Coroner's Finding: SISSONS Anthony Vincent

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 18th day of December 2017 and the 5th day of February 2018, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Anthony Vincent Sissons.

The said Court finds that Anthony Vincent Sissons aged 38 years, late of St Michael's Rest Home, 494 Fullarton Road, Myrtle Bank, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 24th day of June 2012 as a result of metastatic poorly differentiated carcinoma on a background of delirium and schizoaffective disorder. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Anthony Vincent Sissons died on 24 June 2012 at the Royal Adelaide Hospital. He was 38 years of age. A pathology review was conducted by Dr Iain McIntyre from Forensic Science South Australia. Having regard to Dr McIntyre’s report1, I find the cause of Mr Sissons’ death to be metastatic poorly differentiated carcinoma on a background of delirium and schizoaffective disorder.

2. Reason for Inquest 2.1. At the time of his death Mr Sissons was subject to a Level 1 Inpatient Treatment Order under the Mental Health Act 2009. The original order was instituted by Dr Catherine 1 Exhibit C2a

Chesterman2 on 20 June 2012 and confirmed by Dr Nicholas Adams3 on 21 June 2012.

The order was due to expire on Wednesday 27 June 2012. Accordingly, his 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. Anthony Sissons was one of three children.

3.2. His parents described him as being a lively, active child and a good sportsman. He left school early, not because he was a bad student, but because he wanted to obtain work to keep himself busy. He hated being inside and preferred to be outdoors. He was a hard worker and was always very busy with the work that he was able to obtain, including a short-lived apprenticeship at Repco and truck driving.

3.3. When Mr Sissons was about 18 years old he travelled with his father and grandmother to Fiji following the death of his grandfather. His paternal grandmother had wanted to return to her family in Fiji.

3.4. Mr Sissons clearly enjoyed the lifestyle in Fiji so he made a decision to live there permanently and took up employment in Fiji as a truck driver. He had the support of his extended family, and this seemed like good option for him. Regrettably, about three months after this move, Mr Sissons became mentally unwell.

3.5. Mr Sissons returned home and shortly after was admitted to the Modbury Hospital suffering from psychosis. In July 1993 he was diagnosed with bipolar and schizoaffective disorder. From that point Mr Sissons was in and out of mental health facilities, including Glenside and Hillcrest. He then moved to a number of residential facilities. He was placed on a community treatment order and would receive fortnightly depot injections of anti-psychotic medication. At one point he was undergoing ECG4 to manage his mania. His diagnosis and the frequent hospitalisations were very hard on Mr Sissons and he described to his parents the mental anguish of not being able to work and suffering from a disability.

2 Exhibit C8 - Statement of Dr Chesterman 3 Exhibit C9 - Statement of Dr Adams 4 Electroconvulsive Therapy

3.6. Mr Sissons had been a heavy user of cannabis and methamphetamine, along with alcohol and cigarettes from the age of 18 until about two years prior to his death. He spoke freely of his drug use to anyone that knew him, and often in a detailed way.

Towards the end of 2010 Mr Sissons left supported accommodation to move back home with his parents. His parents were able to assist him in abstaining from illicit substances and alcohol. Regrettably, even though he was abstaining from illicit substances, his mental health issues continued and indeed in some ways were exacerbated.

3.7. In January 2011, following a psychotic episode, Mr Sissons moved to St Michael's Rest Home in Myrtle Bank. His ongoing depot injections and mental health management were overseen by his general practitioner, Dr Owen Watson5. His medications included Clopixol, which was the depot injection, with Lethicar and Seroquel twice daily. He was described as being happy at St Michael's because he had his own room and he liked the people there.

4. Medical history 4.1. Mr Sissons clearly had a lengthy mental health history as set out above. He was compliant with his depot medication at the time of his death.

4.2. Those close to him knew that Mr Sissons would drink at least two litres of milk each day, along with a high volume of soft drink. Apart from that he did not have a strong appetite and would often miss meals. He appeared to have a distended stomach which his friends and relatives attributed to the milk and soft drink consumption.

4.3. A few months prior to his death Mr Sissons complained to his family and those at his accommodation about having a sore back and chronic constipation.

5. The events leading to Mr Sisson’s death 5.1. On Wednesday 13 June 2012 Mr Sissons presented to the Flinders Medical Centre complaining of a two week history of constipation. Upon examination of the abdomen the doctor felt impacted faeces in the lower quadrant, which was compatible with a diagnosis of constipation. Mr Sissons was prescribed Microlax whilst in hospital and 5 Exhibit C15

he passed some stools. He wanted to go home and was given Movicol (laxative) sachets.

5.2. The following day, Thursday 14 June 2012, Mr Sissons presented to his general practitioner with constipation. He said that he had not defecated for three weeks. The general practitioner, Dr Watson, was unaware of the Flinders Medical Centre presentation the day before. Dr Watson examined Mr Sissons and found his abdomen felt normal and it produced normal bowel sounds. He recommended a Microlax enema and he provided a prescription for Movicol.

5.3. On Friday 15 June 2012 Mr Sissons presented to the Royal Adelaide Hospital complaining of constipation for two weeks. Mr Sissons was seen by Dr Angela Chang6.

Dr Chang was aware of the Flinders Medical Centre visit, but she was unaware of the general practitioner visit. Her initial assessment was either a diagnosis of constipation or a bowel obstruction. Dr Chang conducted an examination and ordered some abdominal X-rays. These did not show any evidence of a bowel obstruction and a diagnosis of constipation was made.

5.4. Mr Sissons was given several enemas and when these had no effect he was given a dose of GoLytely. This also had no effect on his bowel movement. Mr Sissons was discharged and given Coloxyl with Senna and sorbitol to take home. He was advised to return should symptoms persist or if the pain became worse.

5.5. On Saturday 16 June 2012 the South Australian Ambulance Service responded to a call made by Mr Sissons. Daniel Siddons7 who was a paramedic intern, noted Mr Sissons to be complaining of abdominal pain, but he was not specific in his complaint.

Mr Sissons was described as ranting and inconsistent, but insistent on getting pain relief. He was told that he would have to go to hospital in order to obtain pain relief, but Mr Sissons refused citing the fact that he had already attended at the hospital and the doctors had done nothing.

5.6. The following day, Sunday 17 June 2012, Mr Sissons again attended at the Royal Adelaide Hospital. Further investigations were conducted and a complex renal kidney 6 Exhibit C6 7 Exhibit C10

mass was discovered. Dr Coventry, Associate Professor of Surgery, oversaw these investigations.

5.7. On 19 June 2012 Mr Sissons was informed of a need for further testing to investigate this potential malignant cancer. It was news that he did not react well to. Whether because of his diagnosed mental health issues or the effects of his aggressive cancer, Mr Sissons became progressively thought disordered, erratic and aggressive and refused medical investigations. A code black was called as Mr Sissons' behaviour was considered to be dangerous to both himself and those around him. He was required to be shackled to his bed and a security guard was assigned to his room.

5.8. On 20 June 2012 Mr Sissons was placed on a Level 1 Inpatient Treatment Order by Dr Chesterman, Psychiatric Registrar at the Royal Adelaide Hospital. She concluded that Mr Sissons was suffering from a significant medical illness that required further inpatient investigation, as well as lithium toxicity, possibly due to dehydration from renal impairment.

5.9. The Inpatient Treatment Order was confirmed on 21 June 2012 by Dr Nicholas Adams, Senior Psychiatrist at Eastern Mental Health and a Consultant Psychiatrist at the Royal Adelaide Hospital. It was Dr Adams' assessment that Mr Sissons' decision not to cooperate was influenced by paranoia, and that he was likely to be impulsive. The Inpatient Treatment Order was confirmed to ensure that he could have adequate investigation and appropriate treatment.

5.10. Investigations into Mr Sissons' organic complaint progressed and on 22 June 2012 CT scans were reviewed by Dr Coventry confirming a large aggressive renal tumour invading into the liver with extensive omental caking and peritoneal thickening involving the tissues around the bowel. A biopsy showed malignant cells. When Mr Sissons' was told this news, he reacted with relief in knowing that he had cancer.

This was in contrast to his previously adverse reaction to the early diagnostic information.

5.11. Mr Sissons made a request that he not be for resuscitation and this was confirmed by his family. Family discussions concluded that Mr Sissons was unlikely to agree to any intensive therapy and it was agreed that he receive palliative care to help with pain management and nausea.

5.12. There were a number of other code black calls regarding Mr Sissons during his detention at the Royal Adelaide Hospital as he was displaying increased violence and agitation. He was verbally abusive and disruptive to other patients despite the presence of a security guard and a special nurse assigned for his care. He would place his fingers down his throat to make himself vomit and he pulled his morphine line out. He assaulted a nurse requiring the nurse to attend for a shoulder X-ray. There were attempts to control Mr Sissons with medication, including morphine, clozapine and clonazepam, a tranquiliser of the benzodiazepine class, however these did not provide the necessary sedative effect.

5.13. As a consequence it was necessary that he be shackled. The shackles were removed from Mr Sissons in periods when he slept, but they needed to be reinstated upon waking as he became acutely agitated and violent.

5.14. Mr Sissons’ condition deteriorated and he died at 11:50am on 24 June 2012.

6. The investigation into Mr Sissons’ death 6.1. Given the advanced nature of the cancer suffered by Mr Sissons it is unlikely that the outcome would have been different if his condition had been diagnosed 11 days earlier when he attended at Flinders Medical Centre. In the circumstances, a diagnosis at that stage was not to be expected. No criticism should be made of the staff at Flinders Medical Centre, nor of Mr Sissons’ General Practitioner for missing the real problem.

It is plain that Mr Sissons experienced a very swift decline upon the diagnosis.

Unfortunately, the mental health difficulties that Mr Sissons suffered from made him a very poor historian.

6.2. Mr Sisson’s father attended the hearing, and made a suggestion for people in the same position as his son. He suggested that it might be possible for people who are subject to community treatment orders to have additional tests that could be put forward when they are having their lithium levels or their medication levels checked periodically. He acknowledged that this would come at a cost to the public health system. He offered a useful example concerning his own involvement in a medical research trial. He said that as a result of volunteering to participate, he underwent a blood test, and he was rejected from the trial. His results were sent to his general practitioner as a result of which he was referred to a haematologist. He was diagnosed with an indolent myeloma.

The point he was making was that opportunities for spotting anomalies might arise in

the course of the routine tests carried out upon people subject to community treatment orders.

6.3. Mr Sissons’ father pointed out that people such as his son are fearful, often paranoid or under the influence of alcohol and other drugs, and they are prone to ‘fall through the cracks’. He very graciously acknowledged all of the good efforts that were done on his son’s behalf. I think that his suggestion, coming as it does from the father of a man such as Mr Sissons, deserves to be considered. Accordingly, I propose to forward this finding to the Minister for Mental Health to consider Mr Sissons’ father’s suggestion.

7. Recommendations 7.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Psychiatric/Mental Illness; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 5th day of February, 2018.

State Coroner Inquest Number 17/2017 (0999/2012)