Coroner's Finding: ASTACHNOWICZ Maria

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 September and the 18th day of December 2020, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Maria Astachnowicz.

The said Court finds that Maria Astachnowicz aged 76 years, late of Oakden Clements House, 200 Fosters Road, Oakden South Australia died at Lyell McEwin Health Service, Haydown Road, Elizabeth Vale , South Australia on the 19th day of August 2017 as a result of left lower lobe pneumonia complicating metapneumovirus infectionenter.

The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Maria Astachnowicz was born on 30 June 1941 and died at the Lyell McEwin Hospital1 on 19 August 2017 at the age of 76. A pathology review by Dr Jane Alderman2 of Forensic Science South Australia provided the cause of death as being left lower lobe pneumonia complicating metapneumovirus infection. I find the cause of death to be as stated in the pathology review. Her body was identified by a registered nurse.

2. Reason for inquest 2.1. At the time of Mrs Astachnowicz's death a Level 2 Inpatient Treatment Order3, was in place. Therefore this is a mandatory inquest pursuant to Section 21(1)(a) of the Coroners Act 2003.

1 LMH 2 Exhibit C2

3 ITO

2.2. Mrs Astachnowicz had mental health issues for many years and as a result had an extensive history of ITOs until her death. On 27 July 2017 Mrs Astachnowicz, who was a resident at Clements House, Oakden, was assessed by Dr Rebecca Wheatley and placed on a Level 1 ITO. A previous Level 3 ITO had expired. On 28 July 2017 psychiatrist, Dr Duncan McKellar, confirmed that Level 1 ITO. On 2 August 2017 Dr McKellar confirmed a Level 2 ITO. This was due to expire on 13 September 2017.

Mrs Astachnowicz died on 19 August 2017 whilst the Level 2 ITO remained active.

3. Background 3.1. Mrs Astachnowicz's background has been obtained from the statement of her son, Michael Astachnowicz.4 She was born in Poland and was one of four children. She was a qualified nurse and moved to Australia with her husband, taking up residence in Adelaide. The couple had one child, Michael, but Mrs Astachnowicz's husband had six children from a previous marriage. In 2003 her husband died, having battled prostate cancer for many years.

4. Medical History and treatment 4.1. Michael Astachnowicz stated his mother had a history of mental illness for as long as he could recall. He was aware she had been officially diagnosed with bipolar schizoaffective disorder. He stated that since 1980 she was regularly admitted to hospital due to mental health issues. The admissions would last anywhere from a month to six months and when she was discharged she continued to receive outpatient treatment. Michael Astachnowicz stated in the three or four years prior to his mother's death she had been in some form of permanent care due to her mental illness.

4.2. In 2014 an application was made to the South Australian Guardianship Board5 for Michael to be appointed full guardian and administrator of her estate. The application was granted on 27 May 2014. In April 2016 the South Australian Civil and Administrative Tribunal6 reviewed the previous order and was satisfied Mrs Astachnowicz suffered from a mental condition that rendered her incapable of participating in her care. SACAT maintained an order granting her son full administration of her estate.

4 Exhibit C5 5 Now the South Australian Civil and Administrative Tribunal

6 SACAT

4.3. On 11 March 2015 Mrs Astachnowicz was moved to Oakden’s Clements House nursing home. She remained there until a few days prior to her death. Michael Astachnowicz stated he has seen a general decline in mental health services over the years. In regards to Oakden, he stated it was the best and only place for his mother and the care was reasonable. He stated although there were times personal hygiene was not the best, he did not blame the staff as it was part and parcel of his mother's illness.

4.4. Michael Astachnowicz said his mother was non-compliant with her medication which made her care more difficult as she did not trust anyone. He was aware his mother had developed a chest infection about a week prior to her death and had been prescribed antibiotics at Clements House. He visited her in the days prior to her passing away.

4.5. Michael Astachnowicz requested that the last week of his mother's life be investigated and he questioned the use of medication to sedate her and the contact she had with the medical practitioners. Before I move to the last week of her life, it is important I set out some further medical background.

4.6. Mrs Astachnowicz had several admissions to hospital throughout her life and had a significant history of mental illness and ITOs. Attached to the SAPOL investigating officer's statement is a table which provides a summary of her extensive admissions and the medications prescribed from 1980 to 2014.7 In the LMH casenotes a letter to SACAT from Dr Patrick Flynn, senior psychiatrist, dated 22 April 2016 provided an extensive history including a background of schizoaffective illness dating back to 1975.8

4.7. On 11 March 2015 she was moved to Clements House. Psychiatrist, Dr McKellar, was the head of the unit for Older Persons Mental Health Services in the Northern Adelaide Local Health Network9 in August 2017. His duties included providing medical and clinical leadership at acute inpatient services which included the Oakden campus.

Dr McKellar personally saw Mrs Astachnowicz from 4 May 2017 onwards. She had an extensive psychiatric history. Dr McKellar stated her primary diagnosis was schizophrenia but with an affective mood component sometimes referred to as bipolar.

She presented with delusional beliefs that had been treated for many years.

7 Exhibit C12, Attachment MD9 8 Exhibit C13, volume 9

9 NALHN

4.8. Dr McKellar stated it was the metapneumovirus which precipitated her transfer to hospital prior to her death. She had respiratory symptoms and was seen by a locum resident medical officer and senior medical practitioners. Dr McKellar stated Mrs Astachnowicz did have mobility issues but he does not believe those issues were associated with her medication.

4.9. Dr McKellar stated the mobility difficulties were due to her respiratory condition, possibly complicated by her longstanding diabetes and obesity. Dr McKellar believed it was unlikely there was a profound impact in terms of sedation and respiratory depression associated with the use of clonazepam. The metapneumovirus coupled with her obesity and overall clinical picture was such that she did not have the resilience, physically, to manage the deterioration. It was, at that stage, she was sent to an acute medical environment where she could be managed. The last time Dr McKellar saw Mrs Astachnowicz was on 2 August 2017, when he confirmed the Level 2 ITO.

4.10. Dr Wheatley, a general practitioner, first met Mrs Astachnowicz in March 2015 at Clements House and continued to care for her until February 2017, and resumed care from July 2017 to the date of her death. Dr Wheatley had a good knowledge of her medical history. Dr Wheatley stated Mrs Astachnowicz had schizoaffective disorder, or bipolar with significant psychosis. In addition, she had type 2 diabetes which required insulin. She had hypothyroidism, abnormal liver function and pancytopenia, which was troublesome for her in relation to her antipsychotic medication.

Dr Wheatley stated Mrs Astachnowicz was prescribed medication which included depot injections for her psychosis. The full list of the medications are in Dr Wheatley's statement.10 The doctor confirmed she did not want to adhere to her medication regime as she was quite paranoid and often concerned her food was being poisoned.

4.11. Mrs Astachnowicz was regularly reviewed by geriatricians regarding the management of her diabetes which was fragile due to fluctuating levels.

4.12. She had received the services of a podiatrist, physiotherapist, occupational therapist and Dr McKellar.

4.13. Dr Wheatley stated Mrs Astachnowicz had the 7 Step Pathway Resuscitation Plan which was completed by Dr Harphas.11 On 9 August 2017 she was seen by Dr Harphas 10 Exhibit C6, pages 4-6 11 Exhibit C6

regarding a sacral wound. At that time other people in the facility had been diagnosed with a virus. Mrs Astachnowicz had developed a cough but declined a nasal swab. On 11 August 2017 she had upper airway noise and was prescribed antibiotic medication and commenced on nebulised salbutamol. The following day she refused the nebuliser.

On 17 August 2017 Dr Wheatley was informed Mrs Astachnowicz had finally provided a nasal swab, which had tested positive for the metapneumovirus. Consideration was given to removing her from the antibiotics as they had no effect on a virus. No treatment was commenced for the virus as Tamiflu, which is an antiviral medication, should be used within the first 72 hours of infection. She had already passed that window. At 10pm on the same day observations taken by nursing staff raised concerns regarding her health and the decision was made to transfer her to hospital. A short time later she was conveyed by ambulance to Modbury Hospital. On the same day she was initially taken to the Modbury Hospital but was moved to LMH the following day on 18 August 2017 at about 9am.

5. Events just prior to Mrs Astachnowicz’s death 5.1. I turn to the day and the circumstances surrounding her death. On 19 August 2017 Enrolled Nurse Jodie Cresswell was on afternoon shift at the LMH, Ward 1E, and responsible for the care of Mrs Astachnowicz. She was the last person to see her alive.

On several occasions Mrs Astachnowicz pulled the oxygen cannulas out of her nose, threw pillows and removed her clothing. Ms Cresswell stated it was difficult to calm her as she did not understand English. Throughout the shift Ms Cresswell checked and took observations, which were acceptable. Ms Cresswell confirmed Mrs Astachnowicz was seen by doctors and her care was maintained as instructed. At 9:05pm Ms Cresswell found Mrs Astachnowicz at the bottom of the bed, on her back with no clothing, and the oxygen cannula removed. A MET call was made and her care was taken over by the MET.

5.2. Dr Kuppa was an intern and part of the MET that attended the call. Dr Kuppa stated the ECG monitor revealed Mrs Astachnowicz was asystole and completely unresponsive. As she was not for CPR, no resuscitation attempts were made and she was declared deceased at 9:15pm.

6. Coronial investigation 6.1. Due to the ITO, a police investigation commenced. Officers Travis Devine,12 Grant Bell,13 Matthew Fullston,14 and crime scene examiner Daniella Pellegrino,15 all provided statements as to their observations when attending the LMH. Brevet Sergeant Jerome Lienert, the investigating officer, has provided a helpful and thorough final report.16 The police investigation found the care and treatment at Clements House, Modbury Hospital and the Lyell McEwin Hospital was appropriate. The ITO was valid and appropriate. The investigation found no suspicious circumstances surrounding the death of Mrs Astachnowicz. No deficiency of care was identified.

7. Recommendations 7.1. I agree with the findings of the police investigations. I have considered the concerns of her son in making that finding.

7.2. I make no recommendations.

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 18th day of December, 2020.

Deputy State Coroner Inquest Number 78/2020 (1645/2017) 12 Exhibit C8 13 Exhibit C9 14 Exhibit C10 15 Exhibit C11 16 Exhibit C12