Coroner's Finding: TAEGER Luke Victor

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 November 2019 and the 3rd day of December 2019, by the Coroner’s Court of the said State, constituted of Elizabeth Ann Sheppard, Deputy State Coroner, into the death of Luke Victor Taeger.

The said Court finds that Luke Victor Taeger aged 89 years, late of Kalyra McLaren Vale Aged Care, 19 Aldersey Street, McLaren Vale, South Australia died at the Flinders Medical Centre, Bedford Drive, Flinders Park, South Australia on the 11th day of January 2016 as a result of pneumonia on a background of advanced Parkinson’s disease and dementia. The said Court finds that the circumstances of his death were as follows:

1. Reason for inquest 1.1. Luke Victor Taeger was born on 16 January 1926 and died at the Flinders Medical Centre on 11 January 2016, aged 89 years and 11 months.

1.2. Mr Taeger was admitted to the Flinders Medical Centre on 8 January 2016 after his behaviour proved too difficult for staff at Kalyra Aged Care to manage.

1.3. At the time of death, Mr Taeger was subject to an Inpatient Treatment Order (ITO).

1.4. Because Mr Taeger died in custody, an inquest is mandatory pursuant to the Coroners Act 2003.

2. Cause of death 2.1. A pathology review was conducted by Dr Iain McIntyre1 of Forensic Science South Australia, which described the cause of death as pneumonia on a background of 1 Exhibit C2a

advanced Parkinson's disease. I accept Dr McIntyre’s opinion as to the cause of death, but with the inclusion of a reference to dementia.

2.2. I find that the deceased’s challenging behaviours, including delirium, agitation and aggression, required sedation to manage him. He developed a form of aspiration pneumonia which led to respiratory failure and death.

2.3. According to Dr McIntyre, Mr Taeger’s presentation to hospital required both chemical and physical restraint. During his admission, he was found to have bilateral pneumonia which failed to respond to treatment.

2.4. Ultimately a decision was taken to move to palliative care where Mr Taeger was kept comfortable until his death shortly after.

2.5. Proof of identification is satisfied by the affidavit from Mr Taeger's son, Claude Taeger.

The affidavit provides helpful background which I accept explains his father’s gradual deterioration towards the end of his life2.

3. Background 3.1. Mr Taeger moved permanently into the Kalyra Aged Care facility at McLaren Vale on 14 February 2014 after he struggled to live independently at home. His wife, who suffered from dementia, had moved to the same facility in 2012 and was still there when Mr Taeger died.

3.2. In about mid-2015, Claude Taeger observed a deterioration in his father’s mental state.

3.3. According to the treating general practitioner who managed Mr Taeger at Kalyra, his mental health started to deteriorate noticeably in September 2015. Dr Andrew Ryan appropriately screened him for urinary infection which was ruled out as a possible cause of his changed behaviour3.

3.4. According to Dr Ryan, a diagnosis of dementia was later made in consultation with the Older Persons Mental Health Services. Dr Ryan considered that Kalyra was unable to cope with Mr Taeger’s behavioural issues and therefore had little choice about transferring him to an acute hospital.

2 Exhibits C1a and C1b 3 Exhibit C6

3.5. It is difficult to gauge from the materials in this inquest whether Dr Ryan was in a position to advocate for an urgent consult with a geriatrician when matters were escalating towards the end of December 2015.

3.6. Mr Taeger’s behaviour was becoming increasingly disruptive and distressing to other residents.

3.7. Staff often struggled to get him to take prescribed medications, which included Thyroxine, Oxazepam, Sertraline, Risperidone, Mirtazapine and Sodium Valproate.

3.8. Following discussions with staff, Claude Taeger agreed to attend a meeting at the nursing home on 12 January 2016 to discuss his father's care, however events which saw his father transferred to hospital meant that the meeting never took place.

4. Lead up to admission to Flinders Medical Centre 4.1. By 27 December 2015, Mr Taeger’s level of agitation, non-compliance and aggression had worsened to the point where an ambulance was called about 2am the next morning.

4.2. The ambulance crew took Mr Taeger to the Noarlunga Health Services’ Emergency Department. By reference to the records, it had been noted that Mr Taeger was ‘not for resuscitation and not for transfer to hospital’4.

4.3. The ambulance service had been called previously for similar episodes, but staff had usually been able to calm Mr Taeger down by talking to him, thereby avoiding a transfer.

4.4. This time, when the ambulance crew arrived, Mr Taeger was compliant with them and was also compliant with staff at the Noarlunga Emergency Department5. His respiratory examination was said to show ‘normal airway, normal breath sounds and no tenderness’. He was returned to Kalyra at 9:42am the same day, 28 December 2015.

4.5. According to Kate Hocking, Acting Director of Care at Kalyra, Mr Taeger became very aggressive during the afternoon of 7 January 20166.

4 Exhibit C10 5 Exhibit C10 6 Exhibit C7

4.6. The case notes from Kalyra indicate that Mr Taeger was given 7.5mg of Alepam and Risperidone with minimal effect until about 90 minutes had passed. By about 5am on 8 January 2015, Mr Taeger’s agitation had worsened and he refused his medication. He posed potential risks to himself and others by yelling angrily at staff and demanding to go through doorways where there were hazardous chemicals and other items. Staff struggled to cope with the demands, but did not think it necessary to call for medical assistance during their overnight shift7.

4.7. It appears that the following day, Acting Director at Kalyra telephoned Claude Taeger to update him about his father’s escalating behaviour and to inform him that an additional carer would be rostered on exclusively for that purpose.

4.8. Meanwhile, a decision was taken by Acting clinical nurse Patricia Perkins to arrange for a hospital transfer. One of the reasons noted to justify this decision was the unavailability of a geriatrician review until 18 January 20168. In the circumstances, it might have been prudent for the specialist to have been contacted days earlier on a more pressing basis to expedite this review, although it is unclear on the documents whether that was an available option.

5. Mr Taeger’s presentation to Flinders Medical Centre (FMC) 5.1. At his initial medical assessment at FMC, on 8 January 2016 at 5:15pm, Mr Taeger was described as ‘pleasantly confused’. I note that a physical examination revealed bilateral respiratory crackles. He was commenced on oxygen and intravenous antibiotics9.

5.2. By about 10pm, Mr Taeger was said to have lashed out at a security guard who had been in attendance since his admission. A code black was called leading to the attendance of Dr Crabbe. At 10:21pm on 8 January 2016, a Level 1 ITO10 was authorised by Dr Crabbe which was due to expire by 2pm the following day, 9 January 2016.

5.3. According to the affidavit of Dr Vincent Siaw11, Mr Taeger presented to the Acute Medical Unit in a physically and verbally aggressive state. I accept that a justifiable 7 Exhibit C13 8 Exhibit C13 9 Exhibit C11 10 Exhibit C10a, MD1 11 Exhibit C4

decision was taken to restrain Mr Taeger to enable staff to treat him. I am satisfied that the decision was taken with an appropriate knowledge of the health risks involved.

5.4. I find that it was prudent and appropriate to have a ‘nurse special’ allocated to monitor Mr Taeger on a continuous 24 hour per day basis to mitigate the risks whilst he was subject to either physical or chemical restraint.

5.5. Dr Charoenporn, was the consultant psychiatrist at FMC who confirmed the Level 1 ITO at 4pm on 9 January 2016, which meant that it would remain in place for 7 days until 15 January 201612. According to Dr Charoenporn, Mr Taeger was in a state of delirium and still at risk of aggression.

6. Medical and nursing care during Flinders Medical Centre admission 6.1. Mr Taeger was admitted to the Acute Care of the Elderly Unit at FMC. By the time he was reviewed by Dr Siaw later that day, Mr Taeger was heavily sedated and difficult to rouse. He was showing signs of pneumonia with gurgling sounds consistent with aspiration which is common in elderly sedated patients. This, according to Dr Siaw, is due to a loss in functioning of the protective reflexes in the airway.

6.2. From this point Mr Taeger was hydrated only with intravenous fluid and given antibiotics to treat the pneumonia until further review13.

6.3. When Claude Taeger visited his father at the FMC on 10 January 2016 he saw him behaving somewhat aggressively. He was resistant towards staff and trying to remove his oxygen mask. During this time, there was continual special nursing support in place14.

6.4. At a medical review noted in the case notes at 8:15pm on 10 January 2016, Mr Taeger was drowsy. There was obvious concern that his respiratory depression was secondary to over sedation. Nurses were instructed to make a MET call if there was any further deterioration.

6.5. Later that evening, Mr Taeger became aggressive again and appeared very confused.

When his respiratory system began to fail, two emergency calls (MET) were made and 12 Exhibit C5, MD3 13 Exhibit C4 14 Exhibit C3

responded to by intensive cardiac care unit (ICCU) medical practitioners. A decision was made after the first call at 9:30pm, in telephone consultation with Dr Gieroba, to change the antibiotics and consider admission to ICCU for invasive medical intervention.

6.6. The second MET call resulted in the staff reaching a different position in consultation with Dr Gieroba. At about 12:30am on 11 January 2016, Claude Taeger was updated on his father’s condition and he agreed to adopt a palliative plan which would have the shackles removed and treatment stopped, with the exception of oxygen therapy only if tolerated.

6.7. According to the special agency nurse caring for Mr Taeger, the oxygen mask was abandoned. It was replaced with nasal prongs which Mr Taeger tolerated without resistance. He appeared to remain calm and comfortable until his breathing stopped shortly after 1:15am. Mr Taeger was pronounced deceased at 1:22am by a medical practitioner.

6.8. Claude Taeger makes it plain that he has no criticisms of the level of care provided to his father at Kalyra and also the Flinders Medical Centre.

7. Expert overview 7.1. Due to the use of sedation and restraints upon admission to FMC, and the rapid decline and death which followed, a review was requested from Professor Gregory Crawford, a professor of palliative medicine at the University of Adelaide and currently the president of the Australasian Chapter of Palliative Medicine for the Royal Australasian College of Physicians.15

7.2. Professor Crawford summarised the lead up to Mr Taeger’s hospital admission in his report. It was acknowledged that clear plans were communicated with staff at Kalyra to attempt to de-escalate aggression and to minimise confrontation with Mr Taeger.

Support was provided also from the Rapid Access psychiatric community team, Noarlunga Health Services Emergency Department community geriatric team and South Australia police before Mr Taeger was admitted finally to FMC.

15 Exhibit C8a

7.3. In the Professor’s opinion, the doses of medications prescribed to Mr Taeger had been ‘consistent with current evidence-based practice, albeit at the lower end of the range’.

It was considered that there was a timely and appropriate response to the escalation of Mr Taeger’s behaviours.

7.4. Professor Crawford considered that the quality of the documentation of Mr Taeger at Kalyra was excellent and the day to day pharmacological management appeared to be good.

7.5. The making of treatment orders at FMC were justified according to Professor Crawford and the use of restraints and medication were consistent with current best practice.

7.6. Professor Crawford considered that the documentation supported a finding that an appropriate and proportionate use of restraints and medication was the intention of the medical management. According to Professor Crawford, Parkinson’s Disease and dementia were likely to contribute to the loss of safe swallowing which, apart from the added effects of sedation, would predispose Mr Taeger to aspiration regardless.

7.7. The only criticism which in Professor Crawford’s view might be made was concerning whether it ought to have been recognised at FMC at an earlier stage that Mr Taeger was likely to die during the admission. Had he been assessed by a treating consultant physician, it may have enabled the family to be forewarned earlier that his condition was likely to be terminal. That might have altered the focus of his management and earlier acceptance of the palliative care model.

7.8. As to whether Mr Taeger’s death could have been prevented, the Professor expressed the following opinion: ‘Mr Taeger had an illness that was inevitably going to cause the end of his life. The way his condition unfolded with difficult aggression made his care challenging. There is clear evidence of appropriate and timely assessments and interventions to try to manage his needs. I believe that aspiration pneumonia was highly likely because of his neurodegenerative disease, Parkinson’s disease, his progressive dementia and the need for medication to manage the aggression that has a recognised side-effect of some sedation.

There is no evidence that the intention was just sedation, but on the contrary, a clear plan to minimise the risk of sedation and to maximise the benefits of interventions both pharmacological and non-pharmacological is outlined.’

7.9. I accept the opinions expressed by Professor Crawford.

8. Recommendations 8.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Natural Causes; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed her hand and Seal the 3rd day of December, 2019.

Deputy State Coroner Inquest Number 0077/2016 (37/2019)