Coroner's Finding: CREEPER Lindy Jayne

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 March 2019 and the 14th day of May 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Lindy Jayne Creeper.

The said Court finds that Lindy Jayne Creeper aged 54 years, late of 1/6 Ellard Street, Mount Gambier, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 4th day of May 2016 as a result of malignant melanoma with brain metastases. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for Inquest 1.1. Ms Lindy Jayne Creeper died on 4 May 2016 at the Royal Adelaide Hospital. She was 54 years of age. The cause of death at pathology review was malignant melanoma with brain metastases1, and I so find.

1.2. At the time of her death Ms Creeper was the subject of a Level 2 Inpatient Treatment Order (ITO) under the Mental Health Act 2009 and accordingly hers 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.

1 Exhibit C2a

2. Background and medical history 2.1. Ms Creeper had lived in Mount Gambier for over two decades. She had one daughter who also lived in Mount Gambier. She was employed as a security guard at the Mount Gambier Hospital.

2.2. On 11 September 2012 Ms Creeper underwent surgery for the excision of a right leg melanoma and sentinel lymph node biopsy at the Mount Gambier Hospital.

2.3. Three years later on 17 November 2015 a CT scan confirmed enlarged lymph nodes requiring further investigation. This revealed large nodes in her groin and femoral canal requiring surgery. Ms Creeper was told by her doctor that the melanoma she had removed from her leg in 2012 had spread to her lymph nodes and that this was an incurable disease.

2.4. Ms Creeper had the surgery and as there was extensive melanoma she was referred for radiotherapy. Her daughter noticed her mother's memory was affected. She attributed this at the time to the surgery and the medication she had been placed on following the procedure.

2.5. In April 2016 Ms Creeper commenced the first of 20 fractions of adjuvant radiotherapy at the Adelaide Radiotherapy Centre. She stayed at the Greenhill Lodge which is a Cancer Council accommodation in Adelaide.

3. Ms Creeper’s detention 3.1. On 22 April 2016 at 0857 hours Ms Creeper was found incoherent and confused, dressed only in her underwear outside of her room at the Greenhill Lodge. She was conveyed to the Royal Adelaide Hospital by ambulance where she was admitted for examination. CT scans revealed evidence of intracranial metastases suspected to be melanoma. Attempts to investigate further and to provide treatment were hampered by Ms Creeper's agitation and level of distress.

3.2. In order to advance the investigations and treatment and to provide Ms Creeper some comfort, she was detained on a Level 1 ITO under the Mental Health Act 2009 by an intern in the medical oncology unit at the Royal Adelaide Hospital at 1640 hours on 22 April 2016. The confirmation of the Level 1 order was signed by the on-call consultant psychiatrist, Dr Bernard Baune, at 0941 hours the following day.

3.3. Dr Baune found her to be confused, disoriented to person, time, place and agitated.

Ms Creeper reportedly told Dr Baune she wanted to leave the ward and it was for that reason that he confirmed the ITO.

3.4. Over the next six days Ms Creeper's condition did not improve and the case notes reflect that she continually tried to leave the ward. There were multiple code blacks over this period, primarily to stop Ms Creeper from leaving the hospital.

3.5. Unfortunately in Ms Creeper’s case it was not possible to control the intracerebral metastases. There were a few other possible treatments for Ms Creeper, but they all required her cooperation and ability to remain still during the course of the treatment.

Due to her level of agitation this could not be achieved. Ms Creeper was placed on some steroidal medication to bring down the swelling and fluid on her brain, but this then contraindicated the use of other medication.

3.6. During her admission and until the day of her death, Ms Creeper remained untreatable due to her clinical status. In my opinion the need for the ITO was obvious. Ms Creeper was in a state of agitation throughout the period and up to just hours prior to her death.

Medical and pharmaceutical options were explored to address the swelling, however this was not able to be achieved with any level of success. Ms Creeper died at the Royal Adelaide Hospital on 4 May 2016 at 3pm.

4. Conclusion 4.1. In my opinion the care provided by the Royal Adelaide Hospital oncology department was appropriate and the Inpatient Treatment Orders were necessary to manage Ms Creeper's level of agitation due to her advanced disease.

4.2. I have no recommendations to make in this matter.

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 14th day of May, 2019.

State Coroner Inquest Number 15/2019 (0819/2016)