Coroner's Finding: JONES Melissa Irene

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 5th day of March 2019 and the 8th day of May 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Melissa Irene Jones.

The said Court finds that Melissa Irene Jones aged 45 years, late of 3/66 Lindsay Avenue, Valley View, South Australia died at The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, South Australia on the 19th day of September 2015 as a result of methicillin resistant staphylococcus aureaus (MRSA) endocarditis of the mitral valve with contributing chronic renal failure requiring dialysis. The said Court finds that the circumstances of her death were as follows:

1. Introduction, reason for Inquest and cause of death 1.1. Melissa Irene Jones was 45 years of age when she died at The Queen Elizabeth Hospital on 19 September 2015. At the time of Ms Jones' death she was subject to a Level 2 Inpatient Treatment Order (ITO) that had been made under the Mental Health Act 2009.

Accordingly, Ms Jones' 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.

1.2. An autopsy was carried out and the pathologist gave the cause of death as methicillin resistant staphylococcus aureus (MRSA) endocarditis of the mitral valve with contributing chronic renal failure requiring dialysis1, and I so find.

1 Exhibit C3a

2. Medical history and background 2.1. Ms Jones had a medical history including chronic renal failure, likely related to lithium toxicity. In his report the pathologist commented that Ms Jones' chronic renal failure may have predisposed her to a formation of infected vegetation around her heart as her immune system was already impaired. Once the heart was infected, the bacteria spread throughout Ms Jones' body and this accounted for her progressive deterioration and death.

2.2. Melissa Jones was the daughter of Mrs Christine Jones who vigilantly assisted her daughter with her medical conditions, including attending medical appointments throughout her life and was by her side until the time of her death. Ms Jones had suffered from bipolar disorder since her teenage years. She exhibited symptoms of bipolar disorder from the age of 14 years and was first officially diagnosed when she was 18. Her mother recalls a sharp decline in Ms Jones’ mental health following her father’s suicide when she was 18 years old. Melissa's father also suffered from bipolar disorder.

2.3. In 2015 Ms Jones was diagnosed as suffering stage 5 renal failure secondary to lithium toxicity. Lithium is the preferred choice to medicate bipolar disorder, but it can have toxic side effects. Although Ms Jones was no longer taking lithium in the lead-up to her death, the medication had already damaged her renal system and she was first diagnosed with renal failure in 2004.

2.4. By 2015 Ms Jones required dialysis at least three times per week. For the purpose of dialysis she had an access catheter inserted. An incident involving Ms Jones removing this catheter is likely responsible for the infection that unfortunately would later cause her death.

3. Ms Jones’ detention 3.1. The progression of the renal disease in 2015 saw a destabilisation of Ms Jones' bipolar disorder which had previously been successfully managed in the community. This led to two hospital admissions on the basis that she was presenting as manic and failing to attend for scheduled dialysis. The first was on 17 August 2015 for which she was discharged on 21 August 2015. Her second admission was to the Royal Adelaide Hospital (RAH) 24 August 2015.

3.2. The first period of detention proximate to Ms Jones' death was 17 to 21 August 2015.

On 21 August 2015 Ms Jones was successfully dialysed and her mental health state stabilised. Her treating psychiatrist, Dr Tony Davis, revoked the ITO and discharged Ms Jones.

3.3. The second period of detention under an ITO was initiated by Dr Jonathon Symon at the RAH on 25 August 2015 regarding a mania episode and the requirement for urgent dialysis which Ms Jones had been resisting.

3.4. Whilst at the RAH Ms Jones continued to become progressively agitated and aggressive as a consequence of her psychiatric condition. This caused her to pull out her permacath on 26 August 2015. This is the catheter that had been inserted for the lifesaving dialysis therapy. The catheter needed to be reinserted in theatre. It was decided that because of these actions, Ms Jones was not competent to understand that withdrawing therapy could be fatal.

3.5. On 27 August 2015 Ms Jones was transferred to The Queen Elizabeth Hospital (TQEH) in a closed ward in the Cramond Clinic. This transfer was necessary as Ms Jones required a mental health bed due to her ITO, but also required a hospital with dialysis capacity.

3.6. A Level 2 ITO was imposed on 28 August 2015 by Dr Angela Okungu to ensure that medical treatment could be facilitated. This ITO was confirmed in accordance with the Mental Health Act 2009 and was due to expire on 30 September 2015 at 2pm.

3.7. There had been discussion at the TQEH about removal of Ms Jones’ ITO when she was intubated. However, because Ms Jones would become agitated when sedation was removed, her psychiatrist was unable to safely determine whether the ITO could be removed.

4. Ms Jones’ decline in health 4.1. It was suspected that Ms Jones had developed bacteremia either on 26 or 28 August 2015 as a result of either the removal of the permacath, or from reinsertion of the permacath in surgery. Dr Robert Carroll, consultant for the CALHN Renal and Transplant Services, stated that infections in these lines are common and patients are at risk of developing bacteremia or sepsis even if the permacath has not been tampered

with. He said permacaths are not the preferred option, but there was no other available option for Ms Jones. On 31 August 2015, as a result of a code blue medical emergency involving collapse, Ms Jones was transferred from the psychiatric ward to the ICU at The Queen Elizabeth Hospital where she was commenced on antibiotics.

4.2. On 1 September 2015 Ms Jones was suffering a significant hypertension, difficulty breathing and was febrile, which is all indicative of sepsis. It was necessary for her to be sedated and intubated. By 3 September 2015 it was confirmed that Ms Jones had grown both E. coli and staph aureus in her blood cultures despite the antibiotics prescribed. She became progressively worse despite treatment as the sepsis seeded to her spine, brain, lungs and heart valves. Sedation was necessary because Ms Jones would recurringly become agitated when it was weaned and attempt to remove equipment providing her with treatment.

4.3. The combination of the infection and the renal failure meant that Ms Jones' prognosis was extremely poor. Her condition had not improved despite maximum therapy.

Because of her deteriorating condition discussions regarding a palliative approach to care were commenced on 9 September 2015. This was accepted by Ms Jones' family on 15 September 2015 and although dialysis was continued until 16 September 2015, on 19 September 2015 she died.

5. The coronial investigation 5.1. The circumstances of Ms Jones' death were investigated by Detective Brevet Sergeant Michaela Nash who provided a characteristically excellent report. This report sets out a helpful timeline of events, including the diagnosis and occasion of the death. Of note, Detective Nash concluded that there is little that staff could have done to prevent Ms Jones from removing her permacath, which she did because she wanted to leave hospital to smoke a cigarette. Although the wound was immediately dressed, because of the tampering it became a prime site for infection, and obviously the infection has subsequently caused Ms Jones' death. Once the infection had taken hold there is little that could have been done that was not done to manage Ms Jones' condition.

5.2. The conclusions expressed by Detective Nash are that the care and treatment of Ms Jones by the Royal Adelaide Hospital and The Queen Elizabeth Hospital where she

was detained and ultimately died, were appropriate. She did not identify any deficiency or issues surrounding Ms Jones' care of management whilst a patient. I agree with her conclusions.

5.3. 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 8th day of May, 2019.

State Coroner Inquest Number 9/2019 (1710/2015)