Coroner's Finding: HANCKEL Jonathan Mark

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 3rd day of March, the 29th day of May and the 5th day of June 2020, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Jonathan Mark Hanckel.

The said Court finds that Jonathan Mark Hanckel aged 58 years, late of Bridgewater, South Australia died at Daw House Hospice, Goodwood Road, Daw Park, South Australia on the 18th day of October 2016 as a result of the effects of chronic alcoholism . The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Mr Jonathan Mark Hanckel died at the Repatriation General Hospital (RGH) on 18 October 2016. He was 58 years of age at the time of his death. Prior to his death Mr Hanckel had been the subject of a series of Inpatient Treatment Orders (ITO) pursuant to the Mental Health Act 2009 which had required his detention in an appropriate treatment centre that the Flinders Medical Centre (FMC) is. Although the ITOs were no longer in force at the time of Mr Hanckel’s death, and that Mr Hanckel had been transferred from the FMC to the RGH where he would die, for reasons that I will explain in a moment this matter was investigated as a death in custody.

1.2. Mr Hanckel had a medical history that included excessive alcohol consumption and alcohol dependence with Childs class C cirrhosis with a previous episode of variceal bleeding in September 2016. He also had coagulopathy and a thrombocytopaenia. He had recently been admitted to the Royal Adelaide Hospital (RAH) Emergency Department in September 2016 with a laceration to the head. He also had a history of

aortic stenosis. Also in September of 2016 it was suspected that Mr Hanckel had experienced a myocardial infarction (heart attack).

1.3. A post mortem examination of Mr Hanckel’s remains was conducted by Dr Karen Heath, a forensic pathologist at Forensic Science South Australia. In Dr Heath’s report she expresses the cause of death as the ‘effects of chronic alcoholism’1. Dr Heath states that the cause of death was multifactorial and due to the combined effects of multiple pathologies which can be related to chronic excessive consumption of alcohol.

Dr Heath’s post mortem findings also supported a recent myocardial infarction which can predispose to cardiac arrhythmia and sudden death. However, she concluded that in Mr Hanckel’s case the clinical picture was not of sudden cardiac death but was more in keeping with death due to multiple neuropathological abnormalities combined with sepsis and hepatic encephalopathy.

1.4. Micro and macroscopic brain reports have been produced by Professor Peter Blumbergs, a neuropathologist2. Professor Blumbergs comments that Mr Hanckel’s brain showed a complex combination of multiple haemorrhages of varying sizes and sites consistent with coagulopathy. These included cortical contusion and multifocal APP positive axonal changes consistent with trauma and microabscess and microinfarcts consistent with septicaemia. An Alzheimer Type II change consistent with hepatic encephalopathy was also identified. Professor Blumbergs' reports were considered by Dr Heath in reaching her conclusions in respect of Mr Hanckel's cause of death. In her report Dr Heath has noted that at autopsy recent brain haemorrhages were in evidence.

1.5. It is apparent from the reports of both Drs Heath and Blumbergs that Mr Hanckel’s brain haemorrhages had multiple origins including trauma, coagulopathy which is a blood clotting disorder in this case likely from liver failure, septicaemia which is blood poisoning which may have originated from either the lungs or the kidneys or both and hepatic encephalopathy that can occur as a result of severe liver disease of which Mr Hanckel had a clinical history and which was also identified by Dr Heath at autopsy.

It is obvious that Mr Hanckel had been a very sick man prior to his death. Dr Heath’s 1 Exhibit C2a 2 Exhibits C3a and C3b

report states that at autopsy Mr Hanckel was 174cm and 70kg. There is no suggestion in the report that Mr Hanckel had been malnourished.

2. Reason for inquest 2.1. On 18 September 2016 Mr Hanckel had been placed on a Level 1 Inpatient Treatment Order (ITO) by Dr Medway. On 19 September 2016 this order had been confirmed by Dr Randall Long3. The order expired on 23 September 20164.

2.2. Dr Long reviewed Mr Hanckel on 22 September 2016 as the Level 1 ITO was due to expire the following day. A Level 2 ITO was imposed by Dr Long. This order was due to expire on 3 November 20165. However, on 13 October 2016 the Level 2 ITO was revoked by Dr Rene Pols after Mr Hanckel sustained an intracranial haemorrhage after a fall in the FMC. He was transferred to the Intensive Care Unit in respect of this injury. As Mr Hanckel could no longer leave the hospital the least restrictive model of care was considered appropriate. As the fall and its possible sequelae occurred while Mr Hanckel was the subject of an ITO, this death was investigated as a death in custody.

An inquest pursuant to section 21 of the Coroners Act 2003 was therefore conducted.

These are the findings of that inquest.

3. Finding as to cause of death 3.1. It is to be noted that it was not concluded by Dr Heath that the cause of Mr Hanckel’s death was as a result of an intercranial haemorrhage due exclusively to trauma but more broadly due to the combined effects of multiple pathologies which could be related to chronic excessive alcohol consumption.

3.2. I have accepted Dr Heath’s analysis. I do not believe that traumatic brain haemorrhage played a role of significance in Mr Hanckel’s death. I have found that the cause of Mr Hanckel’s death was the effects of chronic alcoholism.

4. Background 4.1. The statement of Mr Hanckel’s mother6 reveals that at one time Mr Hanckel worked as a jeweller. He also worked on an apple orchard for many years and at a vineyard.

3 Exhibit C13c 4 Exhibit C13b 5 Exhibit C13d 6 Exhibit C4

Mr Hanckel never married but had conducted a brief relationship with a woman resulting in the birth of a son. He is described as a gentle person by nature and not characteristically prone to aggressive behaviour. I accept that Mr Hanckel was brought up in a nurturing family environment. It is clear from the witness statements of the members of his immediate family that they were conscious of Mr Hanckel’s difficulties during his life and that they continued to display a high level of concern for his welfare.

4.2. Mr Hanckel’s mother states that in the years prior to his death Mr Hanckel was somewhat reclusive and preferred to be contacted via telephone. He did not allow people to visit his home and if they did attend he would not let them in. In early 2016 Mr Hanckel’s mother visited his home for the first time to find the exterior in a state of neglect. She was concerned for Mr Hanckel's safety so she contacted the police who attended the house. Police found Mr Hanckel to be intoxicated.

5. The events preceding Mr Hanckel’s death 5.1. On 22 April 2016 Mr Hanckel attended the Hahndorf Medical Centre with complaints of itchy skin and bilateral leg swelling. A baseline blood test was requested by Dr Frances Wong7. Mr Hanckel was found to have an abnormal liver function. He was also referred to a dermatologist.

5.2. On 27 April 2016 Dr Wong again reviewed Mr Hanckel. An abdominal ultrasound showed heterogeneous liver, an enlarged spleen and ascites which is consistent with chronic liver disease secondary to alcohol abuse. Dr Wong noted that Mr Hanckel had been consuming half a ‘carton’ of wine per day for the last 20 years. He was referred to a gastroenterologist at the RAH on 29 April 2016. Dr Wong advised him to stop drinking alcohol and to limit his salt intake.

5.3. On 16 August 2016 Mr Hanckel presented to the gastroenterology unit at the RAH and was admitted for decompensated Child C liver cirrhosis secondary to alcohol abuse.

He was reviewed by Drug and Alcohol Services and was discharged on 21 August 2016 to be monitored by his general practitioner for renal and liver function.

5.4. On 7 September 2016 Mr Hanckel saw Dr Wong and reported that he had been in a car accident in which his car had descended into a ditch. Dr Wong referred him to the 7 Exhibit C8

Emergency Department at the RAH and he was admitted into the care of the gastroenterology unit from 7 to 10 September 20168.

6. The events leading to Mr Hanckel’s detention and deterioration 6.1. On 11 September 2016 at about 8:30am Mr Hanckel was involved in a single vehicle accident on the Yorke Highway. He had been discharged from the RAH earlier that day. Constable Gavin Moore attended the scene and found the vehicle to have crossed onto the wrong side of the road before colliding with vegetation9. He found an off-duty nurse treating Mr Hanckel at the vehicle. Based on observations of both Constable Moore and members of the public, Mr Hanckel seemed to be confused and appeared possibly drunk or drugged. Nevertheless, the breathalyser test that Constable Moore subjected Mr Hanckel to returned a zero reading. Mr Hanckel was conveyed to Maitland Hospital for treatment and subsequent blood test results indicated a negative result to both alcohol and drugs.

6.2. Mr Hanckel had suffered a head injury which was sutured, but due to his slurred speech and apparent confusion he was admitted to the RAH for further assessment. A CT scan showed no acute injury. It was recommended that Mr Hanckel stay overnight but he discharged himself at 12:10am on 12 September 2016.

6.3. At about 3:30pm on 17 September 2016 Brevet Sergeant Noel Fealy pulled over Mr Hanckel on Port Wakefield Road10. Brevet Sergeant Fealy describes Mr Hanckel as having driven at 80 kilometres per hour in a 100 kilometre per hour zone and that he had been unable to maintain his car within its lane. Brevet Sergeant Fealy found Mr Hanckel to be visibly unwell with pale and ashen skin, laboured speech and with a confused manner. He also observed several cuts and dried blood on Mr Hanckel's head and arms which Mr Hanckel related to the previous accident that had occurred on 7 September 2016.

6.4. Brevet Sergeant Fealy conducted a roadside breath test which gave a reading of 0.015 which was consistent with Mr Hanckel's assertion that he had previously consumed only the one beer. Brevet Sergeant Fealy was concerned about Mr Hanckel's health and safety and so accompanied him to the Port Wakefield police station where he contacted 8 Exhibit C5 9 Exhibit C9 10 Exhibit C10

Mr Hanckel's mother. Brevet Sergeant Fealy offered to call an ambulance which was declined. It was apparent that Mr Hanckel required general care rather than emergency treatment. Mr Hanckel’s mother arrived at the police station to collect her son and later called Brevet Sergeant Fealy to confirm that he had been admitted to the FMC that evening.

6.5. Mr Hanckel presented at the FMC with Child C cirrhosis with evidence of portal hypotension and variceal bleeding. He was examined and found to be haemodynamically stable but not oriented as to time or place, with clear evidence of liver disease11.

6.6. At 1:30pm on 18 September 2016 Mr Hanckel self-discharged from the FMC. His mother and sister called the hospital to advise that based on telephone calls that they had been receiving from him, he was still within the hospital grounds12. Mr Hanckel was located and returned to his ward. He stated that he had been concerned about his mother's intentions in bringing him to the hospital. He thought people were plotting against him and that his family were making his skin conditions worse by throwing things at him and that those things needed to be dug out. Due to this presentation of paranoia it was determined that Mr Hanckel had an underlying chronic psychotic disorder and was therefore placed on the Level 1 ITO to which I have earlier referred.

6.7. The Level 2 ITO was imposed on 22 September 2016 due to a diagnosis of alcoholic brain injury with Wernicke-Korsakoff syndrome, a chronic delirium due to hepatic encephalopathy, and the possibility of frontal lobe dementia secondary to chronic alcohol abuse. Dr Long states that there was a clear lack of capacity due to cognitive impairment and paranoia. Nursing notes during Mr Hanckel's admission at the FMC indicated that he often refused medication and did not allow staff to dress his wounds.

He tolerated only a very limited diet. Nursing records indicate that Mr Hanckel resisted efforts to assist him with showering and toileting.

6.8. On 4 October 2016 Mr Hanckel was found attempting to take a taxi from the hospital.

Following this incident a guard special was put in place to maintain visual contact with him.

11 Exhibit C7 12 Exhibits C1 and C4

6.9. On 5 October 2016 Mr Hanckel suffered a myocardial infarction suspected as having been caused by hospital acquired pneumonia. He was reviewed by a cardiologist but could not be offered blood thinners due to a high risk of bleeding13.

6.10. In the early hours of the morning of 13 October 2016 Mr Hanckel experienced a fall on the ward. I will come to the circumstances of that in a moment. Ms Linda Tipple was the registered nurse on duty that night. In her witness statement14 she asserts that she attended to Mr Hanckel every half hour and describes him as alert but verbally agitated.

He allowed Ms Tipple to check his vital signs only on limited occasions. She found that his blood pressure was low and that his overall clinical presentation required a medical review. The night cover doctor requested that Ms Tipple continue to monitor Mr Hanckel and to report any further deterioration.

6.11. Ms Tipple indicates that on the occasions she attended Mr Hanckel the guard was sitting in a chair located outside Mr Hanckel’s room but with the door open in order to maintain visual contact with the patient.

6.12. Ms Tipple reports that at the 10pm ward round Mr Hanckel was lying in bed watching television, was alert but verbally agitated and was yelling at her to get out. Thereafter she checked on Mr Hanckel every half hour. At times he appeared to be settled and was lying down and watching television. At about midnight he was again verbally agitated.

6.13. Shortly after 12:30am (on 13 October 2016) Ms Tipple returned to Mr Hanckel's ward to find him on the floor in an extremely distressed state. He appeared to be hallucinating, was waving his arms around and was uttering incomprehensible sounds.

The guard special informed Ms Tipple that Mr Hanckel had woken in a highly agitated state and had clambered around the rails on his bed and had collapsed onto the floor.

Mr Hanckel had sustained a large skin tear on his left elbow. The bleeding was difficult to control. The guard special said that he did not see Mr Hanckel hit his head when he fell. A medical emergency team was called and Ms Tipple worked with them to comfort and treat Mr Hanckel. A nurse special was allocated exclusively to care for and monitor Mr Hanckel as he was medically unstable. The guard, who was employed by an 13 Exhibit C7 14 Exhibit C5

external agency, made no record of the incident at the time and so the only account of the event under discussion was that given verbally by the guard to Ms Tipple.

6.14. In the course of the police investigation into Mr Hanckel’s death the identity of the guard special was established through his employer’s work roster. Detective Brevet Sergeant Liouxeese Hadley originally attempted to take a statement from the security guard on 16 October 2016. On that occasion the security guard indicated that he had no recollection of the incident in question. This was the case even when shown records indicating that he had been the guard on duty at the FMC at the relevant time. A witness statement was not taken from the guard.

6.15. Following the hearing of this inquest I caused further inquiries to be made in relation to the guard. These inquiries were conducted by Detective Sergeant Andrew Bissell of the Mount Barker Criminal Investigation Branch. Mr Bissell had been the original investigator in charge of the SAPOL investigation into Mr Hanckel’s death. Mr Bissell contacted the gentleman in question on 27 April 2020. This individual again advised that he had no recollection of the incident and asserted that he saw no point in making a statement.

6.16. There is something of an unsatisfactory impasse in relation to the attempts that have been made to obtain a definitive eye witness account of what transpired in relation to Mr Hanckel in the early hours of the morning of 13 October 2016. In saying this I am not critical of police who have been involved in the attempts to take a statement from the guard. Having carefully considered the matter I have no reason to doubt the account given by the guard to Ms Tipple. And there is certainly no evidence to the contrary.

The guard’s account as imparted to Ms Tipple would be in keeping with Mr Hanckel’s earlier demeanour that night.

6.17. Having come to the conclusion that the fall that Mr Hanckel experienced, and indeed any internal head injury that he suffered as a consequence, did not significantly contribute to his death, I have further concluded that there is no public or private interest to be served for the delivery of the findings in this inquest to be further delayed by an insistence on this Court hearing from the guard.

6.18. Later that same morning following the incident described above, Mr Hanckel was found to be alert and responsive with a GCS of 14 which is considered normal. However, at a clinical review conducted by Dr Rene Pols it was found that Mr Hanckel had

experienced significant and profound deterioration in his level of consciousness. His GCS score later dropped to 11. Mr Hanckel was transferred to the Intensive Care Unit.

A CT scan showed two large intraparenchymal haematomas with mass effect and extension to the subarachnoid space15.

6.19. At 5pm Dr Pols completed a revocation of the ITO16 on the basis that Mr Hanckel would be unable to leave the hospital in any event due to the intracranial haemorrhage. A follow-up scan on 14 October 2016 showed a new right occipital haematoma.

Mr Hanckel had recovered from pneumonia but was found to have an infection which was treated with antibiotics.

6.20. Over the next days discussions were undertaken with Mr Hanckel's family about palliative care. FMC medical notes indicate that Mr Hanckel’s mother felt that there should be no further treatment unless there was a reasonable chance of good recovery.

An agreement was made for palliative care. Mr Hanckel was admitted to the RGH on 17 October 2016 for comfort care. He was unresponsive until he passed away at around 2:50pm on 18 October 2016. Mr Hanckel was certified deceased by Dr Teng Kang who expressed the opinion that the bleed pattern of Mr Hanckel's brain was not what would usually be seen in a head injury and that he would have likely died soon regardless of the fall that had occurred on 13 October 2016, a fall which he opined may or may not have accelerated his death17. I have earlier observed that the intracranial bleeding at autopsy was found to have multiple pathological origins not only traumatic.

Dr Kang’s opinion as to the bleed pattern are in keeping with the post mortem findings.

7. Conclusions 7.1. I am grateful for the thorough report into the circumstances of Mr Hanckel’s death that was compiled by Detective Sergeant Bissell to whom I have referred. His report is dated 2 November 201718.

7.2. Mr Hanckel’s death was the subject of a very comprehensive police investigation.

Detective Sergeant Bissell’s report expresses a number of conclusions in respect of the circumstances surrounding Mr Hanckel’s death. Detective Sergeant Bissell concluded, as have I, that the Inpatient Treatment Orders of both levels had been lawfully and 15 Exhibit C7 16 Exhibit C13e 17 Exhibit C12 18 Exhibit C13a

appropriately imposed on Mr Hanckel and had been imposed with his clinical interests in mind. It is my opinion that neither order, nor the detention imposed pursuant to them, contributed in any way to Mr Hanckel’s death. I so find.

7.3. As to the appropriateness of the care that was provided to Mr Hanckel at the Flinders Medical Centre and the Repatriation General Hospital, Detective Sergeant Bissell expresses the conclusion that the care so provided to Mr Hanckel was appropriate.

7.4. Having considered all of the evidence presented to the Court, I find that the care provided to Mr Hanckel both at the Flinders Medical Centre and at the Repatriation General Hospital was appropriate.

7.5. For reasons already expressed, I have also concluded that the cause of Mr Hanckel’s death was the effects of chronic alcoholism. I have accepted the forensic medical opinion that there were multiple haemorrhages within Mr Hanckel’s brain that had varying origins, for the most part, if not exclusively, caused by coagulopathy and hepatic encephalopathy. This pathology in my opinion was no doubt the result of excessive alcohol consumption over many years. Mr Hanckel was a very unwell individual even before the incident on the morning of 13 September 2016. I accept that any trauma that Mr Hanckel experienced as a result of what is believed to have been a fall from bed did not significantly contribute to the cause of his death.

8. Recommendations 8.1. I have no recommendations to make in this matter.

8.2. During the course of the inquest a submission was made on behalf of Mr Hanckel’s family that in relation to any incident within a hospital in which trauma has been occasioned to a patient and which has been witnessed by or has occurred in the presence of a guard, that the incident should be the subject of a written report or other documentation compiled by that guard. It is suggested that such documentation should be placed in the clinical file of the patient and be submitted with the agency with which the guard is employed. Although this would not appropriately form the basis of a formal coronial recommendation, the legitimacy of such a measure is obvious and I would commend it to the Chief Executive Officer of the Department of Health.

8.3. A submission was also made to the Court that Mr Hanckel’s fall from bed could have been prevented by the institution of a nurse special at an earlier point in time. This point was not developed to any significant extent during the course of the inquest.

Clearly there would be resource implications involved in such a measure. In addition, the evidence was not sufficiently persuasive to enable the Court to reach a conclusion that in all cases such as Mr Hanckel’s a nurse special would be appropriate or necessary, particularly having regard to the deployment of a guard special. I simply draw this submission also to the attention of the Chief Executive Officer of the Department of Health.

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 5th day of June, 2020.

Deputy State Coroner Inquest Number 5/2020 (2021/2016)