some pain. At 6:20pm nursing staff were present with her when she died at the nursing home.

3.3. Mr Gregory Weir asserts in his statement that he had always found the staff and management at Kapara to be friendly and professional. In his opinion the centre was well managed, always clean and that his mother was well cared for. He states that he and his family never had any concerns or reason to suspect mistreatment. He states that they were consulted and made aware of any changes in the care and treatment plan which they would cite and sign when visiting Mrs Weir.

3.4. The investigating police officer, Detective Brevet Sergeant Daryl Mundy of the Western Adelaide Criminal Investigation Branch4 concluded that all efforts had been made to ensure the best possible comfort for Mrs Weir during her residence at Kapara 3 Exhibit C6 4 Exhibit C11

in accordance with the palliative care plan. I have no reason to doubt that this was the case.

4. Conclusions 4.1. Mrs Weir died of natural causes.

4.2. Mrs Weir’s custodial circumstances had no bearing on her medical treatment and did not contribute to her death.

4.3. Mrs Weir’s detention pursuant to section 32 of the Guardianship and Administration Act 1993 was at all times lawful.

5. Recommendations 5.1. The Court does not make any recommendation consequent upon these findings.

Key Words: Death in Custody, Section 32 Powers; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 25th day of August, 2017.

Deputy State Coroner Inquest Number 39/2016 (1739/2014)