Coroner's Finding: FOSTER Patricia Marie

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 11th day of June 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 Patricia Marie Foster.

The said Court finds that Patricia Marie Foster aged 76 years, late of St Laurence's Court Nursing Home, 56 High Street, Grange, South Australia died at the Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, South Australia on the 23rd day of July 2018 as a result of infective exacerbation of chronic congestive cardiac failure due to Respiratory Syncytial Virus on a background of advanced dementia and schizophrenia. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Patricia Marie Foster was born on 5 February 1942 and died on 23 July 2018 at the Queen Elizabeth Hospital (QEH). She was 76 years old.

1.2. A pathology review of Ms Foster’s clinical history and medical records was performed by Dr Iain McIntyre from Forensic Science South Australia in discussion with Dr John Gilbert, forensic pathologist.1 The cause of death stated in his report of that review is infective exacerbation of chronic congestive cardiac failure due to Respiratory Syncytial Virus in a woman with advanced dementia and schizophrenia, and I so find.

1.3. Ms Foster’s death was subject to a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Ms Foster was detained under an Inpatient Treatment Order 1 Exhibit C2a

(ITO) at the time of her death. Ms Foster had been detained at the QEH on 19 July following her presentation that day with a number of medical issues. She was suffering from advanced stage dementia and schizophrenia. As a result of those conditions she was acting aggressively and refusing medical treatment.2 Consequently she was placed on a Level 1 ITO pursuant to section 21 of the Mental Health Act 2009. That order was due to expire on 26 July 2018 and was therefore in effect at the time of Ms Foster’s death on 23 July 2018.3 There are no concerns in relation to the lawfulness of custody.

2. Background and medical history 2.1. Ms Foster was living at the St Laurence’s Court Nursing Home in Grange. She had been a resident at that location for about four years prior to her death.

2.2. The following medical history is noted in the pathology review of Dr McIntyre: Advanced dementia • Schizophrenia • Ischaemic heart disease • Chronic congestive cardiac failure • Postural hypotension • Diabetes, Type 2 • Macular degeneration •

• Falls 4

3. Ms Foster’s clinical circumstances and decline 3.1. Ms Foster was admitted to the QEH on 6 July 2018 with shortness of breath. The shortness of breath was multifactorial, with contributing factors including lower respiratory tract infection, congestive cardiac failure and anaemia.5

3.2. As noted above Ms Foster had a significant medical history that included schizophrenia, dementia, congestive cardiac failure, type 2 diabetes, hyperlipidaemia, chronic obstructive pulmonary disease, chronic kidney disease, anaemia, recurrent respiratory tract infections, macular degeneration, dual incontinence, osteoarthritis and recurrent 2 Exhibit C5 3 Exhibit C8 MD3 4 Exhibit C2a 5 Exhibit C5

falls. Ms Foster was treated for her condition and on 10 July 2018 she returned to her nursing home.6

3.3. On 19 July 2018 Ms Foster was readmitted to the QEH following a cardio-respiratory arrest in her nursing home. South Australian Ambulance Service attended and paramedics commenced CPR successfully before sighting Ms Foster’s not for resuscitation directive. Ms Foster was conveyed to the QEH.7 Upon admission Ms Foster was noted to be hypoxic and in respiratory distress. An X-ray confirmed it was an infective exacerbation of her cardiac failure. A nasal swab revealed the causative organism to be a Respiratory Syncytial Virus. Ms Foster’s treating team formed the opinion that Ms Foster was suffering multifactorial respiratory distress with contributing factors of hospital acquired pneumonia, Respiratory Syncytial Virus, decompensated cardiac failure and anaemia. Ms Foster was treated with bronchodilators, oxygen and steroid therapy intravenously. The situation was further complicated by Ms Fosters schizophrenia.

3.4. During the course of her admission Ms Foster was noted to have intermittent confusion, agitation and aggression towards staff, in addition to disorientation and nonsensical speech including delirium. She was observed to intermittently remove her oxygen mask making adherence to medical treatment difficult and placing her physical health at risk of further deterioration.

3.5. On 19 July 2018 Ms Foster was examined by the resident medical officer in the acute medical unit of the QEH, Dr Vicki Christodoulou. Dr Christodoulou formed the opinion that Ms Foster posed a risk to herself with the potential for further deterioration of her physical health and a risk to others in the context of displaying verbal and physical aggression. Accordingly, Dr Christodoulou imposed a Level 1 ITO upon Ms Foster. That order was confirmed by a psychiatrist the following day and was due to expire on 26 July 2018.

3.6. Despite ongoing treatment and medication Ms Foster’s medical condition continued to decline.

6 Exhibit C5 7 Exhibit C5

3.7. On 22 July 2018 Enrolled Nurse Luciano Calderisi was looking after Ms Foster’s care.8 At the start of his shift at 9:16pm Mr Calderisi noted Ms Foster was awake and alert and they had a conversation, although Ms Foster was in a confused mental state due to her dementia and mental illness.

3.8. Ms Foster was noted as being awake at about 2am on 23 July 2018, but she became unsettled and then fell asleep. She was observed asleep and breathing at 4am.

3.9. At about 4:50am Mr Calderisi returned to Ms Foster’s room for a routine observation and noticed she was un-responsive and not breathing. A MET9 call was activated, but no attempts at resuscitation occurred in light of the not for resuscitation directive.10 A short time later Ms Foster was declared life extinct.

4. Coronial investigation and conclusion 4.1. Detective Brevet Sergeant Nicholas Blandford from the Western District Criminal Investigation Branch of SAPOL was tasked with investigating Ms Foster’s death in custody. Detective Blandford conducted a thorough investigation and provided a report to the State Coroner which was tendered to the inquest.11

4.2. Following his investigation Detective Blandford formed the opinion that the care provided to Ms Foster was appropriate and that her detention under the Mental Health Act 2009 was lawful. I agree with the conclusions of Detective Blandford and find that Ms Foster received an appropriate level of care at the QEH and her detention was both necessary and lawful in the circumstances.

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 53/2020 (1387/2018) 8 Exhibit C3 9 Medical Emergency Team 10 Exhibits C3, C4 and C5 11 Exhibit C8