Coroner's Finding: FORT Merilyn Jane

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 20th day of February 2020 and the 8th day of May 2020, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Merilyn Jane Fort.

The said Court finds that Merilyn Jane Fort aged 62 years, late of 17 Orleana Street, Flagstaff Hill, South Australia died at the Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 1st day of December 2016 as a result of general inanition on a background of end-stage dementia. The said Court finds that the circumstances of her death were as follows:

1. Introduction 1.1. Merilyn Jane Fort died on 1 December 2016 at the Repatriation General Hospital (the RGH). She was 62 years of age.

2. Cause of death 2.1. Mrs Fort’s clinical case notes were reviewed by Dr Iain McIntyre and discussed with Associate Professor Neil Langlois, a forensic pathologist at Forensic Science South Australia. The written pathology review of Dr McIntyre1 states that the cause of Mrs Fort’s death can be determined from the case notes with some certainty. An autopsy was not recommended. The cause of death suggested in the pathology review is general inanition in a woman with end-stage dementia. I accept that evidence. I find 1 Exhibit C2a

the cause of Mrs Fort’s death to have been general inanition on a background of endstage dementia.

3. Reason for inquest 3.1. At the time of her death Mrs Fort was the subject of an Inpatient Treatment Order (ITO) that had been imposed pursuant to the Mental Health Act 2009. Accordingly, her death was a death in custody for which an inquest was mandatory. These are the findings of that inquest.

3.2. In fact two separate ITOs had been made in respect of Mrs Fort. A Level 1 ITO had been imposed by Dr Eliza Santosaputri on 15 November 2016. It had been confirmed by Dr Rene Pols, a psychiatrist, on 16 November 2016.

3.3. On 22 November 2016 Dr Christopher Veale, psychiatrist, reviewed Mrs Fort and imposed a Level 2 ITO. This order was current at the time of Mrs Fort’s death.

3.4. I have found that both ITOs were lawfully and appropriately imposed.

4. Background and medical history 4.1. Mrs Fort was born in Menindee near Broken Hill. Her father's unemployment resulted in her family moving to Adelaide so that he could seek work. Mrs Fort had a son from her first marriage. Her second marriage was to Mr Gary Fort whom she married in

5. They were married for 39 years and had two children. Mrs Fort was known to her husband, Gary Fort, as Jane. At one time she had been the bookkeeper in his furniture manufacturing business and had also worked at the Op Shop at The Hub.

Mr Fort in his statement2 suggested that his wife particularly relished this latter occupation. Mrs Fort also enjoyed overseas travel, her gym activities and ran the City to Bay marathon.

4.2. Mrs Fort's medical history included Alzheimer's dementia, cerebral atrophy, cervical dysfunction and basal cell carcinoma.

4.3. In 2014 a deterioration in Mrs Fort’s memory had been noted by her husband. While she appeared to retain a clear recollection of her childhood, her memory of recent events 2 Exhibit C1b

and circumstances was impaired. She was often incoherent. In August 2015 Mrs Fort was diagnosed with early-onset dementia.

4.4. On 22 July 2016 Mrs Fort completed an advanced care directive which included the declaration 'If I am dying, please provide me with palliative care and ensure my comfort'.

4.5. On 5 November 2016 Mrs Fort was admitted to the Flinders Medical Centre (FMC) Emergency Department after an apparent seizure. She was experiencing increased agitation and anxiety. She complained of being hot and was constantly removing her clothing with no regard to her location or to the people in her presence, behaviour which was no doubt out of character for her and which was the product of her illness.

4.6. Behavioural assessments conducted between 10 and 16 November 2016 determined that Mrs Fort was impulsive and at an increased risk of falls. Nursing notes over the same period indicate that she was frequently distressed, confused and was removing her clothing.

4.7. On 15 November 2016 Mrs Fort was agitated, restless and distressed. She was found wandering into other patients' rooms. She was non-compliant and spitting out oral medication. To ensure appropriate treatment she was prescribed clonazepam and placed on the Level 1 ITO to which I have referred.

5. Mrs Fort’s decline 5.1. On 17 November 2016 Mrs Fort was transferred to the RGH under the care of geriatrician Dr Dinesh Kannusamy. Dr Kannusamy noted that Mrs Fort was agitated, pacing, incoherent, screaming and was hitting her head on the walls. She was essentially resistant to care.

5.2. On 22 November 2016 psychiatrist Dr Christopher Veale conducted an assessment of Mrs Fort. Based on her behaviour, agitation and refusal of medication and nourishment he imposed the Level 2 ITO to which I have referred.

5.3. On 24 November 2016 there was further deterioration in Mrs Fort's condition. She was refusing oral intake.

5.4. On 25 November 2016 a family meeting was held to discuss Mrs Fort's pain and anxiety. The decision was made by Mr Fort, Dr Kannusamy and Dr Tarun Kapil, who is a geriatric registrar, to commence a morphine and midazolam subcutaneous infusion.

This was designed to relieve her pain and anxiety. Due to Mrs Fort developing an allergic reaction to morphine her pain relief was altered to fentanyl.

5.5. On 28 November 2016 Dr To, a palliative care consultant, became involved in Mrs Fort’s treatment. Following this the subcutaneous infusion was altered to hydromorphone, midazolam and Buscopan.

5.6. Mrs Fort ultimately became unresponsive and exhibited a rapid decline. On 1 December 2016 Mrs Fort was located deceased in her hospital bed. Mrs Fort was observed to have been comfortable during earlier nursing observations that night.

6. Conclusions 6.1. The circumstances surrounding Mrs Fort’s death were thoroughly examined by Brevet Sergeant Monique Vickery of the SAPOL Sturt Criminal Investigation Branch. In her investigation report3 Ms Vickery expresses the conclusion, with which I agree, that the ITOs in respect of the deceased were appropriate and valid. She points out that Mrs Fort had a confirmed mental illness as well as a terminal illness and that these circumstances had given rise to a necessity for medical intervention, including palliation, for her general care and wellbeing. Mrs Fort was demonstrating clear signs of mental health decline and was exhibiting behaviours that required intervention in order to manage her distress and pain. Such a conclusion is irresistible in my opinion. The ITOs of both Levels were in my view appropriate and lawful and were designed to promote the medical interests of Mrs Fort.

6.2. As to the appropriateness of Mrs Fort’s care and treatment at the RGH, the conclusion has been expressed by Ms Vickery that the deceased’s palliation, which was expected by both her health practitioners and family members, was appropriately delivered. I agree with that conclusion. I also agree with the conclusion that the general care and treatment of Mrs Fort at the RGH was appropriate.

3 Exhibit C12a

6.3. Mrs Fort’s husband, Mr Gary Fort, asserts as follows in his witness statement: 'I can understand why Flinders couldn’t control her without medicating her and that the girls at the Repat were fantastic.' I agree with the observation about the need for Mrs Fort to be medicated at the FMC and I acknowledge Mr Fort’s observations in relation to nursing staff at the Repatriation General Hospital.

7. Recommendations 7.1. I make no recommendations in this matter.

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 8th day of May, 2020.

Deputy State Coroner Inquest Number 2/2020 (2304/2016)