Coroner's Finding: EVANS Wendy Marion

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 24th day of May 2017 and the 29th day of March 2018, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Wendy Marion Evans.

The said Court finds that Wendy Marion Evans aged 76 years, late of no fixed abode died at the Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 23rd day of June 2015 as a result of end-stage liver failure with encephalopathy due to hepatic cirrhosis. The said Court finds that the circumstances of her death were as follows:

1. Introduction 1.1. Wendy Marion Evans was 76 years old when she died on 23 June 2015. She died at the Repatriation General Hospital at Daw Park. Her cause of death was established by way a pathology review conducted by Dr Iain McIntyre of Forensic Science South Australia. A post mortem examination was not required. Dr McIntyre expresses the cause of death as end stage liver failure and encephalopathy due to hepatic cirrhosis. I find that to have been the cause of Ms Evans’ death.

1.2. At the time of her death Ms Evans was the subject of a Level 2 Inpatient Treatment Order (ITO) that had been imposed pursuant to the Mental Health Act (the Act). On 9 February 2015 Ms Evans had been detained by police in Murray Bridge. She had been acting strangely and wandering in and out of shops. Pursuant to section 57 of the Act police took Ms Evans into their care and control and conveyed her to the Murray Bridge Hospital for her to be psychologically assessed.

1.3. At the hospital Ms Evans was assessed and diagnosed as suffering from acute psychosis. She was deluded and paranoid. As a result she he was initially detained on a Level 1 ITO. Following liaison with the Elderly Mental Health team, arrangements were made to have her transferred to the Flinders Medical Centre (FMC). Ms Evans arrived at the FMC on 9 February and was examined again. On 10 February 2015 her Level 1 ITO was confirmed by psychiatrist, Dr Randall Long. Later that day Ms Evans was transferred to the Repatriation General Hospital (RGH). A CT scan that was conducted while Ms Evans was an inpatient at the RGH revealed extensive clinical vascular disease in her brain. This explained her general condition and erratic behaviour.

1.4. On 16 February 2015 Dr Christopher Veale, a consultant psychiatrist, examined Ms Evans. At that time her Level 1 ITO was about to lapse. Ms Evans’ mental condition had not improved. As a result Dr Veale imposed a Level 2 ITO. This would expire on 23 March 2015. Psychologically, Mrs Evans had little or no insight into her own behaviour.

1.5. Ms Evans' physical condition was also declining with the detection of severe liver disease and the contraction of norovirus.

1.6. By the time the Level 2 ITO was due to expire, Ms Evans was suffering acute liver failure and was being palliated. For that reason the ITO was allowed to lapse. However, following an assault on a doctor who was attending to her, on 19 May 2015 another Level 1 ITO was instituted. This order was confirmed by Dr Veale on 20 May 2015.

Upon it lapsing on 26 May, Dr Veale instituted a second Level 2 ITO. On 23 June 2015 Ms Evans died during the currency of that order. For that reason this was a death in custody in respect of which an Inquest was mandatory. These are the findings of that Inquest.

1.7. Prior to the events of February 2015 Ms Evans is understood to have been living in a caravan that was parked in a privately owned paddock near Murray Bridge. She had no previous medical records when she came to hospital, no Medicare number, no driver’s licence and no known family. For those reasons no medical history pre-dating her hospital admission was known by staff. Ms Evans had lived a reclusive lifestyle for many years.

1.8. Since these events it has been established that Ms Evans had been born in New Zealand and had come to Australia in the 1960s. She had initially lived in Sydney where she had met and married. The marriage broke down quickly. Ms Evans then returned to New Zealand where she met another man who originated from South Australia. They were married and moved to South Australia. Following the breakdown of that marriage Ms Evans remained in South Australia. She apparently acquired a caravan and lived in it from the 1980s until she was taken to hospital by police in February 2015.

1.9. Ms Evans was reportedly a very private person. This was exemplified, among other things, by her reluctance to register for Medicare, her refusal to use banks or ATMs.

1.10. Through the course of her approximately four month hospital admission in 2015, she was diagnosed with extensive clinical vascular disease, akin to what would be found in a person suffering from dementia. She displayed symptoms of perseveration which involves the repetition of words. This was highly suggestive of frontal lobe damage.

At times she would refuse food and drink on the basis of her stated belief that hospital staff might have put something in it.

1.11. Ms Evans also displayed severe ataxia when walking. This was indicative of damage to the cerebellum and provided an explanation for her erratic behaviour and condition.

She was considered to be untreatable. It was thought that this condition alone would eventually cause her death. However, in conjunction with that condition Ms Evans was also diagnosed as suffering from severe cirrhosis of the liver. As her liver function deteriorated she began to suffer abdominal pain and bloating with water retention. She then contracted norovirus which is a viral gastroenteritis causing her further medical complication. There is no evidence that these conditions were caused by excessive consumption of alcohol. When her caravan was searched by police no evidence of alcohol consumption was identified.

1.12. On 1 March Ms Evans entered acute renal failure. She was transferred to the intensive care unit. By mid-May her condition had still not improved. It was expected that she would eventually succumb to her illness. Ultimately Ms Evans died peacefully in her sleep while under a palliative care regime.

1.13. The investigating officer, Detective Brevet Sergeant Peter Graves of Sturt CIB, reports no concerns or issues regarding the medical treatment that Ms Evans had received at the hands of many practitioners. His investigation has established that from the time

she was detained by police in Murray Bridge to her ultimate death she received excellent care. It is hard to disagree and I so find.

1.14. Ms Evans’ custody pursuant to the Mental Health Act was both lawful and appropriate.

Her custodial circumstances did not contribute to her death. On the contrary, it ensured that she received the best of care.

1.15. The Court does not make any recommendation arising out of this matter.

Key Words: Death in Custody; Natural Causes; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 29th day of February, 2018.

Deputy State Coroner Inquest Number 13/2017 (1086/2015)