Coroner's Finding: JAKSA Stan

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 9th day of April and the 21st day of May 2020, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Stan Jaksa.

The said Court finds that Stan Jaksa aged 82 years, late of 9 Gilpipi Avenue, Edwardstown, South Australia died at the Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 1st day of September 2016 as a result of malignant mesothelioma (palliated). The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Mr Stan Jaksa was born on 24 February 1934 and died at the Repatriation General Hospital on 1 September 2016 at the age of 82 years.

1.2. A pathology review based upon Mr Jaksa’s medical records and case notes was undertaken by Dr Jane Alderman in discussion with Dr Karen Heath, forensic pathologist, from Forensic Science South Australia1. An autopsy was not recommended as the cause of death could be determined from the medical notes. The cause of death as stated within the review is malignant mesothelioma (palliated). I find that to have been the cause of Mr Jaksa’s death.

1.3. Mr Jaksa's body was identified by his son, Mr Viano Jaksa2.

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1.4. Mr Jaksa’s death was the subject of a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mr Jaksa was under a Level 3 Inpatient Treatment Order (ITO) at the time of his death.

2. Background 2.1. According to the statements of Mr Jaksa’s son, Mr Viano Jaksa, Mr Stan Jaksa was born in the former Yugoslavia. He had five siblings, two of whom migrated to Australia in the 1950s. Mr Jaksa followed them to Australia and worked in the Whyalla Shipyard until 1959. Mr Jaksa brought his mother and younger brothers to Australia while his father remained in Europe.

2.2. Mr Jaksa met his wife Maria in 1953 and they married in 1954 and had three sons. In 1959 Mr Jaksa was recruited to play soccer in Adelaide for a Croatian team.

Unfortunately, at the age of 24, his soccer career ended following an ankle injury.

2.3. Mr Jaksa's employment history included working in the shipyards and later at Longyear Australia as a quality inspector. According to his son he was very healthy, even in his retirement. He did not smoke and always maintained a good diet. He was passionate about Australian rules football and building furniture.

2.4. I should note here that Mr Jaksa's son raised no concerns with regard to the care and treatment provided to his father prior to his death3.

3. Medical history 3.1. Mr Jaksa was diagnosed with mesothelioma in 2014. Mesothelioma is a type of aggressive cancer characterised by a thin layer of tissue that usually covers the pleura of the lungs and chest wall. It is caused by exposure to asbestos and usually presents itself many years after exposure. Mr Jaksa was exposed to asbestos during his work at the Whyalla Shipyard.

3.2. A significant tumour was located on Mr Jaksa's right lung in March 2016. It was decided in discussion with Mr Jaksa that treatment would not be suitable. The consequences of chemotherapy would have put undue stress on his body. Mr Jaksa's last medical episode commenced on 8 June 2016 when he was admitted to the Flinders 3 Exhibits C1b and C1c

Medical Centre under referral from his general practitioner, Dr Colin Harris at the Bedford Medical Centre. His wife Maria had found him to be confused, irritated, and exhibiting uncharacteristic anger and aggravation.

3.3. Several cognitive tests, CT and MRI scans were conducted over the month of June that indicated a moderate level of dementia. Mr Jaksa was transferred to Ward 5 at the Repatriation General Hospital on 22 June 2016 for increased medical and palliative care management in the context of malignancy.

3.4. On 24 June 2016 Dr Amalia Spiliopoulou4 assessed Mr Jaksa and stated: 'He presented as polite but disorientated. He expressed vague and tangential thoughts about his past in Yugoslavia.' Dr Spiliopoulou believed the initial diagnosis of frontal temporal dementia was most likely inaccurate. She preferred the position that Mr Jaksa's cognition and the MRI scan of his brain which showed neurodegeneration, were more aligned with a diagnosis of Alzheimer's.

3.5. Mr Jaksa's medication was regularly evaluated and altered to correspond with the progression of his condition. The details of his prescribed medications are set out in the statement of Dr Spiliopoulou.

4. The circumstances surrounding Mr Jaksa’s detention 4.1. Consultant geriatrician Dr Dinesh Kannusamy5 stated that Mr Jaksa's medication was greatly reduced as the psychiatric team found that there was a lack of response and he was becoming terminally unwell. Mr Jaksa fluctuated emotionally from a spirited state to depression and pessimism. He was gradually eating less and intermittently refusing medication. He often needed reassurance and sedation to help him sleep. His thought process became increasingly disorganised and irrational. For instance, he believed that people had poisoned his food and he did not want to eat it. Mr Jaksa began to express suicidal ideation and was placed on a Level 1 ITO on 27 June 2016.

4.2. He was reviewed by Dr Jessica Huang who determined that his behaviour needed to be safely monitored to avoid self-harm. The ITO was confirmed by Dr Christopher Veale.

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Mr Jaksa was also prescribed quetiapine, an antipsychotic, to address his florid delusional thoughts.

4.3. On 4 July 2016 the Level 1 ITO was reviewed by consultant psychiatrist Dr Deborah Blood. She initiated a Level 2 ITO. She commented that Mr Jaksa was generally pleasant and cooperative, but exhibited flairs of impatience and irritability. He was emotional, expressed persecutory delusions on a background of presumed delirium and pain related to his mesothelioma. Mr Jaksa stated that he had accepted his condition and was ready to die.

4.4. Over the course of the Level 2 ITO Mr Jaksa's level of consciousness fluctuated between semi-alert states, drowsiness and intermittent agitation where he would be resistive to personal and nursing care. He continued to voice his distrust about staying in hospital and expressed passive suicidal ideation. It was established that he was often experiencing severe pain which he did not always report and his low mood could be related to that pain.

4.5. On 8 August 2016 he attempted suicide by attaching a dressing gown cord to a television stand. The cord did not hold and he fell to the ground. He was uninjured but due to the seriousness of this incident he was referred to Ward 18 for more intensive psychiatric supervision. While waiting for a bed to become available, he had one-toone nursing care and was noted to become settled in the following 24 hours.

4.6. On 9 August 2016 he was reviewed by senior registrar Dr Bonita Lloyd. On 10 August 2016 he was further reviewed by consultant psychiatrist Dr Richard Weeks6.

4.7. It was decided that given his suicidal attempt and the up-and-coming expiry of the Level 2 ITO, it was necessary to apply for a Level 3 ITO from SACAT. Mr Jaksa attempted self-harm again at 5pm on 10 August 2016 by hitting his head with a shaving cream can. However, following this incident he became calm and did not express suicidal thoughts again. The one-to-one nursing care continued until 15 August 2016, but was gradually replaced by observations every 15 minutes.

4.8. On 15 August 2016 Mr Jaksa was seen by the palliative care consultant Dr Wendy Muircroft. She stated in the medical notes that she was struck by his reluctance to ask for pain relief despite persistent chest pain. Dr Muircroft recommended continued 6 Exhibit C5

psychiatric evaluation and increased Oxycontin and OxyNorm for pain relief and Pregabalin for neuropathic pain related to mesothelioma, as was the discussion with his family concerning palliative care.

4.9. On 16 August 2016 SACAT conducted a bedside hearing at the Repatriation General Hospital. A Level 3 ITO was put into effect on 19 August 2016. An unusual complication had occurred with his ITO, but it was resolved at the SACAT bedside hearing and had not affected his care.

4.10. On 17 August 2016 Mr Jaksa experienced an unwitnessed fall attributed to general muscle weakness. Neurological observations were conducted by Dr Huang, but no injury or abnormalities were found. On 20 August 2016 Mr Jaksa was nauseous and refused meals. Antiemetics were prescribed to combat nausea.

5. Mr Jaksa’s decline 5.1. For the next few days he remained in bed and ate very little. He presented as confused and depressed. He became progressively weaker. On 29 August 2016 a meeting was held with Mr Jaksa's wife and the palliative care team regarding his treatment and approaching end of life.

5.2. In view of ongoing restlessness and unstable swallowing, subcutaneous hydromorphone was trialled for prolonged pain management.

5.3. On 31 August 2016 Mr Jaksa was restless and distressed, pulled out his subcutaneous needle and syringe pump. He had a couple of unwitnessed falls in the early morning and was found to have a bump on his forehead and a slight bruising and graze on his right shoulder.

5.4. He was reviewed again by Dr Weeks as it was determined that he had entered the terminal phase of mesothelioma and did not have much longer to live.

5.5. Mr Jaksa was under active palliative care. Dr Weeks determined the Level 3 ITO was still appropriate given his pain, confusion and agitation.

5.6. On 1 September 2016, Mr Jaksa's breathing was shallow and laboured and audible secretions were found upon chest examination. He was placed on breakthrough analgesia and sedation medication. Mr Jaksa died at 4:50pm on the same date.

6. Coronial investigation and conclusions 6.1. Mr Jaksa’s death was subject to a coronial investigation by Brevet Sergeant Monique Vickery of SAPOL Sturt Criminal Investigation Branch. In her report7 Brevet Sergeant Vickery concluded that Mr Jaksa received the appropriate level of care and treatment and that his detention was lawful. I agree with those conclusions.

7. Recommendations 7.1. There are no recommendations to be made 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 21st day of May, 2020.

Deputy State Coroner Inquest Number 12/2020 (1674/2016) 7 Exhibit C10a