Coroner's Finding: DUNSTAN Carole Ann (Redacted)

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 28th day of May and the 9th day of July 2020, by the Coroner’s Court of the said State, constituted of Simon James Smart, Deputy State Coroner, into the death of Carole Ann Dunstan.

The said Court finds that Carole Ann Dunstan aged 70 years, late of 14 Clifford Street, Prospect, South Australia died at the Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 17th day of June 2017 as a result of end stage dementia. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Carole Ann Dunstan was born on 13 October 1946 and died on 17 June 2017 at Repatriation General Hospital (RGH). She was 70 years old. Mrs Dunstan’s body was identified by her son Paul Bruce Dunstan.1

1.2. A ‘Death Report to Coroner - Medical Practitioner’s Deposition’ was completed by geriatric advanced trainee, Dr Dhanashri Desai. In that document Dr Desai has provided a suggested cause of death of end stage dementia with behavioural psychological symptoms. I find the cause of Mrs Dunstan’s death to have been end stage dementia. No pathology review or post mortem was conducted and Mrs Dunstan’s death was expected.2

1.3. Mrs Dunstan’s death was the subject of a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as she had been detained under an Inpatient 1 Exhibit C1 2 Exhibit C5

Treatment Order (ITO) at the time of her death. On 3 March 2017 a Level 1 ITO was imposed on Mrs Dunstan pursuant to section 21 of the Mental Health Act 2009 by Dr Lauren Kennedy at the Flinders Medical Centre (FMC). That order was reviewed and confirmed by Dr Vivienne Van Wyngaard on 4 March 2017. It was due to expire on 10 March 2017.

1.4. On 7 March 2017 a Level 2 ITO was imposed upon Mrs Dunstan and reviewed and confirmed by consultant psychiatrist Bonita Lloyd on 10 March 2017.3 Mrs Dunstan was transferred to the Queen Elizabeth Hospital that day and on 14 March 2017 she was transferred to ward 18 of the RGH following a request by her family due to their closer proximity to that hospital.

1.5. On 5 April 2017 the South Australian Civil and Administrative Tribunal (SACAT) received an application from Dr Michael Papadopoulos seeking a Level 3 ITO in relation to Mrs Dunstan. A hearing was conducted on site at the RGH on 18 April 2017 by member Janece Petrie. Due to Mrs Dunstan’s condition she was deemed unsuitable to attend the hearing. Her husband was in support of the application, but did not attend in person.

1.6. Ms Petrie confirmed the Level 3 ITO on 18 April 2017 and it was due to expire on 17 October 2017.4 Mrs Dunstan died on 17 June 2017 while that order was still in place.

There are no concerns in relation to the lawfulness of custody.

2. Background 2.1. Mrs Dunstan was born at Woodville in 1946. She was the second of four children having an older sister and two younger brothers.5 Mrs Dunstan went to school and when she was 17 she started working as a nurse in Yorketown.

2.2. It was in Yorketown that she met her husband of 49 years, Bruce Dunstan. They married in 1967, when Mrs Dunstan was 21 years of age. Together they had two children. In 1968 their daughter Sonya was born and in 1970 they had their son Paul.

Following the birth of their children, Mrs Dunstan focused on being a housewife and mother.

3 Exhibit C5 4 Exhibit C6 5 Exhibit C4

2.3. In 1975 the family moved from Yorketown to Naracoorte and in 1976 Mrs Dunstan and her husband purchased a hotel, remaining in the hotel industry until retirement. The last hotel purchased by the couple was the Windsor Hotel on North East Road, Windsor Gardens which was sold in 2002 when they retired. Following retirement Mrs Dunstan and her husband purchased a farm on Kangaroo Island where they spent significant time, including with their grandchildren.

2.4. Mrs Dunstan [Redacted]6. She was a heavy smoker, sometimes smoking 50-60 cigarettes per day.

2.5. Around ten years prior to her death Mrs Dunstan’s husband and siblings noticed she was becoming forgetful. Approximately five years later in 2016 Mrs Dunstan saw a dementia specialist in Woodville where she was formally diagnosed with dementia.

Following her diagnosis Mrs Dunstan’s condition slowly deteriorated and in February 2017 it reached a point where her husband could no longer appropriately care for her.

2.6. On 9 February 2017 Mrs Dunstan was at home and she had a knife to her throat, drawing a little blood, and saying things to the effect of ‘what’s the point of me being here?’. Mrs Dunstan’s husband called an ambulance and Mrs Dunstan was taken to the Royal Adelaide Hospital where she remained for about a week before moving to the Estia aged care facility on 23 February 2017.7

3. Medical history and placement at Estia 3.1. Mrs Dunstan had a history of severe alcohol abuse and diminished cognition in accordance with her 2016 diagnosis of dementia. She also suffered chronic airways disease from a reported lifelong smoking habit.

3.2. It was initially intended that Mrs Dunstan would remain at Estia for a two week respite period and that a formal care plan would be formulated for her. However on 3 March 2017, following consultation between Mrs Dunstan’s husband, her treating doctor, Dr Tim Manners and Estia Care Director, Lorraine Dzeka, it was determined that Mrs Dunstan required greater care than Estia could provide. Consequently, she was transferred to the FMC. Mrs Dunstan’s husband was aware that she would not be coming home as she was too unwell. He gave medical staff full control over her 6 Redacted for personal privacy 7 Exhibit C7

treatment and instructed she was not for resuscitation as he did not wish to prolong her suffering.

4. Mrs Dunstan’s clinical circumstances 4.1. On 3 March 2017 a Level 1 ITO was instituted due to Mrs Dunstan’s ongoing agitation and multiple incidents of threatened or actual violence that resulted in code blacks being called.8

4.2. On 10 March 2017 Mrs Dunstan was reviewed by Dr Bonita Lloyd who noted that she was difficult to engage with. Mrs Dunstan came across as agitated and anxious. She displayed psychological symptoms of Alzheimer’s dementia or borderline personality disorder. Her levels of agitation and confusion were such that she could not be managed without an ITO.

4.3. Mrs Dunstan was transferred to the Queen Elizabeth Hospital on 10 March 2017 and then to the RGH on 14 March 2017 to be closer to her family.

4.4. Whilst at the RGH medical staff had questions regarding the cause of her chronic delirium. Possible causes included chronic pain, constipation or infection, although no evidence of infection was noted.

4.5. On admission to the RGH Mrs Dunstan was prescribed antipsychotic medications risperidone and quetiapine; sedatives oxazepam, temazepam, zopiclone and clonazepam, along with duloxetine for her depression. Mrs Dunstan had limited response to the sedative drugs as she had a high tolerance to benzodiazepines, which is not uncommon in someone with a significant alcohol history. This made optimising her medication difficult for treating doctors.

4.6. Arrangements were made for electro convulsive therapy (ECT) to be conducted in an attempt to treat her depression. This commenced on 4 April 2017 and following 15 sessions no clear benefit was observed.9

4.7. On 18 April 2017 SACAT approved the Level 3 ITO10 application as a result of continued deterioration in Mrs Dunstan’s condition with her being impulsive, intrusive, 8 Exhibit C5 9 Exhibit C5 10 Exhibit C6

wandering and occasionally hitting patients on the ward through misidentification.

There was ongoing verbal agitation with severe cognitive defects.11

4.8. On 29 May 2017 Mrs Dunstan was moved to ward 5 of the RGH where the geriatric team could more appropriately manage her end stage dementia, with a focus on symptom relief and palliation.12

4.9. Mrs Dunstan’s medications were amended and on 16 June 2017 she was prescribed amitriptyline, buprenorphine and oxycodone for pain relief and promethazine, clonazepam and zopiclone for their sedative effects. Given Mrs Dunstan was suffering end stage dementia, her prognosis was terminal and her death was expected.

Mrs Dunstan remained in ward 5 until her death.

5. Mrs Dunstan’s death 5.1. At 6:45 am on 17 June 2017 Nurse Kerry March commenced her shift and noted that Mrs Dunstan was semi-conscious13. At 10am she noted Mrs Dunstan’s condition had deteriorated to the point where she was completely unconscious. She continued to check on Mrs Dunstan every half hour to hour throughout her shift and at 12:30pm Ms March attended on Mrs Dunstan and noted that her respiration had ceased and her pulse was absent. Mrs Dunstan was lifeless and non-responsive. Mrs Dunstan was declared life extinct by Dr Nicholas Tiekink at 3:13pm.14

6. Coronial investigation 6.1. Detective Brevet Sergeant Belinda Laird from the Sturt Criminal Investigation Branch of SAPOL was tasked with investigating Mrs Dunstan’s death in custody. Detective Laird conducted a thorough investigation and provided a report for the Court15.

Detective Laird is of the opinion that the care provided to Mrs Dunstan was appropriate and that her Inpatient Treatment Order was lawful. No concerns were raised by Mrs Dunstan’s next of kin.

11 Exhibit C5 12 Exhibit C5 13 Exhibit C2 14 Exhibit C3 15 Exhibit C11

7. Conclusions and recommendations 7.1. Consistent with the SAPOL Investigating Officer’s views it is my finding that Mrs Dunstan’s detention was lawful and did not contribute to her death. I further find that there are no concerns relating to her care at the Estia aged care facility, the Flinders Medical Centre or the Repatriation General Hospital.

7.2. 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 9th day of July, 2020.

Deputy State Coroner Inquest Number 33/2020 (1123/2017)