Coroner's Finding: BOES Johannes Josephus

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 7th day of May and the 18th day of June 2020, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Johannes Josephus Boes.

The said Court finds that Johannes Josephus Boes aged 92 years, late of 62 Cliff Avenue, Port Noarlunga South, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 8th day of September 2017 as a result of pulmonary thromboembolic disease on a background of infective exacerbation of chronic obstructive pulmonary disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mr Boes, known as John, was born on 23 May 1925. He died at the Flinders Medical Centre on 8 September 2017, aged 92 years. Mr Boes was formally identified by his daughter, Ms Vanessa Sims, at the Flinders Medical Centre on 9 September 2017.

1.2. A pathology review of Mr Boes’ medical and clinical history was undertaken by Dr Jane Alderman and discussed with Dr Stephen Wills, forensic pathologist, at Forensic Science South Australia. Dr Alderman noted a history including heart disease, vascular dementia, chronic obstructive pulmonary disease, and chronic kidney disease.

In her report1, Dr Alderman provided a suggested cause of death. On that basis, I find 1 Exhibit C2a

that the cause of Mr Boes’ death was pulmonary thromboembolic disease on a background of infective exacerbation of chronic obstructive pulmonary disease.

2. Reason for inquest 2.1. At the time of his death Mr Boes was the subject of a Level 1 Inpatient Treatment Order (ITO) under the Mental Health Act 2009. As such, Mr Boes was detained and his death was reportable to the State Coroner as a death in custody. Accordingly, this is a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003.

3. Background and medical history 3.1. Mr Boes migrated to Australia from Holland in 1960. Mr Boes was a record company manager in Holland, and in Australia he worked as an electrical goods buyer for various stores, and was a restaurateur in Hahndorf. Mr Boes was a former smoker, and in his younger years was known to smoke up to 80 cigarettes per day. He started to develop emphysema in his 60s and managed to quit his smoking habit2.

3.2. In September 2016 Mr Boes attended Noarlunga Hospital suffering a chest infection.

A CT scan was conducted from which doctors discovered Mr Boes had vascular dementia. On 22 July 2017 Mr Boes was taken by ambulance to the Flinders Medical Centre due to breathing difficulties. At the hospital Mr Boes was diagnosed with pneumonia, and respiratory syncytial virus. He remained in Flinders Medical Centre until 9 August 2017. During this stay Mr Boes exhibited aggressive and confused states, attributable to his dementia and delirium.

3.3. Following his return home Mr Boes was cared for by his wife of 41 years, Teresa Boes.

Mrs Boes noted that Mr Boes was increasingly anxious, particularly about toileting. At about 11am on 7 September 2017 Mrs Boes assisted Mr Boes to the toilet at which time he fell to the ground. Mrs Boes helped him to the lounge room utilising his walker.

Mr Boes, in attempting to sit, missed his chair and landed on his side on the carpet.

Mrs Boes was unable to lift him and called an ambulance. Mr Boes was taken to the Flinders Medical Centre where he remained until his death.

2 Exhibit C3 – Statement of Teresa Boes, Mr Boes’ wife

4. Admission to Flinders Medical Centre 4.1. Mr Boes was admitted to the acute medical unit at Flinders Medical Centre on 7 September 20173. At that time he was agitated, aggressive and refusing treatment.

Mr Boes was refusing to keep his oxygen on, which could have immediately ended his life. There were safety concerns due to his trying to leave his bed. A Level 1 ITO was instituted by Dr Fadak Mehammaela at 10:45pm on 7 September 2017. Mr Boes was given haloperidol which is an antipsychotic medication used for agitation and aggression. Haloperidol was administered on 7 and 8 September 2017. At 9am on 8 September 2017 Mr Boes was provisionally diagnosed by consultant physician Dr Zuhair Jabbar with a lower respiratory tract infection. A scan subsequently confirmed that Mr Boes had a lung clot.

4.2. Dr Dudridee Charoenporn, a psychiatrist, reviewed the ITO at 11:20am on 8 September 2017 in compliance with the requirements of the Mental Health Act 20094. After reviewing the medical notes and examining Mr Boes, Dr Charoenporn found Mr Boes settled, but disoriented and confused. Dr Charoenporn determined that due to delirium Mr Boes did not have capacity to make decisions regarding his treatment. He still required treatment. Dr Charoenporn confirmed the ITO to facilitate medical treatment for Mr Boes.

4.3. Mr Boes died at 7:35pm on 8 September 2017. Dr Jabbar opined that a combination of age, acute infection, a lung clot, kidney disease and dementia created health problems from which death was expected5. Cardiopulmonary resuscitation was performed on Mr Boes by a doctor at about 7:20pm on 8 September 2017. The resuscitation attempts ceased upon Mr Boes' medical notes being reviewed and a non- resuscitation order being located.

5. Coronial investigation 5.1. Senior Constable Bretag and Constable Jessica Zarnow attended the Flinders Medical Centre on 8 September 2017 following the death of Mr Boes in line with police protocol. Detective Brevet Sergeant William McDonald was tasked to investigate the 3 Exhibit C11 – Flinders Medical Centre casenotes for Mr Boes 4 Exhibit C5 5 Exhibit C6

death in custody of Mr Boes. Nothing of concern was noted in his thorough investigation6.

6. Conclusion 6.1. The family members of Mr Boes did not raise any concerns in relation to his care. I find that Mr Boes’ care and treatment at the Flinders Medical Centre was appropriate.

I further find that the imposition of the Inpatient Treatment Order was lawful and appropriate.

7. Recommendations 7.1. 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 his hand and Seal the 18th day of June, 2020.

Deputy State Coroner Inquest Number 23/2020 (1817/2017) 6 Exhibit C10