Coroner's Finding: DILETTOSO Giuseppe

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 4th day of May 2016 and the 8th day of February 2018, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Giuseppe Dilettoso.

The said Court finds that Giuseppe Dilettoso aged 79 years, late of Salisbury Private Nursing Home, 147 Frost Road, Salisbury, South Australia died at Salisbury, South Australia on the 20th day of May 2014 as a result of aspiration pneumonia. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mr Giuseppe Dilettoso was 79 years of age when he died on 20 May 2014. He died at the Salisbury Private Nursing home (the facility) where he was a resident.

1.2. Dr Ching Thim Chow who was Mr Dilettoso’s visiting general practitioner at the facility has stated in a witness statement1 that Mr Dilettoso’s cause of death was aspiration pneumonia. I find that to have been the cause of his death. His clinical circumstances as described in the statements of nursing staff tendered to the Court support that diagnosis.

2. Reason for Inquest 2.1. At the time of his death Mr Dilettoso was the subject of a detention order pursuant to section 32 of the Guardianship and Administration Act 1993. This order had been imposed by the Guardianship Board of South Australia in circumstances that I will 1 Exhibit C4a

describe presently. As a result of that order Mr Dilettoso was detained in the facility.

He died in that facility whilst detained. Accordingly, Mr Dilettoso’s death was a death in custody for which a mandatory Inquest was required. These are the findings of that Inquest.

3. Background 3.1. According to the statement of Mr Dilettoso’s son, Mr Alex Dilettoso2, in 2000 his father suffered a fall in a hotel. As a result he was admitted to the Royal Adelaide Hospital (RAH). Mr Dilettoso had suffered an internal head injury for which he was treated in the Intensive Care Unit of the hospital. It appears from Mr Alex Dilettoso’s statement that the injury had been life threatening but that ultimately his father had survived.

After some months his father appeared to be back to normal.

3.2. From 2000 until 2011 Mr Alex Dilettoso did not observe any ill effects in respect of his father’s well-being. However, from about 2011 he saw signs that his father ‘was letting a few of the basic things go, but not completely’3. Mr Alex Dilettoso could still hold a conversation with his father who was still managing his own affairs, but it appeared that he was starting to let himself go particularly with personal hygiene and nutrition.

Mr Alex Dilettoso expresses the view that his father was beginning to exhibit signs of dementia which he thought may have been the result of his fall in 2000.

3.3. In March 2013 Mr Dilettoso had another fall in which he again suffered an internal head injury. It appears that on this occasion members of the public had found Mr Dilettoso unconscious on the pavement. In the first instance he had been taken to the Lyell McEwin Hospital and had subsequently been transferred to the RAH. At the RAH a CT scan confirmed fractures to the skull. Mr Dilettoso underwent emergency surgery that involved the removal of part of his skull and the removal of an underlying blood clot on the brain. He had sustained damage to his brain in the form of contusions to the frontal lobe. There was also old damage seen in the temporal lobe on the right hand side of the brain which was believed to have been the result of the injury sustained in 2000.

3.4. Following Mr Dilettoso’s discharge from the RAH he underwent a period of six weeks rehabilitation at the Hampstead Centre. Mr Dilettoso’s progress at the Hampstead 2 Exhibit C7 3 Exhibit C7, page 6

Centre is described in the statement of Dr Maria Paul who is a Consultant in rehabilitation medicine at the Centre. Dr Paul’s comprehensive and detailed statement4 describes a somewhat stormy and unsuccessful rehabilitation. Mr Dilettoso’s attempted rehabilitation was complicated by his mental condition and dementia and by a general inability to effectively participate in his rehabilitation. He had several falls at the Hampstead Centre and exhibited other unsafe and inappropriate behaviours. He constantly attempted to escape, thereby setting off the alarm and disturbing other patients. He was tried on various medications. In due course it became obvious that Mr Dilettoso was not making any progress in rehabilitation and that his dementia presentation was not improving. This meant that he would need to be looked after in a nursing home environment and be provided with the type of care that such a facility could provide.

3.5. Mr Dilettoso was assessed for suitable nursing home care. Complicating matters was that Mr Dilettoso had to be maintained on a soft diet and thin fluids because he was at risk of choking or aspiration. This was due to weak swallowing muscles and the fact that due to poor attention and poor learning skills he was unable to learn the strategies required to prevent choking when swallowing food.

3.6. Thus it was arranged with Mr Alex Dilettoso that Mr Dilettoso would be placed into a nursing home for constant care.

3.7. In his statement Mr Alex Dilettoso confirms that his father was required to leave the Hampstead Centre because doctors there had classified him as a person who required the high level of care that the Hampstead Centre could not provide. He was informed that his father’s condition was not going to improve. In the event, within a very short period of time the Hampstead Centre was able to arrange accommodation for Mr Dilettoso at the Salisbury Nursing Home. Mr Alex Dilettoso was content for his father to be accommodated at that facility as his mother had been accommodated there previously.

3.8. It was in those circumstances that the application was made to the Guardianship Board of South Australia for orders that placed Mr Dilettoso under the guardianship of his son. As well, the orders for detention were imposed by the Board. Thus it was that Mr Dilettoso was detained at the facility for his protection. The orders were imposed 4 Exhibit C6

on 22 August 2013. The section 32 powers of detention were in the process of being reviewed at the time of his death.

3.9. Mr Dilettoso entered the facility on 2 August 2013 and this was where he would remain until his death.

4. Mr Dilettoso’s decline and ultimate death 4.1. Mr Dilettoso’s decline was well documented. It is also the subject of detailed evidence that was tendered to this Court. Mr Alex Dilettoso states that during his father’s period of accommodation at the facility he noticed a decline in his father’s health. Although his father could still hold a conversation, he would go off on tangents. He required care with personal hygiene and toileting. Mr Alex Dilettoso states: 'The staffs at the nursing home were good and would contact me of any falls, colds or infections. I was asked by the nursing home if I wanted a do not resuscitate clause if dad took a turn for the worst, which I did as I had the same issues with my mum when she passed.' 5

4.2. Mr Dilettoso’s doctor was Dr Chow to whom I have already referred.

4.3. Mr Dilettoso died in the early hours of the morning of 20 May 2014. He died peacefully in bed. His death was expected.

5. Conclusions 5.1. Mr Dilettoso’s death was thoroughly investigated and reported on by investigating police. I agree with the conclusion expressed by Senior Constable First Class Anthony Gough of the Elizabeth CIB that no deficiency in the care and attention afforded to the deceased whilst at the Hampstead Centre, the RAH, the Lyell McEwin Hospital or the Salisbury Private Nursing Home, nor by treating doctors throughout his residency at the nursing home, have been identified. Senior Constable Gough concluded that the care of the deceased, in particular at the nursing home, was more than appropriate. The evidence would demonstrate that this conclusion is correct and I so find.

5 Exhibit C7, page 5

5.2. Mr Dilettoso’s guardianship, residence and detention imposed by virtue of the Guardianship Board orders was highly appropriate. His circumstances of detention did not contribute to his death.

6. Recommendations 6.1. There are no recommendations to be made in this matter.

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 8th day of February, 2018.

Deputy State Coroner Inquest Number 19/2016 (0831/2014)