Coroner's Finding: COULTER Brenton Thomas

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 6th day of May and the 17th day of June 2020, by the Coroner’s Court of the said State, constituted of Elizabeth Ann Sheppard, Deputy State Coroner, into the death of Brenton Thomas Coulter.

The said Court finds that Brenton Thomas Coulter aged 60 years, late of Gawler Supportive Care, 6/8 East Terrace, Gawler, South Australia died at the Modbury Hospital, Smart Road, Modbury, South Australia on the 8th day of October 2017 as a result of ischaemic heart disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for inquest 1.1. Brenton Thomas Coulter, born 9 October 1956 died on 8 October 2017 at Woodleigh House, which is an inpatient mental health facility operated in association with Modbury Hospital. At the time of death at age 60 years, Mr Coulter was subject to an Inpatient Treatment Order (ITO), hence this mandatory inquest into the cause and circumstances of his death1.

1.2. Mr Coulter was hospitalised on 22 September 2017 primarily as a result of a decline in his mental health, thought to be associated with non-compliance with medication prescribed to manage symptoms of schizophrenia. There had been admissions to hospital for the same reason previously.

1 Pursuant to section 21(1)(a) of the Coroners Act 2003

1.3. On 8 October 2017 nurses at Woodleigh House discovered Mr Coulter lying unresponsive on the floor of his bathroom, blocking access through the door. After obtaining access, attempts by medical and nursing staff to resuscitate Mr Coulter were unsuccessful.

2. Cause of death 2.1. A post mortem examination was conducted on 12 October 2017 by forensic pathologist Dr Stephen Wills of Forensic Science South Australia. Dr Wills noted a number of key cardiac observations relevant to the cause of death. A stent was in place in the left anterior descending coronary artery from a previous intervention, however there was ‘focally severe coronary artery disease within the right coronary circulation, relatively extensive myocardial scarring and some pallor, possibly representing more acute ischaemic change to the posterior papillary muscle’.2

2.2. Additionally, Dr Wills observed cardiomegaly assessed at around 90th centile for the body mass of the deceased.3

2.3. It was noted that Mr Coulter had a relevant medical history of cerebrovascular accident, myocardial infarction, hypercholesterolaemia, hypertension, ischaemic heart disease and emphysema. His prescribed medications, including clozapine were noted, but not elaborated upon.

2.4. Dr Wills expressed his concluded finding as follows: ‘Taking all of the findings into consideration, it appears most probable this gentleman has died as a result of ischaemic heart disease. Individuals with scarring of the heart muscle, focal acute ischaemic damage and significant narrowing of the major epicardial coronary arteries are known to be at increased risk of cardiac dysfunction, arrhythmia and sudden, unexpected death.’ 4

2.5. I adopt the findings of Dr Wills as to the cause of death.

2 Exhibit C2a 3 Exhibit C2a, page 2 4 Exhibit C2a, page 2

3. Background 3.1. Mr Coulter was prescribed Clozapine by his treating practitioners to manage symptoms of schizophrenia which became a problem for him after he witnessed some traumatic events and started using cannabis as a young man.5

3.2. Mr Coulter’s level of functioning gradually declined. His mother provided care and support for him until she passed away in 1988. After that he was supported by his brothers, Andrew, Greg and Des who helped guide him through numerous medical appointments and hospital presentations.6

3.3. Over the intervening years Mr Coulter suffered a number of serious health events, including a myocardial infarction and bowel obstruction. During this time there were several presentations to hospitals including psychiatric facilities to manage these issues.

In 2011 for instance, Mr Coulter was said to be sedentary and overweight. He had a family history of heart disease, was a heavy smoker and had elevated lipids.

Dr Margaret Arstall was one of Mr Coulter’s treating cardiologists and managed him in September 2007 when he suffered an acute myocardial infarction. He underwent stenting of the coronary artery in the Royal Adelaide Hospital and was discharged back to Whyalla.

3.4. In November 2011 Mr Coulter was found ‘unresponsive’ by staff at Amaroo after suffering a collapse. He was retrieved to the Royal Adelaide Hospital where he was intensively hydrated and intubated in ICU to stabilise him. After being discharged he was re-admitted in March 2012 to treat a large bowel obstruction. Clearly, these types of events were potentially life threatening and appear to have been managed appropriately each time.

3.5. Mr Coulter was said to be a challenge to manage because of his risk factors including his smoking. He was also being monitored with ultrasound and annual ECG as required because of the potential for Clozapine toxicity which may lead to cardiomyopathy.

When Dr Arstall last saw him in 2014, his cardiac function was stable and he was compliant. It was acknowledged that he was always at risk of another infarction.

5 Exhibit C1b 6 Exhibit C1b

3.6. Mr Coulter remained relatively settled in supportive accommodation in Whyalla called ‘Amaroo’ and he remained there engaged in regular activity with Phoenix for almost 15 years until Amaroo closed in April 2016.

3.7. After Amaroo closed, the forced change of accommodation and routine resulted in a deterioration in Mr Coulter’s mental health. He started to become uncooperative and to refuse to take his medications and even refused to shower.7 It was around this period that his presentation led to him being medicated with Clozapine. He was unhappy taking the medication and was frequently non-compliant. He started to act out aggressively even towards his brother Gregory.8 During a lengthy admission to Whyalla Hospital in August 2016, he presented with psychosis and aggression which was attributed to non-compliance with his Clozapine.

3.8. According to his treating psychiatrist, Dr Contractor, Mr Coulter’s management was challenging. He appeared to have treatment resistant schizophrenia. Clozapine appeared to be the only drug found to be beneficial, but it only worked if he was compliant. Dr Contractor outlines in his affidavit how Clozapine is known to cause cardiomyopathy on a long term basis, hence the need for periodic echocardiography. It was understood that this was a significant worry for patients like Mr Coulter who had ischaemic heart disease. In that situation it was necessary to balance the competing risks.

3.9. Arrangements were made in consultation with family and treating doctors to have Mr Coulter placed into a supported facility where his cardiac and psychiatric medications could be monitored.9

3.10. In December 2016 Mr Coulter moved to an assisted living facility, Gawler Supportive Care, where his brothers noticed a gradual deterioration in his health and functioning.

During that time Mr Coulter was admitted to the Lyell McEwin Hospital on a few occasions following his refusal to take his medication. During this period he was managed by psychiatrist Dr Jorg Strobel as an outpatient at the Gawler Hospital to conduct six-monthly reviews required because Mr Coulter was taking Clozapine10.

During this period Mr Coulter was prescribed 350mg, rather than the 400mg previously, 7 Exhibit C13 8 Exhibit C1b 9 Exhibit C10 10 Exhibit C12

as well as having 5mg Olanzapine at night and when required. Dr Strobel only saw him for review in March 2017, at which time he was said to be stable and compliant.

The September review was missed however because Mr Coulter was hospitalised.11

3.11. Mr Coulter’s general practitioner was Dr Malcolm Richards. An occupational therapist was involved in assisting Mr Coulter to try to increase his level of activity, however it was noted that he generally preferred to stay in his room.12

4. Admission to Lyell McEwin Hospital and then Woodleigh House on 22 September 2017

4.1. Staff at Mr Coulter’s assisted living facility in Gawler became increasingly concerned about Mr Coulter’s behaviour in the lead up to his admission to the Lyell McEwin Hospital on 22 September 2017. His carers had reported to ambulance staff who transferred him that his behaviour was abnormal. He was aggressive to staff and slammed the door after they came to give him his medication. Staff were concerned that he was spitting out his medication after they left. Mr Coulter was also seen to crawl under his bed and also his table, grazing his elbows.13

4.2. Emergency Department consultant at Lyell McEwin Hospital, Dr Omar Tariq, assessed Mr Coulter on the evening of 22 September 2017. He was ‘netted’ for protection en route to the hospital and the ambulance was given a police escort. A code black was called at the Emergency Department after which Mr Coulter’s vital signs were monitored frequently. After being sedated Mr Coulter was able to be assessed and transferred to a bed. Bloods were taken to assist in his management. Dr Tariq initiated an ITO due to Mr Coulter’s presentation. There is no criticism of this decision, nor the decision subsequently to confirm and extend the order.14

4.3. Dr Tariq has conceded that he was not provided handover information from ambulance officers that Mr Coulter had pre-existing cardiac issues, however there is no suggestion that in this period it resulted in adverse management of those issues. Furthermore, the ambulance officer’s handover documents in the medical notes, which would have been 11 Exhibit C12, page 5 12 Exhibit C12 13 Exhibit C9 14 Exhibit C8

provided on the night, clearly note Mr Coulter’s significant medical history, including his cardiac issues.15

4.4. I also note that there is evidence in the medical notes that following his admission a Clozapine investigation review was commenced, with bloods taken for that on 26 September 2017. 16

4.5. Mr Coulter was referred to the Mental Health Team over the weekend of 23 and 24 September 2017 under the care of psychiatrist, Dr Timothy Cheng, and registrar, Dr Nabil Cherawala. By this time the Level 1 ITO imposed by Dr Tariq had been confirmed after assessment by Dr Eli Rafalowicz. I am satisfied that the relevant criteria for these decisions were met.17

4.6. Essentially, Mr Coulter posed a risk of harm to others from his mental illness and had impaired decision making capacity. There was no less restrictive means available for managing him at that time. During this period Mr Coulter had blood tests and an ECG to assess cardiac function. Background medical information was sought also from Mr Coulter’s general practitioner and Mr Coulter’s brother, Greg, and further investigations were conducted including a CT scan of the brain and liver function tests.

Some of Mr Coulter’s medications were stopped as a precaution in light of abnormal liver enzymes.

4.7. The more difficult challenge during this time was to re-establish the Clozapine gradually. Dr Cheng explains what was required as follows: 'If this medication has not been taken for 48 to 72 hours, the Clozapine Patient Monitoring System (CPMS) Protocol dictates that the mediation must be titrated up from the lowest dose. Mr Coulter was meant to be taking 400mg per day but as he was thought to have ceased this medication for several days, this was restarted at a dose of 25mg and needed to be gradually increased over the course of several weeks back to his previous dose.' 18

4.8. From the available documentation, including medical notes, I am satisfied that there was adequate information available to Mr Coulter’s treating medical staff to manage his presentation appropriately. Mr Coulter’s brother Andy was in attendance 15 Exhibit C21 16 Exhibit C21 17 Exhibit C7, page 4 18 Exhibit C7, page 8

periodically monitoring the situation for the family and providing assistance and company.

4.9. By 28 September 2017 Mr Coulter’s behaviour was improving and by 3 October 2017 he was tolerating 300mgs per day with acceptable blood test results. However, upon assessment on 29 September 2017, Dr Cheng decided it was necessary to extend the ITO to a Level 2 because of persistent auditory hallucinations and delusional thinking.19

4.10. A plan was documented to discharge Mr Coulter a week from 3 October 2017, however on 4 October 2017 Mr Coulter put himself on the floor of the bathroom and appeared frightened. He gradually improved thereafter until the day of his death on 8 October

2017. During that day he was said to be spending time watching television and he was compliant with his medication.

4.11. When Enrolled Nurse Dapper went to speak to Mr Coulter at about 2:30pm he appeared not to want to talk, however there was no indication of any problem. At about 5:15pm he was seen in the dining room by Enrolled Nurse Anne Hanson with nothing out of the ordinary noted. Staff were called away for a medical emergency after that and by the time Ms Dapper returned to do her round at 6:26pm, she was unable to find Mr Coulter when she entered his room.

4.12. Ultimately, Ms Dapper and Ms Hanson located Mr Coulter in the bathroom by looking through the gap in a closed toilet door. They were unable to get a response, but from previous experience they knew that he needed to be enticed out and so decided to obtain some medication to offer him first.

4.13. When they returned one of them climbed on a chair to see why Mr Coulter was not responding. It became clear that he was not breathing. After much effort the door was freed. It proved very difficult to pull Mr Coulter out of the toilet until two orderlies gave assistance. A code blue was called, however the efforts to resuscitate Mr Coulter were unsuccessful and were abandoned at 7:01pm.

4.14. Following Mr Coulter’s death CCTV footage was retrieved which shows his movements from 5:33pm on 8 October 2017. It is said to depict Mr Coulter leaving his bedroom and going into the bathroom carrying his bedding. He remained there for 20 minutes. Over the next 20 minutes he walked in and out of the bathroom five times 19 Exhibit C7, page 9

before entering the bathroom for the final time at 6:12pm. There is nothing on the footage to suggest that he was suffering chest pain when he was moving about and he is said to be walking normally.

5. Conclusion and recommendations 5.1. I have had the advantage of reviewing a large number of medical notes which have been tendered as part of this inquest. It appears that Mr Coulter had been subject to numerous admissions to hospitals over many years. Ultimately, I am satisfied that his death occurred in circumstances where he was being competently managed with a view to discharge back to the supported care facility.

5.2. With Mr Coulter’s risk factors he was always a candidate for a fatal cardiac event, notwithstanding interventions from his doctors.

5.3. 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 her hand and Seal the 17th day of June, 2020.

Deputy State Coroner Inquest Number 25/2020 (2056/2017)