Coroner's Finding: CUTTS Charles Desmond

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 21st day of February 2018 and the 27th day of July 2018, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Charles Desmond Cutts.

The said Court finds that Charles Desmond Cutts aged 70 years, late of 59 Magdalene Terrace, Pasadena, South Australia died at Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 9th day of June 2015 as a result of aspiration pneumonia due to seizures. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Charles Desmond Cutts died on 9 June 2015 at the Flinders Medical Centre. He was 70 years old. An opinion as to his cause of death was given by Dr McIntyre of Forensic Science South Australia. Dr McIntyre found that Mr Cutts died from aspiration pneumonia due to seizures, and I so find.

2. Reason for Inquest 2.1. At the time of his death Mr Cutts was subject to a Level 2 Inpatient Treatment Order under the Mental Health Act 2009. Consequently, Mr Cutts' 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.

3. Background 3.1. Mr Cutts had a number of comorbidities including insulin dependent type 2 diabetes, cognitive impairment, hypertension, ischaemic heart disease, depression, alcohol abuse and seizures. He had been under the care of general practitioner, Dr Colin Jacobson, since 1981. In his statement1 Dr Jacobson described Mr Cutts as a man of good health in his early adult life. The decline of his health began when he was diagnosed with diabetes, hyperlipidaemia and then depression following the breakdown of his marriage. Dr Jacobson was aware of a history of alcohol abuse, although Mr Cutts was not open with him about this. Dr Jacobson was therefore unable to obtain an accurate history of how severe this was.

3.2. After reaching retirement age Mr Cutts became socially isolated and his alcohol consumption increased. He developed depression. Dr Jacobson was of the opinion that Mr Cutts' cognitive abilities were adversely affected by his drinking. This brought about a global decline in his health. He had a growing need for support with medications because he could not remember the appropriate management for the various ailments that he was medicated for.

3.3. In 2000 Mr Cutts suffered seizures. He was admitted to hospital for investigation and management. After numerous investigations the cause of the seizures was not diagnosed. Mr Cutts was prescribed anti-seizure medication which Dr Jacobson said had good effect in the short-term. In his statement Dr Jacobson said this: 'Charles from the first time I was seeing him, was an active hard-working man. He gave up smoking in the early 1990s. He consulted a number of different specialists (Endocrinologist, Cardiologist, Psychiatrist, Gastroenterologist, Neurologist and Psychologist) over the years but all in all he was not a sick man. Charles’ health problems were degenerative diseases which gradually worsened both by the ageing process and by his poor compliance at times.' 2

3.4. In May 2012 the Royal District Nursing Service were requested to undertake an occupational therapy assessment for Mr Cutts to measure his ability to live independently in the community. As a result of this assessment domestic assistance was initiated. Grab rails were installed in a number of areas of Mr Cutts’ home 1 Exhibit C6 2 Exhibit C6, page 3

including the shower alcove, bathroom entrance, toilet and front entrance. Regular visits also commenced to assist Mr Cutts with the management of his diabetes.

3.5. In 2012 Mr Cutts was admitted into the Virtual Hospital Program where his blood glucose levels and the supervision of his insulin generally was monitored via daily video phone from the hospital. Once a week a nurse visited Mr Cutts to assess his ongoing diabetic issues. Notwithstanding the support and care of the RDNS, Mr Cutts struggled at times to live independently. He was beset with confusion, non-compliance with medication, falls, depression and suicidal ideation.

4. Mr Cutts’ decline in health 4.1. On 11 May 2015 Mr Cutts was particularly confused when visited by the RDNS service.

He was drowsy and could not specify what day of the week it was. He also reported that he had fallen and hurt his elbows and knees. The RDNS service contacted SAAS who then transported him to the Noarlunga Health Service for review. Once there he had a thorough assessment and was reported as being orientated to time and place.

Mr Cutts was medically cleared and sent home that day.

4.2. The following day it was discovered that he had forgotten how to take his blood glucose level and administer his insulin. A registered nurse visited him at home. He was in a confused state with no memory of the previous day. He was noted to have an increased tremor with a blood pressure of 180/ . He was admitted to the Flinders Medical Centre Emergency Department. The case notes reflect from an early state in the admission that Mr Cutts was acutely confused and was possibly suffering from alcohol withdrawal.

4.3. On 13 May 2015 Mr Cutts reportedly assaulted a nurse. He attempted to leave the ward and when stopped assaulted the same nurse by kicking and punching. A code black was called and he was given risperidone with good effect. The following day Mr Cutts expressed suicidal ideation stating that he wanted to die and that he had had enough.

He was confused and delirious. The delirium continued and appeared to worsen despite medication being increased. The treating team had gathered information from both the RDNS and Mr Cutts' family and established that while Mr Cutts did have some

cognitive deficits, the delirium and acute confusion were new features of his presentation.

4.4. Dr Timothy To was one of Mr Cutts' treating physicians. Dr To stated that underlying the confusion and delirium were suspicions that Mr Cutts' long-term alcohol abuse may have caused damage to his brain. When the confusion started to settle over the course of the admission, Mr Cutts had emerging depressive symptoms which developed into severe depression and associated agitation. A psychiatric review found that Mr Cutts was both acutely suicidal and homicidal. He was placed on an Inpatient Treatment Order for agitated depression. It became clear that major depression was the key issue for Mr Cutts and he was prescribed antidepressant medication.

4.5. On 22 May 2015 the treatment order was lifted but it was reinstated on 25 May 2015 due to Mr Cutts' aggressive behaviour. The treatment order progressed to a Level 2 Inpatient Treatment Order on 1 June 2015. Over the following week to ten days there were a number of code blacks called by nursing staff and medical staff due to Mr Cutts' confused and aggressive behaviour and the Inpatient Treatment Order remained in place.

4.6. On 8 June 2015 Mr Cutts suffered a fall and a seizure. He was found on the floor with the seizure underway and was thought to have aspirated vomit. Mr Cutts was administered midazolam. A CT scan showed no significant bleed or changes. He was transferred to the Intensive Care Unit.

4.7. In accordance with both the wishes of his family and the wishes expressed by Mr Cutts at the time of his admission it was noted that he was not for resuscitation should he deteriorate. While Mr Cutts' condition stabilised in the Intensive Care Unit over the next few hours and he did not require airway support, his Glasgow coma score sharply deteriorated after further seizures and a MET call was initiated. He was given antibiotics, anti-seizure medication and oxygen was administered. He continued to deteriorate and his family agreed to comfort measures only. He died at 1130 hours on 9 June 2015.

5. Conclusions 5.1. In my opinion Mr Cutts’ detention was lawful and appropriate. His medical treatment was entirely satisfactory.

6. Recommendations 6.1. I have no recommendations to make in this case.

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 27th day of July, 2018.

State Coroner Inquest Number 6/2018 (0993/2015)