Coroner's Finding: HANAN Desmond George

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 4th day of June and the 16th day of July 2020, by the Coroner’s Court of the said State, constituted of Paul Marvin Foley, Deputy State Coroner, into the death of Desmond George Hanan.

The said Court finds that Desmond George Hanan aged 90 years, late of 2/336 Marion Road, North Plympton, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 25th day of November 2018 as a result attributed to pneumonia complicating fractured right neck of femur (operated) on a background of hypertension and cerebrovascular disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Desmond George Hanan was born on 19 February 1928 and died on 25 November 2018 at the Royal Adelaide Hospital in Adelaide. He was 90 years of age. Mr Hanan was formally identified by his son, Bruce Hanan, at the Royal Adelaide Hospital on 25 November 20181.

1.2. A pathology review based on Mr Hanan’s medical records and clinical history was conducted by Dr Iain McIntyre from Forensic Science South Australia on 27 November

20182. Dr McIntyre was of the opinion that Mr Hanan’s death was due to pneumonia complicated by a fracture of the right neck of his femur and hypertension and cardio 1 Exhibit C1, PD44 Identification of Deceased 2 Exhibit C2a, Pathology Review by Dr Iain N McIntyre dated 27 November 2018

vascular disease. Dr McIntyre noted a history including a 2013 cerebral infarction, atrial fibrillation, renal carcinoma, total right knee replacement, left inguinal hernia, falls and prostatic hypertrophy.

1.3. I find Mr Hanan’s death was attributed to pneumonia complicating fractured right neck of femur (operated) on a background of hypertension and cerebrovascular disease.

2. Reason for inquest 2.1. Mr Hanan had been detained on a Level 1 Inpatient Treatment Order (ITO) at 10:30pm on 19 November 2018 by psychiatrist, Dr Jane Willet, pursuant to section 21 of the Mental Health Act 2009. The ITO was confirmed by psychiatrist, Dr Jonathan Symon, on 22 November 2018 at 10:20am. The Level 1 ITO was still in place at the time of Mr Hanan’s death on 25 November 2018. Accordingly, Mr Hanan’s death is regarded as a death in custody and as such this is a mandatory inquest pursuant to section 21(1)(a) of Coroners Act 2003.

3. Background 3.1. Mr Hanan had been married to Mrs Vidus Hanan for 63 years having first met in about

1952. Mr Hanan worked for businesses including G & R Wills and Cash and Carry.

After retiring he volunteered as bar manager at his local RSL club. In around 2004 Mr and Mrs Hanan retired to Cedar Court3.

3.2. In approximately 2013 Mr Hanan suffered a major stroke and spent three weeks at the Repatriation General Hospital. He undertook speech and movement therapy. He remained with weakness on his right side. Despite that he could go on outings and to the Marion Shopping Centre. In his final twelve months, Mr Hanan developed issues with his balance4. This affected his ability to rise to his walker.

3.3. On 19 November 2018 Mr Hanan had a fall at home leading up to his final hospitalisation. Mr Hanan had significant pain emanating from his hip. An ambulance was called and he was taken to the Royal Adelaide Hospital.

3 Exhibit C3, Affidavit of Vidus Ethel Hanan dated 12 July 2019 4 Exhibit C8, Affidavit of Dr Ralph Faggoter dated 20 June 2019

4. Mr Hanan’s hospitalisation and detention 4.1. Mr Hanan was admitted to the orthopaedic ward at Royal Adelaide Hospital on 19 November 2018 with a fracture to the neck of his right femur. It was noted he was agitated and cognitively impaired. Mr Hanan was lashing out, removing his oxygen supply and refusing observations. Mr Hanan was then placed on the Level 1 ITO by Dr Willet as noted previously. Mr Hanan was assessed on 20 November 2018 and was unable to provide an accurate history. It was concluded that Mr Hanan was experiencing delirium.

4.2. On 20 November 2018 it was thought that Mr Hanan might be operated on following his fall5. That did not happen. Mr Hanan was aggressive, confused and argumentative.

On 21 November 2018 Mr Hanan’s son, Grant, described Mr Hanan as being in ‘ga ga land’. Mr Hanan was operated upon at 9pm that evening to repair his fractured femur.

The alternative of no surgery was discussed with Mr Hanan’s family and the family chose the surgical option6. Following surgery Mr Hanan displayed further agitation.

4.3. On 22 November 2018 Mr Hanan was described by his son as ‘drugged up’. Dr Symon assessed Mr Hanan on this date and confirmed the ITO. There had been a delay in the review as the Psychiatry Consultation Liaison Service was not notified of the initial order until 21 November 2018, by which day Mr Hanan was in surgery and could not be reviewed. Dr Symon stated the review was undertaken at the first opportunity on 22 November 20187. Dr Symon found Mr Hanan was suffering from delirium and increasing agitation8.

4.4. On 23 November 2018 Mr Hanan’s son Grant stated that Mr Hanan was frustrated and wanted to go home. On 24 November 2018 his son stated Mr Hanan ‘looked very good’ and wanted to go home. On this date it was considered that Mr Hanan’s delirium was improving. However, it was noted Mr Hanan had contracted hospital acquired pneumonia for which he was treated with antibiotics.

5 Exhibit C4, Affidavit of Grant Hanan dated 18 July 2019 6 Exhibit C7, Affidavit of Dr Justin Munt dated 18 December 2019 7 Exhibit C6, Affidavit of Dr Jonathan Symon dated 16 October 2019 8 Ibid at paragraph 3

5. Circumstances of death 5.1. On 25 November 2018 Mr Hanan was visited by his wife and son, Bruce. Whilst Bruce Hanan states that his father was cognitively good, he notes that his father’s chest sounded horrible and he was not clearing the mucus.9

5.2. The nurse attending to Mr Hanan that day, Jessica Schoerghuber, stated the main concern with Mr Hanan was that he was phlegmy post procedure and very chesty. She said Mr Hanan was on antibiotics and in the morning had been jovial and communicative. Despite his chesty cough Mr Hanan did not appear to be in distress10.

Due to concerns a repeat chest X-ray was ordered and continual mouth suctioning was undertaken. Mr Hanan’s cough was a matter of concern, but all other routine observations were in order.

5.3. The Royal Adelaide Hospital protocol for treatment of hospital acquired pneumonia is prompt treatment with intravenous antibiotics. Chest X-rays were immediately ordered once it was suspected Mr Hanan had an infection and at that time he was receiving intravenous antibiotics11.

5.4. Mr Hanan quietly passed just after handover at about 1:20pm on 25 November 2018.

Dr Asunch declared life extinct at 1:52pm on that day.

6. Coronial investigation 6.1. Senior Constable Matthew Walton12 attended the Royal Adelaide Hospital at about 4:55pm on 25 November 2018 in relation to the death of Mr Hanan. Senior Constable Walton observed the body of Mr Hanan and made other observations at the Royal Adelaide Hospital in accordance with standard procedures.

6.2. Brevet Sergeant Darren Lambert attended the Royal Adelaide Hospital at about 6:20pm on 25 November 2018 and undertook the standard photographic procedures applicable to deaths where an ITO has been in place13.

9 Exhibit C1a, Affidavit of Bruce Hanan dated 5 September 2019 10 Exhibit C5, Affidavit of Jessica Alexandra Schoerghuber dated 21 June 2019 11 Supra n.6 at paragraph 12 12 Exhibit C9, Affidavit of Senior Constable Matthew Walton undated 13 Exhibit C10, Affidavit of Brevet Sergeant Darren Lambert dated 13 September 2019

6.3. Brevet Sergeant Jake Wild investigated the death in custody of Mr Hanan and prepared a comprehensive report for the State Coroner that was tendered to the inquest14. Brevet Sergeant Wild found no issues of concern during his investigation.

7. Conclusions and recommendations 7.1. I find that the care and treatment received by Mr Hanan at the Royal Adelaide Hospital was appropriate in the circumstances. I further find that the imposition of the Inpatient Treatment Orders were appropriate and that they had no bearing on Mr Hanan’s death.

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 16th day of July, 2020.

Deputy State Coroner Inquest Number 62/2020 (2287/2018) 14 Exhibit C11, Final Report of Brevet Sergeant Jake Wild dated 30 December 2019