Coroner's Finding: HARVEY Lawrence 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 21st day of May 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 Lawrence George Harvey.

The said Court finds that Lawrence George Harvey aged 85 years, late of 74 Tottenham Court Road, Port Elliott, South Australia died at the Noarlunga Health Service, Alexander Kelly Drive, Noarlunga Centre, South Australia on the 16th day of November 2017 as a result of end stage dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Lawrence George Harvey was born on 2 March 1932 and died at the Noarlunga Health Service (Noarlunga Hospital) on 16 November 2017. He was 85 years of age.

1.2. Following Mr Harvey’s death, Dr Ritu Saxena completed a ‘Death Report to Coroner

• Medical Practitioner’s Deposition’ on 17 November 2017. In that report she provided her opinion that the cause of Mr Harvey’s death was end-stage dementia.1 I accept Dr Saxena’s opinion and find that to have been the cause of Mr Harvey’s death.

1.3. Mr Harvey’s death was subject to a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mr Harvey had been detained on an Inpatient Treatment Order (ITO) at the time of his death. His death was therefore regarded as a death in custody.

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1.4. A Level 1 ITO was made pursuant to section 21 of the Mental Health Act 2009 by Dr Michael Haines at the Flinders Medical Centre on 18 October 2017. That order was reviewed and confirmed by psychiatrist Dr Randall Long on 19 October 2017. That treatment order expired on 25 October 2017.

1.5. A Level 2 ITO was made pursuant to section 25 of the Mental Health Act 2009 by psychiatrist Dr Richard Weeks on 25 October 2017 following an examination of Mr Harvey at the Repatriation General Hospital. The Level 2 ITO was current at the time of Mr Harvey's death with an expiry date of 6 December 2017. There are no concerns in relation to the lawfulness of custody.

2. Background and medical history 2.1. Mr Harvey was married to his wife, June, for 63 years. The pair married in England in 1955 and moved to Australia in 1971. In 1960 prior to their move to Australia Mr Harvey was involved in a motorcycle accident in which he sustained a broken left leg requiring insertion of a number of screws. Following his arrival in Australia Mr Harvey worked at the Chrysler Mitsubishi plant in Tonsley for 16 years. Mr Harvey retired at the age of 60 due to a degenerative spine condition. Mr Harvey and his wife had two children, a daughter Dawn and a son Gary.2

2.2. Mr Harvey had a number of medical conditions which were being managed by his general practitioner of 14 years, Dr Justin Shute who practiced at the Victor Harbor Medical Centre. Dr Shute provided a statement to the Court dated 17 April 2018 which details Mr Harvey’s medical conditions.3

2.3. Mr Harvey was diagnosed with Type 2 diabetes in 1986 which was managed with insulin and Janumet.4 Mr Harvey was diagnosed with ischaemic heart disease in 1994 and took a number of preventative medications. Mr Harvey's heart was considered stable when he saw cardiologist Dr Cameron Bridgman on 28 May 2013. His heart problems were asymptomatic from 2013 onwards with the exception of one occasion in August 2017 when Mr Harvey attended Victor Harbor Medical Centre with angina.

He was subsequently admitted to the South Coast District Hospital for three days and investigations revealed he suffered a small heart attack that was treated with 2 Exhibit C1a 3 Exhibit C3 4 Janumet helps to lower blood sugar levels in patients with Type 2 diabetes mellitus

medication.5 Mr Harvey was formally diagnosed with epilepsy in March of 2013 and with dementia on 27 June 2013. Both of those diagnoses were made by consultant neurologist Dr Parasivam at the Flinders Medical Centre.6

3. Mr Harvey’s decline due to dementia 3.1. From 2016 there was a worsening of Mr Harvey's dementia leading to uncharacteristic behaviour on his part. There were displays of verbal and physical aggression towards his wife, a loss of perception of time which saw him awake during the night as he thought it was daytime. Mr Harvey forgot how to dress and toilet himself and he required 24-hour care from his wife. By early 2016 Mr Harvey would forget who his wife was one minute only to recognise her moments later.

3.2. Mr Harvey's general practitioner prescribed the antipsychotic Risperdal in an attempt to reduce Mr Harvey's difficult behaviours and allow him to sleep at night. Risperdal had some limited positive effect for Mr Harvey.

3.3. By June 2017 Mr Harvey suffered from hallucinations and delusions about people being out to get him or people chasing him. Mr Harvey continued attending his general practitioner monthly from 2016 and last saw Dr Shute on 4 September 2017.7

3.4. South Australia Police and South Australian Ambulance Service paramedics were called to Mr Harvey's home on 9 September 2017 in response to Mr Harvey becoming verbally abusive towards his wife and accusing her of trying to poison him, before barricading himself in a room bracing his walking stick across the door. Mr Harvey was transported to the South Coast District Hospital that evening and was formally admitted on 10 September 2017.

3.5. Attending paramedics stated that Mr Harvey had assaulted his wife with a stick prior to their arrival and he had been violent towards her approximately two weeks prior.

3.6. During his admission to the South Coast District Hospital Mr Harvey was often aggressive towards nursing staff and was constantly agitated and wandering the 5 Exhibit C13 6 Exhibit C9 7 Exhibit C12

corridors. He attempted to hit his wife on 19 September 2017 while he was still in hospital and in the process hit his wrist on a door frame causing a fracture.8

4. Mr Harvey’s detention under the Mental Health Act 2009 4.1. Mr Harvey was transferred to the Flinders Medical Centre on 17 October 2017 as staff at the South Coast District Hospital were unable to manage his behavioural issues.

Mr Harvey’s aggressive behaviour continued at Flinders Medical Centre and he was not tolerating medication. A code black was called in response to Mr Harvey becoming violent towards nursing staff. A guard was appointed to manage Mr Harvey's behaviour. He was not complying with taking his medication and required the use of physical restraints at times to administer antipsychotic and sedative medication. For that reason a Level 1 ITO was instituted on 18 October 2017 by Dr Michael Haines.

That order was reviewed and confirmed the following day by psychiatrist Dr Randall Long. The Level 1 ITO expired on 25 October 2017 at 2pm.

4.2. Further code blacks were called requiring the provision of intramuscular medication to Mr Harvey. The last code black was recorded on 19 October 2017.

4.3. Mr Harvey was transferred to the Geriatric Evaluation and Management (GEM) ward of the Repatriation General Hospital on 24 October 2017. Following his admission psychiatrist Dr Richard Weeks placed Mr Harvey on a Level 2 ITO on 25 October 2017 which was due to expire on 6 December 2017. Dr Weeks instituted the order due to Mr Harvey's dementia triggering his intermittent agitation which was placing himself and others at risk.

4.4. Between 24 and 28 October 2017 inclusive Mr Harvey's aggressive behaviour ceased and he was cooperative with the care that was being provided. He required full assistance with his activities of daily living. However, by 29 October 2017, Mr Harvey was again resistant to taking medication and became angry and agitated at nursing and medical intervention. Mr Harvey struck out at staff on a daily basis between 1 and 5 November 2017.9 8 Exhibit C13 9 Exhibit C10

5. Mr Harvey’s transfer to Noarlunga Hospital and decline in health 5.1. As a result of the closure of the Repatriation General Hospital Mr Harvey was transferred to the Noarlunga Hospital on 8 November 2017. Mr Harvey hit, kicked and spat at nurses on the day of his transfer.

5.2. Shortly after Mr Harvey's transfer his condition deteriorated. He continued to resist nursing care and was refusing food and drink. By 9 November 2017 Mr Harvey's renal function and his ability to swallow had deteriorated. He continued to remain resistant to care.

5.3. A bed was arranged for Mr Harvey in a residential care facility on 10 November 2017 but he contracted norovirus, a contagious gastrointestinal infection, which delayed his transfer.

5.4. Mr Harvey's health continued to deteriorate and Dr Amalia Spiliopoulou advised Mrs Harvey that her husband was nearing the end of his life. Mrs Harvey indicated to the doctor that she did not want any escalation of care for her husband.

5.5. Mr Harvey's family requested palliative care be provided to him on 13 November 2017.

As a result Mr Harvey's oral medications were ceased and the bed that was being held for him at the residential care facility was cancelled.

5.6. Mr Harvey sustained an unwitnessed minor fall from a very low bed onto a crash mat and an examination of him after that incident revealed no visible injuries. On 14 November 2017 Mr Harvey was no longer able to swallow and saliva started to pool in his mouth. He was administered Fentanyl for pain and was provided with further analgesia and sedation on 15 November 2017.

5.7. On 16 November 2017 Registered Nurse Evelyn Wiedner checked on Mr Harvey and observed that he had passed away. Mr Harvey was formally pronounced deceased by Dr Muhammad Ahmad at 5:35am on 16 November 2017.

6. Coronial investigation 6.1. Detective Brevet Sergeant Liouxeese Hadley of SAPOL’s State Operations Service investigated Mr Harvey's death and prepared a comprehensive report for the Court.10 Detective Hadley received assistance from Brevet Sergeant Wayne Langford11 and Senior Constable Steven Taylor.12 As a result of the investigation Detective Hadley did not identify any issues of concern regarding the treatment of Mr Harvey either at the South Coast Hospital, the Flinders Medical Centre, the Repatriation General Hospital or the Noarlunga Hospital. Mr Harvey's next of kin did not raise any concerns with regard to his treatment or care.

7. Conclusions and recommendations 7.1. I find that Mr Harvey died on 16 November 2017 at the Noarlunga Hospital whilst detained in lawful custody under the Mental Health Act 2009. I further find that the care and treatment afforded to Mr Harvey during his period of detention was appropriate in the circumstances.

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 44/2020 (2344/2017) 10 Exhibit C8 11 Exhibit C6 12 Exhibit C5