Coroner's Finding: BICKLEY Jon

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 29th day of October 2019 and the 10th day of January 2020, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Jon Bickley.

The said Court finds that Jon Bickley aged 79 years, late of 2/96 Daly Street, South Plympton, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 12th day of August 2016 as a result of ischaemic heart disease complicating chronic obstructive airways disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Jon Bickley was born on 29 July 1937 and died on 12 August 2016 at the Flinders Medical Centre, at the age of 79 years.

2. Cause of death 2.1. On 16 August 2016, an autopsy was conducted by Professor Roger Byard of Forensic Science South Australia, who determined and reported1 the cause of death to be ischaemic heart disease complicating chronic obstructive airways disease. I accept and find the cause of Mr Bickley’s death to be as stated by Professor Byard.

1 Exhibit C2a

3. Mandatory inquest 3.1. At the time of his death Mr Bickley was subject to an Inpatient Treatment Order pursuant to the provisions of the Mental Health Act 2009. Dr Georgina Deans-Costi imposed a Level 1 Inpatient Treatment Order on 9 August 2016. This order was reviewed and extended by psychiatrist, Dr Rene Pols2 on 10 August 2016 and was current at the time of Mr Bickley’s death.

3.2. A ‘death in custody’, as defined in the Coroners Act 2003, includes the death of a person where there is reason to believe that the death occurred while the person was being detained in any place within the State under any Act or law, which includes detention pursuant to an Inpatient Treatment Order under the Mental Health Act 2009. Section 21 of the Coroners Act 2003 provides that an inquest must be held in such circumstances.

4. Background 4.1. Mr Bickley was married to Marlene Joan Bickley3 for nearly 56 years prior to his death, and together they brought up two children, Terry and Debbie. Mr Bickley worked as a truck driver and then as the caretaker of the Epworth Building in Adelaide. Mrs Bickley remembers her husband as a kind and loving person, who would do anything for anybody.

4.2. Mr Bickley was healthy and fit until about the age of 70, following which he started to suffer health problems, including an enlarged prostate, cancers which were removed from his kidneys, macular degeneration, which eventually rendered him legally blind, emphysema (chronic obstructive airways disease), atrial fibrillation and high blood pressure.

4.3. About five years prior to his death, Mr Bickley was diagnosed with dementia, which caused a worsening of his anxiety, for which he was prescribed antidepressants. He gradually became very reluctant to leave the house. Mrs Bickley cared for her husband at home until his last days.

4.4. On 9 August 2016, Mr Bickley injured his knuckles as a result of fall. He was located by his wife, who dressed his wounds and returned him to bed when he said he did not 2 Statement, Exhibit C5 3 Statement, Exhibit C8

feel well. Later, after waking from a nap, he behaved aggressively towards Mrs Bickley, which was uncharacteristic. An ambulance was called and Mr Bickley was transferred to the Flinders Medical Centre, where he remained aggressive and agitated. He was placed on the Inpatient Treatment Order

4.5. The following morning it was noted that the sedatives he was prescribed were having little effect. Mr Bickley required significant medications to sedate him and calm him sufficiently to enable medical procedures such as a CT scan to identify the reasons for his acute deterioration and delirium.

4.6. Mr Bickley continued to exhibit distress and agitation, and on 11 August 2016 he refused oral intake and removed dressings and his intravenous catheter. He was transferred to another ward for more intensive management.

4.7. On 12 August 2016 Mr Bickley remained distressed and agitated. At about 7:38pm a Medical Emergency Team (MET) call was initiated, as he was observed by the nurse to be experiencing respiratory problems. Mr Bickley had been administered 50mcg of fentanyl prior to this call. Dr Wong4 attended quickly in response to the MET call. A sternal rub was performed without a response. Otherwise, resuscitation was not attempted, as previously directed by Mrs Bickley, who held an enduring power of attorney and an advanced care directive, and Mr Bickley’s head and airway were supported until he stopped breathing. Dr Wong declared him deceased at 8pm.

5. Police investigation 5.1. As Mr Bickley’s was a death in custody, a police investigation was undertaken and a detailed and helpful report was prepared by Detective Brevet Sergeant Melanie Ellis. I shall briefly address two matters brought to my attention by Sergeant Ellis in her report.5

5.2. Resuscitation status At the time of the MET call on 12 August 2016 there was some confusion amongst nurses at Mr Bickley’s bedside as to his resuscitation status.

5.3. Dr Amy Ting6 had been the first Flinders Medical Centre doctor to see Mr Bickley upon his arrival at the Emergency Department on 9 August 2016. She examined Mr Bickley 4 Statement, Exhibit C3 5 Exhibit C12 6 Exhibit C6

and took further history and details from Mrs Bickley, who held an enduring power of attorney and an advanced care directive for her husband.

5.4. After consultation with Mrs Bickley, she ticked the box on the Resuscitation Status document stating, ‘Call MET/code blue but no CPR’ and made a further entry, ‘Not for CPR, intubation, ICU for ward management and comfort care’.

5.5. Another staff member, not identified during this inquest, at some stage wrote underneath the words ‘comfort care’, a further note, ‘If deteriorates, otherwise ceiling of care would be MET and ward measures’.

5.6. Dr Rao, who was Mr Bickley’s treating geriatrician at the Flinders Medical Centre, agrees7 that there was some ambiguity between the two entries and expresses the opinion that a more appropriate wording of what was plainly intended as a clarifying note, would have been, ‘For active ward management and if he deteriorates, the focus of care should be on comfort’.

5.7. In this case, it is clear that nothing was done which was inconsistent with Mrs Bickley’s instruction and I am satisfied that no further coronial consideration of this matter is required and no finding is called for.

5.8. Administration of fentanyl After the death of Mr Bickley a statement was taken from his general practitioner, Dr Koh8, who stated, ‘I would have thought that fentanyl might be a bit strong for a guy of Mr Bickley’s age. A large enough dose might also cause respiratory depression, particularly when combined with diazepam, oxazepam and risperidone’. It was specified in the statement that this was in response to a query by a Detective as to possible side-effects of Mr Bickley’s medications, and it was also clear that the general practitioner was not positively asserting that Mr Bickley had been inappropriately medicated, particularly in a manner which might have contributed to his death.

5.9. In case any interested person is concerned that Mr Bickley was inappropriately medicated, I state that I am satisfied that it was appropriate for Mr Bickley to be administered fentanyl. Dr Rao states that Mr Bickley was administered one 50mcg fentanyl injection on 11 August 2016 and three injections on 12 August 2016. I accept, 7 statement, Exhibit C4 8 Exhibit C7

as stated by Dr Rao, that 50mcg was a small dose, appropriate for Mr Bickley’s age and body weight, and that there were good reasons for using it for pain management. It was chosen above morphine because it does not accumulate in the body, is very short acting and has fewer side-effects than morphine

5.10. Dr Rao’s decision to administer fentanyl was supported by an independent opinion9 obtained on behalf of the Court from Professor Gregory Crawford, Professor of Palliative Medicine, who gave detailed reasons for his conclusion that fentanyl was an appropriate opioid if analgesia was required. It is not necessary here to elaborate on those reasons, except to observe that they are consistent with the reasons given by Dr Rao.

5.11. Consistent with the conclusions of the investigating officer, Mr Bickley was in lawful detention at the time of his death.

6. Conclusions 6.1. I conclude and find that Mr Bickley’s treatment at the Flinders Medical Centre was at all times appropriate, and that the Inpatient Treatment Orders imposed upon him were lawfully imposed, upon proper grounds.

6.2. I make no recommendations.

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 10th day of January, 2020.

State Coroner Inquest Number 35/2019 (1545/2016) 9 Exhibit C15