Coroner's Finding: KARTINYERI Laura Rose

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 15th day of May and the 25th day of June 2020, by the Coroner’s Court of the said State, constituted of Brian Malcolm Nitschke, Deputy State Coroner, into the death of Laura Rose Kartinyeri.

The said Court finds that Laura Rose Kartinyeri aged 44 years, late of 50 Gail Crescent, Murray Bridge, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 8th day of July 2017 as a result of multi-organ failure and polypharmaceutical overdose on a background of severe chronic obstructive airways disease. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Laura Rose Kartinyeri was born on 5 September 1972 and died on 8 July 2017 at the Royal Adelaide Hospital. She was 44 years old.

1.2. Ms Kartinyeri’s medical case notes and clinical history were reviewed by Dr Iain McIntyre of Forensic Science South Australia and discussed with Professor Roger Byard, forensic pathologist. In his report1, Dr McIntyre provides the cause of Ms Kartinyeri’s death as multi-organ failure and polypharmaceutical overdose in a woman with severe chronic obstructive airways disease.

1.3. I note here that following her death Dr McIntyre recommended that admission blood samples should be secured to allow for toxicological testing. Admission bloods were seized and toxicological analysis was requested, however there was insufficient blood 1 Exhibit C1a

to allow a full screening.2 Nevertheless, a drug screening of a sample taken at hospital was positive for benzodiazepines, amphetamines and cannabinoids.

2. Reason for inquest 2.1. As Ms Kartinyeri was subject to an Inpatient Treatment Order (ITO) at the time of her death a mandatory inquest was required pursuant to section 21(1)(a) of the Coroners Act 2003. The Level 1 ITO had been instituted pursuant to section 21 of the Mental Health Act 2009. The order had been made by Dr Adrian Foran on 4 July 2017 and was confirmed by Dr Jon Symon on 5 July 2017. The ITO was current at the time of Ms Kartinyeri’s death. There are no concerns in relation to the lawfulness of custody.

3. Background 3.1. Ms Kartinyeri had no permanent residence in the two years prior to her death. Medical notes tend to suggest that she often stayed with friends or family in Murray Bridge.

Support Services were in the process of assisting Ms Kartinyeri to find accommodation in the Murray Bridge area.

3.2. SAPOL officers investigating Ms Kartinyeri’s death attempted to contact her family members to obtain statements, however most refused to engage or provide a statement.

The limited information that police were able to obtain suggests that Ms Kartinyeri was not employed, that she had four children and that she had been married in her early twenties, but later separated.

3.3. Hospital records indicate that throughout her adult life Ms Kartinyeri would present at hospitals with pain but then self-discharge, abscond, ignore medical advice or refuse treatment.

4. Medical history 4.1. Ms Kartinyeri had a medical history that included severe chronic obstructive pulmonary disease (COPD) with CO retention, hepatitis C, intravenous drug and opioid abuse, hemiplegic migraine, pulmonary embolus, pulmonary hypertension, right heart failure, pyelonephritis and oesophagitis.

2 Chris Kostakis, Forensic Toxicologist, has confirmed that bloods were received but insufficient blood was provided to analyse

4.2. In the year prior to her death Ms Kartinyeri had repeated admissions to hospital with complications from COPD. Ms Kartinyeri’s condition was negatively impacted by her ongoing cigarette use, substance abuse and non-compliance with treatment.3

5. Ms Kartinyeri’s hospital admissions 5.1. Ms Kartinyeri was transferred from the Murray Bridge Hospital to the Royal Adelaide Hospital on 6 February 2017 with invective exacerbation of her COPD. She remained at the Royal Adelaide Hospital until 17 February 2017 when she self-discharged.

5.2. Throughout her admission there were numerous times when Ms Kartinyeri refused treatment and investigations. Ms Kartinyeri also absconded during her admission and returned the following day. She would leave the ward for hours to smoke cigarettes, thereby missing the morning rounds when bloods were ordinarily taken. It was noted in the Discharge Summary that Ms Kartinyeri denied taking any illicit drugs when off the ward, however urine toxicology was positive for benzodiazepines and cannabinoids.4

5.3. On 10 February 2017 nursing staff suspected that Ms Kartinyeri had overdosed on the drug Lyrica5. Nursing staff found a packet of Lyrica tablets with six tablets missing.

These tablets had been obtained from outside the hospital. Ms Kartinyeri was noted as drowsy with low oxygen saturation, nevertheless she refused treatment and walked off the ward. Ms Kartinyeri denied taking the tablets.

5.4. On 11 February 2017 Ms Kartinyeri threatened to obtain Lyrica tablets if the hospital staff did not prescribe them to her. She was noted as yelling and swearing and acting aggressively during her admission.

5.5. On 3 April 2017 Ms Kartinyeri was transferred from the Modbury Hospital to the Queen Elizabeth Hospital Intensive Care Unit with COPD concerns, reporting two days of being unwell and coughing yellowish sputum. Ms Kartinyeri was noted as being aggressive and agitated.

5.6. At 1:30pm on 3 April 2017 Ms Kartinyeri was seen by medical staff attempting to put powder from a capsule into her mouth. Nursing staff removed a bag from 3 History and Examination, Royal Adelaide Hospital, 4 July 2017 4 Final Separation Summary, Royal Adelaide Hospital, 17 February 2012 5 Used to treat epilepsy, neuropathic pain, anxiety

Ms Kartinyeri’s possession that contained a strip of Lyrica 300mg tablets.

Ms Kartinyeri was counselled and apologised. Ten minutes later she was seen again with a capsule in her hand. Nursing staff requested that she not take the capsule, however she proceeded to open the capsule and consume the contents.6

5.7. From 15 to 18 May 2017 Ms Kartinyeri was admitted to the Queen Elizabeth Hospital for continuing treatment of COPD, dyspnoea, tachypnoea and low oxygen saturations.

5.8. On 3 June 2017 Ms Kartinyeri was admitted to the South Coast Hospital at Victor Harbor with an exacerbation of COPD with Chronic Level 2 respiratory failure. It was noted that she was continuing to smoke tobacco. Ms Kartinyeri told hospital staff that she felt her lungs were closing over.7 She was discharged on 10 June 2017 after having improved with oral antibiotics and steroids.8

5.9. On 12 June 2017 Ms Kartinyeri was admitted to the Murray Bridge Hospital where she remained until 18 June 2017. Within 24 hours of her admission Ms Kartinyeri’s condition deteriorated with increased dyspnoea, peripheral oedema and confusion.

Medical notes state Ms Kartinyeri’s treatment was compromised as she refused medical and nursing interventions. She was assessed as having the capacity to refuse treatment.

5.10. Ms Kartinyeri was transferred to the Royal Adelaide Hospital on 18 June 2017 for further management of her acute COPD.9 She was discharged on 21 June 2017 and transferred to Murray Bridge Hospital after refusing treatments or interventions.10

5.11. Ms Kartinyeri remained at the Murray Bridge Hospital from 21 to 30 June 2017 for further management of her condition. During this time efforts were made by social workers to arrange accommodation for Ms Kartinyeri who had no stable housing.

Ms Kartinyeri remained on oxygen throughout her admission and it was noted that she would leave her room to smoke cigarettes.

5.12. On 28 June 2017, a respiratory nurse met with Ms Kartinyeri to discuss the ongoing management of her COPD. It was recommended that Ms Kartinyeri cease smoking for 6 Nursing Progress Note - TQEH ICU, Entire Visit Record, Part B Documents, page 60, 3 April 2017 7 Progress notes, Victor Harbor Hospital, 3 June 2017 8 Medical Officer’s Discharge Summary (Dr N Beech), Victor Harbor Hospital, 8 June 2017 9 Interim Separation Summary, 21 June 2017 10 Interim Separation Summary, 21 June 2017

four weeks so that she could qualify for domiciliary oxygen. Ms Kartinyeri declined and refused to discuss her condition further.11 She was discharged on 30 June 2017.

5.13. On 1 July 2017 Ms Kartinyeri attended the Murray Bridge Hospital seeking a prescription for ‘suboxone and other medications’.12 Hospital notes indicate that Ms Kartinyeri said that she had been ‘discharged from hospital yesterday without scripts’. It was noted that she was on opiate tablets, suboxone 8mg, on alternate days and noted a pulmonary embolism and left ventricular failure for which she was on a blood thinner and a diuretic. It was also noted that she presented in an aggressive and agitated fashion. The hospital staff arranged with the pharmacist for Ms Kartinyeri to receive her medications from the local pharmacy.

6. The circumstances surrounding Ms Kartinyeri’s detention and death 6.1. Due to the refusal of family members and friends to provide statements in this matter there is some ambiguity about exactly what occurred between 1 and 4 July 2017.

Hospital notes indicate that Ms Kartinyeri’s family found her drowsy in bed three days prior and on 4 July 2017, when they visited, she was still in bed. They called an ambulance.13

6.2. Joshua Koolmatrie provided a statement to police14. He was not present when the ambulance was called. On 4 July 2017 Ms Kartinyeri attended Joshua Koolmatrie’s home at 76 Railway Terrace, Murray Bridge. In his statement Mr Koolmatrie referred to Ms Kartinyeri as ‘Aunty Laura’. Mr Koolmatrie stated that ‘Aunty Laura’ looked unwell, ‘her face was swollen and her mouth was dry and white around her mouth’.15 He stated that they were ‘smoking weed and she got us to help her chop her weed’. He thought that Ms Kartinyeri was also drinking wine. There was an argument between Ms Kartinyeri and Michelle Koolmatrie and so Mr Koolmatrie left. He thought the argument was about drugs and told police that ‘Laura wanted me to get gear for her’.16 11 Progress Notes, Murray Bridge Hospital, 28 June 2017 12 Murray Bridge Hospital, Non-admitted unplanned patient attendance record, 2:33pm, 1 July 2017 13 History and Examination, Royal Adelaide Hospital, 4 July 2017; Exhibit C2, page 2 14 Exhibit C3 15 Exhibit C3, page 1 16 Exhibit C3, page 2

6.3. On arrival at Murray Bridge Hospital Ms Kartinyeri was treated for a suspected drug overdose with Naloxone and Flumenazil before being transferred to the Royal Adelaide Hospital where she was admitted at 2:17 pm on 4 July 2017.17

6.4. A psychiatric review was requested due to the possibility of the suspected drug overdose being an attempted suicide. This occurred on 5 July 2017. Ms Kartinyeri was noted as ‘awake but clearly drug affected and perplexed, unable to co-operate and interview’.18

6.5. At 3pm on 4 July 2017 a Level 1 ITO was made by Dr Adrian Foran.19 This order was confirmed by Dr Jon Symon on 5 July 2017.20 The statement of reasons includes ‘Organic Brain Syndrome – medication induced delirium, ? Depression’. Ms Kartinyeri was considered a high lethality suicide risk and was noted as being ‘Perplexed and unable to cooperate with medical care’. A drug screen showed amphetamine, cannabis and benzodiazepines.

6.6. Ms Kartinyeri improved over the next two days but was agitated and confused. She was described as ‘not properly conscious’. Her treatment included vaso-pressers, intravenous fluids, antibiotics, prothrombinex and non-invasive ventilation.

Ms Kartinyeri would occasionally push away nurses and refuse treatment or care.

6.7. On 5 July 2017 hospital notes indicate that given Ms Kartinyeri’s ‘underlying disease, an escalation of organ support is not appropriate’ and that she was ‘not for intubation’.21

6.8. At about 3am on 7 July 2017 Ms Kartinyeri was un-rousable and a ventilation mask was fitted. Dr McArthur stated that, ‘due to her extensive lung disease, intubation was not an option’. There was no improvement over the following hours.

6.9. At about 9pm Dr McArthur and nursing staff had a family meeting with about 15 members of Ms Kartinyeri’s family and discussed palliative care. A decision was made to cease all medical interventions.22 17 Exhibit C2, page 2 18 Progress Notes, Royal Adelaide Hospital, 5 July 2017 19 Exhibit C8a 20 Exhibit C8c 21 Progress Notes, Royal Adelaide Hospital, 5 July 2017 22 Progress Notes, Royal Adelaide Hospital, 7 July 2017

6.10. At about 11pm the ventilation mask was removed and Ms Kartinyeri passed away.

Dr McArthur declared her life extinct at 1am on Saturday 8 July 2017.

7. Coronial investigation 7.1. Sergeant Mariane Morgan23 searched 76 Railway Terrace, Murray Bridge on 8 July

8. Joshua Koolmatrie was present and indicated to Sergeant Morgan which room Ms Kartinyeri had been using before she was taken to hospital. Sergeant Morgan located within that room numerous empty packets of medication. Inside a bag identified as belonging to Ms Kartinyeri was located: Two asthma inhalers; • Two prescriptions in Ms Kartinyeri’s name for inhaler medication issued by • Dr S Boscian on 3 June 2017; An empty bottle of Lyrica 150mg issued on 10 June 2017; • An empty box of Anora Ellipta 62.5/25mg, 30 doses issued on 4 June 2017.

• On the bedside table were: A blister pack of Serta 50 with 4 tablets still in the packet; • An empty bottle of diazepam 5mg in the name of Michelle Koolmatrie; • An empty 14 blister packet of Lyrica; • An empty 10 blister packet of Serta 50.

•

7.2. Joshua Koolmatrie told Sergeant Morgan that the day prior to Ms Kartinyeri being taken by the ambulance her face was very swollen and he wanted her to go to the Murray Bridge Hospital from his house. She refused to go. Joshua Koolmatrie also stated that she had needed assistance walking from a taxi to the bank.

8. Conclusions 8.1. Ms Kartinyeri had a long history of drug use dating back to at least 1995. Hospital notes from the Queen Elizabeth Hospital indicate that she presented with abdominal pain with an additional diagnosis of ‘personal history of harmful use of unsanctioned drugs’. Ms Kartinyeri was noted as using Oxazepam, heroin, barbiturates24, serapax 23 Exhibit C6 24 Queen Elizabeth Hospital Progress Notes, 12 June 1996

and cannabis.25 Ms Kartinyeri underwent an amputation of part of her left finger in 2000 after reporting injecting of heroin in her arm and losing feeling in her fingers.

8.2. Ms Kartinyeri’s hospital notes from 1995 until her death indicate that she persistently ignored medical staff by refusing treatment and absconding from hospital.26

8.3. Consistent with the conclusions of the SAPOL Investigating Officer, Detective Brevet Sergeant Muskee27, in the months before her death Ms Kartinyeri’s medical condition was worsening and her ongoing refusal of medical and nursing interventions compromised her treatment.

8.4. In the absence of a toxicology report it is not possible to determine exactly what medication Ms Kartinyeri ingested prior to being taken by ambulance on 4 July 2017.

Nevertheless, Dr Iain McIntyre has determined the cause of death from the case notes with some certainty.

8.5. Dr McIntyre notes Ms Kartinyeri’s impaired renal and liver function. The liver dysfunction remained static and Ms Kartinyeri remained deeply unconscious in respiratory failure. The suggested cause of death provided by Dr McIntyre is consistent with the locating of the empty packets of tablets and Ms Kartinyeri’s long history of drug abuse in the context of her chronic obstructive airways disease.

8.6. I therefore find that the cause of Ms Kartinyeri’s death was multi-organ failure and polypharmaceutical overdose on a background of severe chronic obstructive airways disease.

8.7. There is some suggestion that due to the number of empty packets of medication that Ms Kartinyeri committed suicide. In the absence of a toxicological analysis there is little else to support that conclusion. In fact, Ms Kartinyeri’s long history of drug abuse and the absence of any history of suicide attempts or intention to suicide, suggest that Ms Kartinyeri’s death is more consistent with death because of an unintended overdose.

I make no formal finding with respect to the question of suicide.

25 Queen Elizabeth Hospital Progress Notes 26 The earliest record is on 18 March 1995, Progress Notes, The Queen Elizabeth Hospital. It was noted in the Domiciliary Midwife Notes 19 April 1995 that ‘Whilst in hospital ante-nattaly [sic] absconded many times.’ 27 Exhibit C8

8.8. I find that Ms Kartinyeri was in lawful detention at the time of her death and that the circumstances surrounding her death are not suspicious. I further find that there is no indication of any third-party involvement in her death and that the care and treatment Ms Kartinyeri received whilst detained was appropriate in the circumstances.

8.9. I make no recommendations in this matter.

Key Words: Death in Custody; Overdose; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 25th day of June, 2020.

Deputy State Coroner Inquest Number 27/2020 (1316/2017)