Coroner's Finding: ASHTON Lorraine June

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 15th day of May and the 25th day of June 2020, by the Coroner’s Court of the said State, constituted of Brian Malcolm Nitschke, Deputy State Coroner, into the death of Lorraine June Ashton.

The said Court finds that Lorraine June Ashton aged 78 years, late of 27/170 Oaklands Road, Glengowrie, South Australia died at the Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 23rd day of September 2017 as a result of advanced dementia (end stage). The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Lorraine June Ashton was born on 24 February 1939 and died on 23 September 2017 at the Repatriation General Hospital (RGH). She was 78 years old.

1.2. An opinion as to Mrs Ashton’s cause of death was provided by Dr Ruchi Saxena of the Repatriation General Hospital. I agree with the opinion of Dr Saxena and find that Mrs Ashton’s cause of death was advanced dementia (end stage).1

1.3. Mrs Ashton was subject to an Inpatient Treatment Order (ITO) at the time of her death and as such her death necessitated a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003. A Level 1 ITO was made pursuant to section 21 of the Mental Health Act 2009. The order was instituted on 25 August 2017 by Dr James Ashby and confirmed by Dr Joanne Hill on 26 August 2017. A Level 2 ITO was made on 1 Death Report to Coroner – Medical Practitioner’s Deposition

1 September 2017 by Dr Christopher Veale. That treatment order was current at the time of Mrs Ashton’s death and was due to expire on 13 October 2017. There are no concerns in relation to the lawfulness of custody.

2. Background 2.1. Mrs Ashton was born in Yorketown and married her husband James Ashton on 30 May

3. Mrs Ashton was a bookkeeper at a local business and then in 1960 James Ashton joined SAPOL and they moved to Adelaide. James Ashby went on to become Chief Superintendent in 1989 and subsequently Officer in Charge Country Region in 1990 until his retirement in 1994.

2.2. Lorraine and James Ashton had three children. James Ashton described his wife as: ' … a model wife, mother and grandmother. She was very capable at anything she did.

She was a loving and no-nonsense person who enjoyed her family immensely. She loved caravanning, social golf and tennis.' 2

3. Medical history 3.1. Mrs Ashton had a medical history that included ischaemic heart disease, hypertension, deafness, glaucoma and macular degeneration, and hypercholesterolaemia.

3.2. In 2014, Mrs Ashton was also diagnosed with non-Hodgkin’s lymphoma. She underwent treatment for the non-Hodgkin’s lymphoma including chemotherapy and responded well to that treatment3. James Ashton stated that it was at about this time that Mrs Ashton’s memory and word association was affected. She became forgetful and unable to perform everyday tasks. Mrs Ashton was subsequently diagnosed with Primary Progressive Aphasia, a rare form of dementia4. Mr Ashton became his wife’s full-time carer with much assistance from their two daughters.

3.3. Mrs Ashton’s condition worsened and the family were advised that she required care in a residential home for the elderly. Mrs Ashton was moved to the Oaklands Residential Care Home on 2 June 2017. After her move Mrs Ashton developed escalating 2 Exhibit C9, page 13 3 Exhibit C1b, page 1 4 Exhibit C5, page 2

behavioural disturbances, including mood lability, tearful or anxious mood, agitation, nocturnal sleep disturbance and wandering.5

4. Mrs Ashton’s admission to the RGH and her decline in health 4.1. Mrs Ashton was transferred to the RGH on 23 August 2017. In the period shortly before this transfer there had been a further escalation of her behavioural disturbance including physical and verbal abuse to staff, intrusiveness and multiple unwitnessed falls6.

4.2. In his statement tendered to the Court, Mr James Ashton stated that at the RGH he would remain with Mrs Ashton for most of the day and always tried to have a family member with her to protect her from other patients and ensure her needs were met7.

4.3. Mr Ashton has expressed some concerns as to the standard of care of his wife received while she was admitted at the RGH. He states that on Friday 25 August 2017 he noticed that Mrs Ashton was ‘very sedated and agitated’. He described the level of care as ‘very low in my opinion’ and that Mrs Ashton started to display bruises on her body that were not explained very well by staff. Mrs Ashton had an X-ray at Mr Ashton’s request which revealed no broken bones8.

4.4. The hospital notes have been thoroughly reviewed with these concerns in mind.

Hospital notes from 23 August 20179 suggest that Mrs Ashton was unsettled. It is noted that she was given prn10 Oxazepam at 4:30pm with moderate settling effect. It is noted that she had been wandering in the ward and was intrusive, but fairly easily redirected.

She was teary and anxious at times. She was cooperative with medications and nursing care. During the night she was found to grab her lower back and wince in pain. It was reported that she remained unsettled all night, was resistive to care, unable to be redirected and was pacing. It is noted that Mrs Ashton lashed out at staff and tried to ‘ram them with her walker’. A nurse was slapped and scratched and Mrs Ashton spat at another nurse. It is noted she eventually settled ‘after much PRN medication as charted’. This was no doubt uncharacteristic behaviour in the sense that Mrs Ashton would not have behaved in such a way prior to the onset of dementia; however, I 5 Exhibit C5, page 2 6 Exhibit C5, page 3 7 Exhibit C1b 8 Ibid 9 EPAS Records, Part B, page 25 10 As necessary

mention it as it is relevant in the context of the subsequent ITO and because there have been concerns expressed as to the level of care.

4.5. Mrs Ashton was seen by a registrar on 24 August 2017 when she appeared confused.

She was noted as having previously expressed signs of back pain. On examination, she had some tenderness in her lower thoracic spine which was investigated on X ray11.

4.6. Dr Christopher Veale, consultant psychiatrist, provided a statement to the Court12.

Dr Veale states that on 25 August 2017 Dr James Ashby reviewed Mrs Ashton as she was ‘agitated, screaming and not willing to take oral medication’. Dr Ashby discussed with Mr Ashton by telephone that medication was necessary for Mrs Ashton’s safety and the safety of staff. Mrs Ashton was subsequently prescribed Clonazepam which was given twice daily.13

4.7. On the same day Mrs Ashton was seen by Dr Spiliopoulou, who noted a change in behaviour when Mrs Ashton’s husband had left the hospital that day. Mrs Ashton’s behaviour progressed into extreme agitation with screaming, refusal of oral medications and she did not respond to discussions.14

4.8. At 6:40pm on 25 August 2017 a Code Black was initiated and Mrs Ashton was placed on a Level 1 ITO which was due to expire on 1 September 2017. The ITO was necessary to manage Mrs Ashton’s agitation with physical restraint and intramuscular medications. The ITO was reviewed and confirmed by consultant psychiatrist Dr Joanne Hill on 26 August 2017. It was reported that Mrs Ashton had been hitting out at staff overnight and was extremely agitated, continuously yelling and swearing.15

4.9. Dr Spiliopoulou provided a very detailed summary of the treatment of Mrs Ashton16.

From 25 August until 8 September 2017 Mrs Ashton would display considerable agitation and distress which included aggressive behaviour towards staff and on occasion family members and other patients. There were regular unwitnessed falls and Mrs Ashton would often spit out the medication provided to her.

11 Exhibit C5, page 4 12 Exhibit C4 13 Exhibit C4, page 2 14 Exhibit C5, page 5 15 Exhibit C5, page 6 16 Exhibit C5

4.10. On 1 September 2017 Dr Veale reviewed Mrs Ashton in the presence of Mr Ashton and his daughter. Mrs Ashton was confused and disoriented. Dr Veale confirmed a Level 2 ITO. This was due to expire on 13 October 2017.

4.11. Mr Ashton stated that he was shocked when on 8 September 2017 he was told by consultant geriatrician, Dr Spiliopoulou, that the RGH were commencing palliative care for Mrs Ashton. Mr Ashton was under the impression that his wife was having her medication changed and not that her condition was as advanced as it was. Mrs Ashton was generally non-responsive, not opening her eyes and suffering recurrent falls.

Mrs Ashton was placed on a hydromorphone pump for pain relief.

5. Mrs Ashton’s passing 5.1. On Friday 22 September 2017 Mr Ashton was visiting his wife with their daughter, Suzanne. Mrs Ashton’s breathing stopped for long periods of time, but she would start breathing again. She was unconscious and not responding to anything they said.

5.2. Registered Nurse Lisa Gohl was providing care for Mrs Ashton overnight on 22 September 2017.17 Ms Gohl checked on Mrs Ashton at 9:30pm and every thirty minutes thereafter. Ms Gohl last saw Mrs Ashton alive at about 2:40am on Saturday 23 September 2017. She next checked on Mrs Ashton at about 3:20am and noticed that she was not breathing, was unresponsive, without a pulse but warm to the touch.

Dr Muhammad Hanif Ahmad attended and certified life extinct at 3:35am.

6. Conclusion and recommendations 6.1. Detective Brevet Sergeant Gledhill from the Southern District Criminal Investigation Branch of SAPOL investigated Mrs Ashton’s death in custody and provided a report which was tendered to the Court.18 Detective Gledhill concluded that Mrs Ashton was in lawful detention at the time of her death. In addition, Detective Gledhill deemed that the care of Mrs Ashton at the Repatriation General Hospital was appropriate for the end stage of her life and the disease she was suffering from.

6.2. I have not found anything in the hospital notes or in the statements of those responsible for the care of Mrs Ashton at the Repatriation General Hospital which would indicate 17 Exhibit C2 18 Exhibit C9

that the care given to her was anything other than appropriate for the end stage of her life. I therefore agree with the conclusions as stated by Detective Gledhill.

6.3. 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 25th day of June, 2020.

Deputy State Coroner Inquest Number 28/2020 (1930/2017)