Coroner's Finding: LAMB Dianne Patricia

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 25th day of June and the 2nd day of November 2020, by the Coroner’s Court of the said State, constituted of Brian Malcolm Nitschke, Deputy State Coroner, into the death of Dianne Patricia Lamb.

The said Court finds that Dianne Patricia Lamb aged 67 years, late of 11 Sylvan Way, Grange, South Australia died at the Queen Elizabeth Hospital, 28 Woodville road, Woodville South, South Australia on the 21st day of April 2019 as a result of disseminated adenocarcinoma of the colon. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Dianne Patricia Lamb was born on 8 September 1951 and died on 21 April 2019 at the Queen Elizabeth Hospital in Woodville South. She was 67 years old.

1.2. A pathology review based upon Mrs Lamb’s medical records was undertaken by Dr Iain McIntyre in consultation with Dr Stephen Wills, forensic pathologist, from Forensic Science South Australia. Dr McIntyre noted a history including metastatic colorectal carcinoma treated with surgery (bowel resection, liver resection, cholecystectomy, lung resections and chemotherapy), obstructive sleep apnoea, laparotomy and excision of teratoma, Meniere’s disease, and benign position vertigo.

1.3. Dr McIntyre did not recommend an autopsy as Mrs Lamb’s cause of death could be determined from the medical records. In accordance with the pathology review1, I find Mrs Lamb’s cause of death to have been disseminated adenocarcinoma of the colon.

1 Exhibit C2a

1.4. As Mrs Lamb died whilst subject to an Inpatient Treatment Order (ITO), her death is regarded as a death in custody, and as such required a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003. Mrs Lamb was detained on a Level 2 ITO at 10:50am on 16 April 2019 by psychiatrist, Dr Elizabeth Markwick2, pursuant to section 25 of the Mental Health Act 2009.

2. Background 2.1. Mrs Lamb had three children, a son and two daughters with her former husband, Robert Lamb. While raising her three children as a single parent, Mrs Lamb worked as a contract manager for the South Australian Government for about 20 years. Mrs Lamb was an A grade squash player. Mrs Lamb met Dennis Young in 2007 and they remained together until her death.

2.2. In 2015 Mrs Lamb was diagnosed with colon cancer.3 2.3. On 25 May 2015 Mrs Lamb, whilst of sound mind, signed an Advanced Care Directive.

That Directive determined Mrs Lamb was not to be put on life support measures if a terminal illness caused no hope of survival.

2.4. On 9 April 2019 Mrs Lamb was admitted to the Queen Elizabeth Hospital and presented to the Oncology Clinic following family concerns about her behaviour. During this admission, she was treated for cancer that had spread through her body to her brain, following the diagnosis of colon cancer in 2015.4 In the previous two weeks Mrs Lamb had become increasingly irritable with fragmented speech and poor hygiene. An MRI scan was conducted which revealed multiple cerebral metastases including lesions with oedema and midline shift. She was treated with dexamethasone which was ineffectual.

Her behaviour worsened and she was becoming intrusive, abusive and disinhibited.

This behaviour was contrary to Mrs Lamb’s usually empathetic approach to life.

Her behaviour was abnormal and a result of her metastatic brain disease.

2.5. Mrs Lamb was placed on a Level 1 ITO at 6:28pm on 11 April 2019 by Dr Mei Mei Chan.5 The Level 1 ITO was confirmed by psychiatrist, Dr Amita Ingole at 12:15pm on 12 April 2019.6 The Level 1 ITO was due to expire on 17 April 2019. Mrs Lamb 2 Exhibit C6 3 Exhibit C8 4 Exhibit C5 5 Exhibit C7 6 Exhibit C7

was therefore assessed at 10:50am on 16 April 2019 by psychiatrist, Dr Elizabeth Markwick. At that time, she was placed on a Level 2 ITO.7 The ITOs were instituted to permit treatment of Mrs Lamb and protect others from her behavioural issues.

2.6. Mrs Lamb’s health continued to decline and discussions were held with her family who made the decision to move to palliative care.

3. Circumstances of death 3.1. On the afternoon of 21 April 2019 family of Mrs Lamb visited her. Nurse Sandra Hockley checked Mrs Lamb at 5:25pm and she was still breathing.8 At about 5:35pm Mrs Lamb’s visitors thought she might not be breathing. They approached Nurse Amilin Chellaparaj who confirmed Mrs Lamb had died.9 Dr Owen Siggs attended and confirmed life extinct at 7:40pm.

4. Coronial investigation 4.1. Detective Brevet Sergeant Jon Welch of the Western District Criminal Investigation Branch of SAPOL investigated the death in custody of Mrs Lamb and prepared a comprehensive report for the State Coroner.10 Detective Welch found nothing of concern during his investigation.

4.2. It is apparent that Mrs Lamb’s partner, son and two daughters provided a strong and supportive family network. They attended hospital most days and were supportive of the hospital’s treatment plan.11

4.3. In her statement tendered to the Court Mrs Lamb’s daughter, Amelia, queried whether the Queen Elizabeth Hospital managed her mother’s condition appropriately as ‘it felt like it got to a level that felt wrong before they would attend to her’. She stated family constantly asked the hospital to protect Mrs Lamb’s dignity and keep her safe. She noted that hospital staff would contact her asking if she could assist in calming her mother. Amelia stated she could not always do that as she did not want to give her mother false hope.12 7 Exhibit C6 8 Exhibit C4 9 Exhibit C3 10 Final Report of Detective Brevet Sergeant Jon Welch dated 7 December 2019 11 Exhibit C7 12 Supra C8 at paragraph 10

4.4. Upon review, it is apparent hospital staff did the best they could in caring for Mrs Lamb.

Mrs Lamb was unfortunately very ill with a terrible disease that caused her to act in a manner that was completely out of character. The medical team reviewed Mrs Lamb’s medication program on many occasions to provide the best relief whilst trying to minimise her behaviours.

5. Conclusions 5.1. I find that Mrs Lamb’s care and treatment whilst an inpatient at the Queen Elizabeth Hospital was appropriate, as was the imposition of the Inpatient Treatment Orders.

5.2. I have no recommendations to make as to the death of Mrs Lamb.

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 2nd day of November, 2020.

Deputy State Coroner Inquest Number 77/2020 (0791/2019)