Coroner's Finding: COCHRAN Henry Reginald

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 16th day of April and the 28th day of May 2020, by the Coroner’s Court of the said State, constituted of Simon James Smart, Deputy State Coroner, into the death of Henry Reginald Cochran.

The said Court finds that Henry Reginald Cochran aged 89 years, late of Helping Hand Aged Care Lealholme, 15 Halliday Street, Port Pirie, South Australia died at Port Pirie, South Australia on the 12th day of June 2017 as a result of ischaemic heart disease and chronic obstructive pulmonary disease with aspiration pneumonia. The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Mr Henry Reginald Cochran was born on 26 September 1927 and died on 12 June 2017 at the Lealholme Nursing Home in Port Pirie. He was 89 years of age.

2. Cause of death 2.1. A post-mortem examination of Mr Cochran’s remains was conducted by forensic pathologist, Dr Cheryl Charlwood, of Forensic Science South Australia on 21 June

3. In her report of that examination Dr Charlwood has provided the cause of death as ‘ischaemic heart disease and chronic obstructive pulmonary disease with aspiration pneumonia’.1 1 Exhibit C2a

2.2. Dr Charlwood commented in her report that Mr Cochran’s death involved a combination of cardiorespiratory disease.2 Of significance, there was bullous emphysematous changes to the lungs with fibrosis and overexpansion of the chest; acute and chronic aspiration pneumonia; and in relation to the ischaemic heart disease, Dr Charlwood found severe coronary artery atheroma, myocardial fibrosis and scarring, and tortuous coronary arteries.

2.3. I find the cause of Mr Cochran’s death to have been ischaemic heart disease and chronic obstructive pulmonary disease with aspiration pneumonia.

3. Reason for inquest 3.1. This is a mandatory Inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mr Cochran was a protected person under the Guardianship and Administration Act 1993 at the time of his death. On 21 August 2015 Mr Cochran was made the subject of an order pursuant to section 32 of the Guardianship and Administration Act 1993 by the Guardianship Board after an application by his daughter. The order declared that Mr Cochran become a protected person and his guardian was to be his daughter, Penelope Farrington.

3.2. The order was reviewed and maintained on an annual basis and the most recent review was commenced on 5 May 2017.3

4. Medical history 4.1. Mr Cochran had a medical history that included hip replacements, frontal lobe damage as a result of the administration of anaesthetic during a transurethral resection of the prostate in 2003. It is noted that mesh remained in Mr Cochrane’s body and had to be removed in 2007 by laparotomy as it had ulcerated through the left wall of the bladder.

Mr Cochran also suffered from Barratt’s Oesophagus, blindness, deafness, gastrooesophageal reflux, glaucoma, hypertension, osteoarthritis, chronic obstructive pulmonary disease and an inguinal hernia and hydrocele.

4.2. Mr Cochran had a long history of alcohol abuse resulting in Korsakoff Syndrome prior to moving to South Australia in 2014.4 2 Exhibit C2a 3 Exhibit C8, Statement of Melana Virgo, Deputy Registrar at the South Australian Civil and Administrative Tribunal 4 Exhibit C7, page 14

5. Background 5.1. Mr Cochran was born in Mount Victoria, New South Wales and married his first wife, Stella Cochran, in 1947. They had eight children together. The family lived in New South Wales and Victoria and then in 1975 he and his wife were divorced. Mr Cochran married his second wife, Enid Joyce Cochran, in 1984. They did not have any children together. They moved to Queensland in the 1990s and then in 2011 Mr Cochran moved into a nursing home in Queensland before moving to South Australia without his wife in 2014.

5.2. Over the years Mr Cochran worked at various occupations including as a painter, tram conductor, postman, in factories performing assembly work and most recently in the boiler room of a hospital in New South Wales until he retired aged 65.

5.3. On arriving in South Australia Mr Cochran initially lived with his daughter Penelope Farrington in Port Pirie.5

5.4. As previously stated, on 21 August 2015 Mr Cochrane was made subject of an order that declared that he become a protected person and his guardian was to be his daughter, Penelope Farrington.

5.5. Mr Cochran lived with his daughter until 3 December 2015 when he became a resident at the Lealholme Nursing Home in Port Pirie. He moved into the home on direction from his daughter due to ongoing behavioural issues including aggression and hallucinations attributed to his dementia.

6. Clinical circumstances leading up to the death 6.1. On arriving in Port Pirie Mr Cochran became a patient of general practitioner, Dr Alan Golding.6

6.2. On 24 October 2014 Mr Cochran presented to Dr Golding with hypertension. He was also unsteady on his feet when walking. Dr Golding advised Mr Cochran’s daughter that his life expectancy would be about five to eight years. He then suffered a fall on 7 November 2014 and was transferred to the Royal Adelaide Hospital with a dislocated right hip prosthesis and acetabular fracture.

5 Exhibit C1b 6 Exhibit C7

6.3. On 30 January 2015 Mr Cochrane presented to Dr Golding with hallucinations. He had been displaying unusual behaviour at home including jumping out of bed, taking his clothes off and generally being unsettled.

6.4. Mr Cochran continued to present to Dr Golding between February and October 2015 with worsening dementia. He was experiencing confusion and panic attacks. His condition was described as worsening and he displayed impulsive and aggressive behaviour. On 8 July 2015 Mr Cochran’s daughter reported to Dr Golding that her father had been drinking mouthwash and presenting with fictitious illnesses which ceased when confronted. He had accused relatives of stealing property and had been hoarding items such as toilet rolls and tissues.7

6.5. Mr Cochran was admitted to Lealholme Nursing home on 3 December 2015 and continued to be seen by Dr Golding at the nursing home. Between his admission and May 2017 he had numerous falls without significant injuries.8

6.6. On 19 August 2016, due to his deteriorating condition, Mr Cochran was made the subject of a Good Palliative Care Plan compiled by Dr Golding.9

6.7. In the days prior to his death Mr Cochran suffered several minor falls without injury and nothing remarkable was noted. Resident progress notes from the days and weeks before Mr Cochran’s death refer to numerous unwitnessed falls and behaviour consistent with his dementia.

7. The circumstances of Mr Cochran’s death 7.1. Mr Cochran was noted as hypoxic from 6 June 2017 and was given oxygen therapy.10 7.2. On 12 June 2017 Mr Cochrane was located at 9:45am by nursing home Registered Nurse Marie Therese Bown sitting at a table in the dining area having fallen asleep after breakfast. He was woken and made his way back to his room.11

7.3. At 10:30am Mr Cochran was located by carer, Jodie Louise Paynter, lying on the floor of the bathroom in his room.12 7 Exhibit C7, page 8 8 Exhibit C6, Statement of Therese Marie Johnson, the Care Services Manager at the Lealholme Nursing Home 9 Exhibit C6, page 4 10 Exhibit C13, Resident Progress Notes, page 1 11 Exhibit C5 12 Exhibit C4

7.4. The South Australian Ambulance Service and Dr Golding were called. Dr Golding pronounced life to be extinct at 11:30am. Dr Golding notes in his statement that Mr Cochran was found on his back with his trousers up with his feet by the toilet and his head by the bathroom door.13 He had vomit in his mouth.

7.5. Dr Golding refers to Mr Cochran’s long history of alcohol abuse resulting in Korsakoff Syndrome, a past frontal lobe embolic stroke and Mr Cochran’s dementia diagnosis.

7.6. A formal identification procedure was conducted with Mr Cochrane’s daughter Penelope Farrington.

8. Investigation and conclusion 8.1. Mr Cochran’s death in custody was investigated by Brevet Sergeant Leighton Gwilym of South Australia Police. In his report Mr Gwilym concluded that Mr Cochran was in lawful detention at the time of his death.14 The circumstances surrounding his death are not suspicious and do not indicate the involvement of any third party or concerns relating to his care.

8.2. It is the opinion of the investigating officer that Mr Cochran’s care and treatment at the Lealholme Nursing Home and by his general practitioner, Dr Golding, was appropriate.

Having reviewed all of the documentation I would agree with that opinion.

9. Recommendations 9.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Section 32 Powers; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 28th day of May, 2020.

Deputy State Coroner Inquest Number 17/2020 (1083/2017) 13 Exhibit C7 14 Exhibit C12a