Coroner's Finding: ALLEN Wendy Elizabeth

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 May and the 3rd day of November 2020, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Wendy Elizabeth Allen.

The said Court finds that Wendy Elizabeth Allen aged 75 years, late of Estia Health, 7 Lancelot Drive, Daw Park, South Australia died at Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 22nd day of October 2017 as a result of general inanition and pneumonia on a background of end-stage dementia. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Wendy Elizabeth Allen was born on 24 January 1942 and died on 22 October 2017 at the Repatriation General Hospital in Daw Park. She was 75 years old. Mrs Allen’s body was identified by her daughter Nyree Spencer.1

1.2. A pathology review of Mrs Allen’s clinical history and medical records was undertaken by Dr Iain McIntyre in discussion with Dr Karen Heath, forensic pathologist, at Forensic Science South Australia. In his report Dr McIntyre provided an opinion as to the cause of death being general inanition and pneumonia in a woman with end-stage dementia.2 I find the cause of Mrs Allen’s death to be general inanition and pneumonia on a background of end-stage dementia.

1 Exhibit C1 2 Exhibit C2

1.3. Mrs Allen’s death was the subject of a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mrs Allen had been detained on an Inpatient Treatment Order (ITO) at the time of her death. A Level 1 ITO had been imposed pursuant to Section 21 of the Mental Health Act 2009. It was instituted by Dr Burch on 17 September 2017 following Mrs Allen’s admission to the Flinders Medical Centre (FMC). The ITO was confirmed by Dr Long on 18 September 2017 as a result of Mrs Allen’s aggressive behaviour and was due to expire on 22 September 2017.3

1.4. On 19 September 2017 Mrs Allen was transferred from the FMC to the Repatriation General Hospital.4 On 22 September 2017 Dr Christopher Veale imposed a Level 2 ITO. It had been noted that Mrs Allen had a history of repeated stroke related dementia and that she was suffering from delirium. Mrs Allen was acting aggressively towards nursing staff and refusing care. She was confused and extremely disorientated.

Mrs Allen required continuing inpatient care and management due to her aggression towards staff.5

1.5. The Level 2 ITO was reviewed and confirmed by senior consultant psychiatrist, Dr Richards Weeks, who agreed with the diagnosis of end stage dementia.6 That Level 2 ITO remained in place at the time of Mrs Allen’s death on 22 October 2017.

There are no concerns in relation to the lawfulness of custody.

1.6. I pause here to make the observation that it is apparent Mrs Allen’s aggression and behaviour that lead to the imposition of the ITO was attributable to her dementia.

2. Background 2.1. Mrs Allen was married to her husband John and was mother to two children, a son and a daughter. Her daughter, Nyree Spencer, had been living in the United States of America for nine years prior to Mrs Allen’s death. Ms Spencer returned to Australia a few weeks before Mrs Allen’s death and they were able to spend that time together.7 Her son, who resides in South Australia, was also present and able to spend time with Mrs Allen in the weeks and days leading up to her death.8 3 Exhibit C4 4 Exhibit C4 5 Exhibit C4 6 Exhibit C4 7 Exhibit C1a 8 Exhibit C4

3. Medical history and clinical circumstances 3.1. Mrs Allen’s prior medical history included osteoarthritis and osteoporosis. Mrs Allen was first diagnosed with dementia in March 2017.9 On 18 May 2017 she was admitted to the FMC following her husband struggling to cope with her at home.10 At that time Mrs Allen presented with severe and advanced dementia. Although Mrs Allen was only diagnosed with dementia in March, it appears she had been symptomatic for at least two years prior. She remained at the FMC for thirteen days prior to transfer to the Estia aged care facility.11

3.2. Mrs Allen was admitted to the secure dementia unit of Estia. Whilst at the facility Mrs Allen’s condition continued to deteriorate causing difficulties in her care by nursing staff. She was wandering and lashing out at people who tried to direct where she should could go.12 Mrs Allen had continual issues of being awake at night, trying to climb out of windows and urinating in other residents’ bedrooms.13 Her behaviour escalated on a number of occasions with Mrs Allen hitting other residents and staff, pulling curtains and suffering from falls. This behaviour seemed to emerge without an apparent trigger.14

3.3. Consequently, on 17 September 2017 Mrs Allen was transferred to the FMC where she was diagnosed with dementia with severe borderline personality disorder including physical aggression, agitation and wandering which required further behavioural management. This led to the initial Level 1 ITO being imposed.15

3.4. Whilst at the FMC numerous tests were conducted on Mrs Allen including a CT brain scan. The results of the scan did not reveal any acute abnormalities. The scan showed moderate vascular disease, mild hippocampal atrophy and temporal atrophy, with the left side more affected than the right. This was suggestive of a mixed dementia 9 Exhibit C2 10 Exhibit C5 11 Exhibit C4 12 Exhibit C3 13 Exhibit C5 14 Exhibit C3 15 Exhibit C3

pathology, vascular and Alzheimer’s. Mrs Allen was also diagnosed with depression and was prescribed mirtazapine for therapy of the depressive symptomology.

3.5. On 19 September 2017 Mrs Allen was transferred from FMC to the Repatriation General Hospital. She was prescribed hydromorphone for her serve agitation, buprenorphine for pain, calcium and vitamin D1 for osteoporosis and her vitamin D deficiency and Movicol for constipation.

3.6. Mrs Allen’s behavioural issues continued and included hallucinating and attempting to engage with her hallucinations.

3.7. On 21 September 2017 Mrs Allen was prescribed the antibiotic Augmentin for an infection on her hand. Her buprenorphine dosage was increased. Mirtazapine was ceased and escitalopram was introduced as a more calming antidepressant. It was noted at this stage that Mrs Allen had contracted a lower respiratory tract infection16.

Treatment for Mrs Allen’s hand wound continued and she was reviewed by the plastics resident doctor on 25 September 2017.

3.8. Mrs Allen continued to exhibit behavioural issues and her medications were again altered in an attempt to obtain positive improvement. On 29 September 2017 Mrs Allen ceased hydromorphone and commenced morphine with a milder sedating effect. There was an increase in the levels of buprenorphine and she was given risperidone.

3.9. Mrs Allen’s behavioural issues continued to worsen and on 30 September and 1 October 2017 she was given extra intramuscular medications to calm her down.

3.10. On 2 October 2017 Mrs Allen suffered a fall due to a lack of distance and shapes understanding. She did not sustain any obvious injuries. She refused examination by hospital staff. Her behaviour continued to worsen. She was referred to Ward 18 of the hospital due to the severity of her aggression and was prescribed clonazepam at night to help her sleep.

16 Exhibit C4

4. Mrs Allen’s decline in health and death 4.1. Mrs Allen was reviewed daily and adjustments were made to her medications and dosages without any real improvement. On 6 October 2017 discussions commenced between hospital staff and family, in particular her son, about the fact that Mrs Allen was in the final days of her life and the options available to make those final days more comfortable for her.17

4.2. Mrs Allen was suffering from a suspected aspiration, which is a form of pneumonia. It was recommended she be treated with antibiotics however her prognosis was poor. On 8 October 2017 she developed a moist cough attributable to the pneumonia.

4.3. Mrs Allen’s condition continued to deteriorate and on 10 September 2017 her care was transitioned to palliative measures. As a result intravenous fluids, antibiotics and other medications were stopped.

4.4. Following her transition to palliative care Mrs Allen was noted as being reasonably settled on 11 September 2017. She was monitored regularly and her comfort level maintained. Mrs Allen’s family remained with her during these final stages and at about 7pm on 22 October 2017 Mrs Allen ceased breathing and died.

5. Coronial investigation 5.1. Detective Brevet Sergeant Marshall Morley from the Southern District Criminal Investigation Branch thoroughly investigated Mrs Allen’s death in custody. Detective Morley concluded that the care provided to Mrs Allen was appropriate and that her detention under the Mental Health Act 2009 was lawful.18

5.2. No concerns were raised by Mrs Allen’s family in relation to her care. Indeed, her daughter Nyree Spencer expressed the view that ‘staff here have been great, they always cared and were really gentle with Mum’.19 17 Exhibit C3 18 Exhibit C8 19 Exhibit C1a

6. Conclusions and recommendations 6.1. Consistent with the opinions of Detective Morley, I find that Mrs Allen’s detention was lawful and did not contribute to her death. I further find that there is nothing to give rise to any concern relating to her care at either Estia, FMC or the Repatriation General Hospital.

6.2. 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 his hand and Seal the 3rd day of November, 2020.

Deputy State Coroner Inquest Number 40/2020 (2166/2017)