Coroner's Finding: HANSLOW Walter Robert

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 Walter Robert Hanslow.

The said Court finds that Walter Robert Hanslow aged 75 years, late of St Josephs House, 22 Norman Street, Port Pirie, South Australia died at the Port Pirie Regional Health Service, The Terrace, Port Pirie, South Australia on the 10th day of June 2018 as a result of bilateral subdural haematoma. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Walter Robert Hanslow was born on 23 November 1942 and died on 10 June 2018 at the Port Pirie Regional Health Service (Port Pirie Hospital). He was 75 years of age.

Mr Hanslow’s body was identified by his son in law, Mr Peter Arbon.

1.2. A pathology review of Mr Hanslow’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 bilateral subdural haematomata due to fall, and I so find.

2. Reason for inquest 2.1. Mr Hanslow’s death was the subject of a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mr Hanslow was detained under a guardianship order with 1 Exhibit C2a

special powers pursuant to section 32 of the Guardianship and Administration Act 1993 at the time of his death.2

2.2. In approximately 2008 Mr Hanslow was diagnosed with Parkinson’s disease and in 2015 Dr Myketa diagnosed Mr Hanslow with Alzheimer’s disease. On 8 November 2017 the South Australian Civil and Administrative Tribunal (SACAT) granted a full guardianship order with special powers under section 32 of the Act in relation to Mr Hanslow. Those powers granted Mr Hanslow’s guardian, his wife Lois Hanslow, with the ability to determine his place of residence and to detain him at the residence if required. Mr Hanslow was detained at St Joesph’s House in Port Pirie. There are no concerns in relation to the lawfulness of custody.

3. Background 3.1. Mr Hanslow was married with seven children. He and his wife Lois were married in 1992 and were parents to five children being Christopher, Clinton, Amanda, Keziah and Natalie. Mr Hanslow also had two children, Geraldine and Brett, from a previous marriage.

3.2. Mr Hanslow had been an Aboriginal education worker until he was forced to cease his employment due to an accident that resulted in a spinal injury in 1979.

3.3. As noted Mr Hanslow had been diagnosed with Parkinson’s disease and Alzheimer’s disease. The level of care required by Mr Hanslow led to his placement and detention in a nursing home in Port Pirie. Mr Hanslow was a tall slender man who was liked by the staff responsible for his care at St Joseph’s House. Staff, and in particular his personal care assistant, Ms Polma Coleman, were very emotional at his passing.3

4. Medical history and clinical circumstances surrounding Mr Hanslow’s death 4.1. It is noted in Dr McIntyre’s pathology review report that Mr Hanslow’s medical history included Parkinson’s disease with associated dementia, falls, chronic renal impairment, bilateral hip fractures of femoral neck, a total knee replacement and Type 2 diabetes.

2 Exhibit C7a 3 Exhibit C5

4.2. At about 3pm on 9 June 2018 personal care assistant Polma Coleman commenced her shift at St Joseph’s House.4 At about 6:10 pm she returned from her meal break and spoke with one of the residents who informed her that Mr Hanslow had been in her room and told her he did not need his wheel chair anymore. He had left his wheelchair in her room. This was of note to Ms Coleman as Mr Hanslow could not walk unassisted.

Ms Coleman went to check on Mr Hanslow. Ms Coleman found Mr Hanslow lying on the ground in the foetal position between the corridor and the doorway of room 14. She immediately activated the emergency bell. Mr Hanslow was conscious. He laughed when asked what he was doing and if he was alright. There were no obvious signs of injury. Mr Hanslow was assisted by a number of staff who spent the next 30 minutes assessing him. There were no obvious injuries or symptoms.

4.3. Ms Coleman and other staff regularly checked on Mr Hanslow for the remainder of the evening and he seemed his normal self. However, at 8:30pm Ms Coleman returned to Mr Hanslow’s room and he appeared very agitated and had soiled himself. His agitation resolved once he was cleaned. Ms Coleman checked on him again at 10pm just prior to completing her shift. Mr Hanslow appeared to be his normal self. He was conscious and watching the football.

4.4. Enrolled Nurse Sandra Champion commenced her shift at 10:45pm that evening.5 At 12:05am she and other medical staff attended Mr Hanslow’s responding to an alarm.

They discovered Mr Hanslow had recently vomited. His eyes were closed and he would not open them. When spoken to by nursing staff he simply responded by making grunting and gagging noises. He was pale in complexion and had a bruise on his right temple.

4.5. Ms Champion took Mr Hanslow’s blood pressure, which was elevated, along with his pulse and temperature, which were normal; and his oxygen saturation levels, which were low.

4.6. The decision was made to transfer Mr Hanslow to hospital and an ambulance was summoned. Whilst waiting for the ambulance Mr Hanslow vomited again. Following their arrival ambulance staff attended to Mr Hanslow for approximately 40 minutes before they transferred him to the Port Pirie Hospital.6 4 Exhibit C5 5 Exhibit C4 6 Exhibit C4

4.7. At about 2:15am on 10 June 2018 Mr Hanslow arrived at the Emergency Department of the Port Pirie Hospital. He presented unconscious. Mr Hanslow had shallow irregular breathing with a right upper eyelid haematoma.7

4.8. Mr Hanslow had an Advance Care Directive instructing that he was not for resuscitation (DNR). An urgent CT scan was conducted which revealed Mr Hanslow had a large left subdural haematoma with a right side haemorrhage and herniation.

4.9. The treating doctor at the Port Pire Hospital, Dr Ali Altalebi, consulted with the on-call neurosurgeon at the Royal Adelaide Hospital and was advised that Mr Hanslow had a very high risk of death if he was not operated on. In light of the DNR directive Mr Hanslow was admitted for palliative care. Mr Hanslow was made comfortable until his death at 10:10am on 10 June 2018.

5. Coronial investigation 5.1. Detective Brevet Sergeant Paul Clonan from the Port Pirie Criminal Investigation Branch of SAPOL was tasked with investigating Mr Hanslow’s death in custody.

Detective Clonan conducted a thorough investigation and provided a report to the State Coroner which was tendered to the inquest.8

5.2. Following his investigation Detective Clonan formed the opinion that the care provided to Mr Hanslow was appropriate and that his detention under the Guardianship and Administration Act 1993 was lawful. I agree with the conclusions of Detective Clonan and find that Mr Hanslow received an appropriate level of care at both St Joseph’s House and the Port Pirie Hospital. I further find that his detention was lawful and did not in any way contribute to his cause of death.

Key Words: Death in Custody; Natural Causes; Section 32 Powers 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 50/2020 (1052/2018) 7 Exhibit C3 8 Exhibit C7a