Coroner's Finding: FRANKLIN Murray Lenard

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 Murray Lenard Franklin.

The said Court finds that Murray Lenard Franklin aged 78 years, late of Estia Health, 7 Langhorne Creek Road, Strathalbyn, South Australia died at the Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 2nd day of March 2017 as a result of general inanition on a background of end-stage dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Mr Murray Lenard Franklin was born on 5 June 1938 and died on 2 March 2017 at the Repatriation General Hospital in Daw Park. He was 78 years of age.

2. Cause of Death 2.1. Mr Franklin’s medical notes were reviewed by Dr Iain McIntyre of Forensic Science South Australia and discussed with forensic pathologist, Dr Cheryl Charlwood. In his pathology review report1 Dr McIntyre has provided a cause of death of ‘general inanition in a man with end-stage dementia’. I find that the cause of Mr Franklin’s death was general inanition on a background of end-stage dementia.

1 Exhibit C2a

3. Reason for inquest 3.1. Mr Franklin’s death was the subject of a mandatory Inquest pursuant to section 21 of the Coroners Act 2003 as at the time of his death he was under a Level 2 Inpatient Treatment Order (ITO) that had been made pursuant to section 25 the Mental Health Act 2009.

3.2. On 10 February 2017 Mr Franklin was placed on a Level 1 ITO by Dr Lynette Jones at the Flinders Medical Centre. This order was confirmed on 11 February 2017 by consultant psychiatrist, Dr James Lally.

3.3. On 13 February 2017 psychiatrist Randall Long imposed a Level 2 ITO. Mr Franklin remained under the Level 2 ITO until his death. The order was due to expire on 27 March 2017.

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

4. Medical history and background 4.1. Mr Franklin had a medical history that included advanced mixed dementia with behavioural issues including severe aggression. Mr Franklin also suffered from prostate cancer, chronic obstructive lung disease and depression and had a history of falls.

4.2. Mr Franklin grew up in Strathalbyn and had six children with his first wife, Heather.

He began a relationship with Wendy Franklin in 1983 after the break down of their respective marriages. They subsequently married and purchased a house in Myponga.

4.3. Mr Franklin was a pilot for most of his working life. Between 1988 and 1998 he and Mrs Franklin lived on Thistle Island, in the Spencer Gulf. They were married in 1992.

4.4. In 1997 Mr Franklin was diagnosed with bowel cancer and became quite ill. The couple then moved back to the mainland to be closer to hospitals. They settled in Goolwa and Mr Franklin was in remission until he was diagnosed with prostate cancer in 2010 for which he had further surgeries and was in remission.

4.5. In 2012 Mr Franklin was diagnosed with dementia by psychiatrist Dr Bruno Franchi.2 Mrs Franklin3 described his behaviour as starting to change in the year or two prior to his official diagnosis. She stated that he had been increasingly forgetful, suffering depression and became a hoarder. He would get angry and frustrated that he was so forgetful. His dementia progressively worsened.

4.6. On 26 April 2016 Mr Franklin moved into Estia Health at Strathalbyn. Whilst in care he became increasingly confused and agitated. Mrs Franklin stated that her husband was not normally aggressive or violent, but that he became increasingly so, and on one occasion he hit another patient.4

4.7. Mr Franklin was admitted to the Strathalbyn Hospital on 11 November 2016 and 3 January 2017 for assessment and management of his aggressive behaviour and wandering.5

4.8. On 4 January 2017 Mr Franklin was transferred from the Strathalbyn Hospital to the Flinders Medical Centre (FMC) because of aggressive behaviour that Estia staff were unable to manage. Whilst a patient at the FMC, Mr Franklin had multiple code blacks6 for aggression.

4.9. On 10 January 2017 Mr Franklin was transferred to the Repatriation General Hospital in Daw Park. He was discharged back to Estia in Strathalbyn on 30 January 2017.7

4.10. Mr Franklin’s continued aggression could not be managed at Estia Health and he was admitted to the Strathalbyn Hospital on 8 February 2017 before being transferred8 to the FMC on the evening of 9 February 2017. Mr Franklin was admitted to the FMC early on 10 February 2017 where he was placed on a Level 1 ITO by Dr Lynette Jones.

4.11. This order was confirmed on 11 February 2017 by Dr James Lally, Consultant Psychiatrist.

2 Exhibit C5 3 Exhibit C3, Statement of Mrs Wendy Franklin 4 Exhibit C3, page 6 5 Exhibit C7, Statement of Dr Peter Michelmore. page 5 6 Personal threat, for example assault, violence, threatening behaviour 7 Exhibit C7, page 6 8 Exhibit C7, page 7

4.12. On 13 February 2017 psychiatrist Randall Long reviewed Mr Franklin’s Level 2 ITO as he continued to be aggressive to staff and to others.9

4.13. Dr Long found that Mr Franklin was suffering from severe dementia of the Alzheimer’s type with behavioural and personality disturbances that included violence, unsafe behaviours that put his safety at risk and he remained in a confused and agitated state.10

4.14. Dr Long noted that during his admission Mr Franklin experienced multiple falls and a lower respiratory tract infection.

4.15. On 14 February 2017 Mr Franklin was transferred to the Geriatric Evaluation and Management Ward at the Repatriation General Hospital due to his increasingly aggressive behaviour.

5. Mr Franklin’s decline in health 5.1. Mr Franklin suffered further complications including the development of acute renal failure and swallowing difficulties which made it difficult to feed him. On 21 February 2017 a decision was made, in conjunction with Mr Franklin’s family, that as his condition had declined further, a comfort care approach was to be adopted.

5.2. Mr Franklin was provided with palliative care, but not life prolonging treatments and he died on 2 March 2017 whilst under the Level 2 ITO.

5.3. Registered Nurse Barbara Zwarts was the last person to see Mr Franklin alive. She had been caring for him on the evening of 2 March 2017.11 From 9:30pm on 2 March 2017 Ms Zwarts was performing checks on Mr Franklin every 10 to 15 minutes. Ms Zwarts then checked on him at 10:25pm and observed a chest movement and then the movements ceased. Dr Basil Albehadaway attended and certified Mr Franklin’s death at about 10:50pm.

5.4. Mrs Wendy Franklin stated that: ‘At no time did I have any concerns about the way Murray was being treated or being looked after at any of the facilities he stayed in.’12 9 Exhibit C4, page 2 and Exhibit C5 10 Exhibits C4 and C5 11 Exhibit C1b 12 Exhibit C3, page 10

Mrs Franklin sets out in some detail in her statement her praise of Estia at Strathalbyn, the Flinders Medical Centre and the Repatriation General Hospital.

6. Conclusion 6.1. Consistent with the conclusions of the SAPOL Investigating Officer, Detective Brevet Sergeant Lucy Schiek, I find that Mr Franklin was in lawful detention at the time of his death.13 The circumstances surrounding his death are not suspicious and there were no concerns relating to the quality of care Mr Franklin received whilst detained.

7. Recommendations 7.1. I have no recommendations to make 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 28th day of May, 2020.

Deputy State Coroner Inquest Number 15/2020 (0403/2017) 13 Exhibit C11a