Coroner's Finding: MAGGS Eric Arthur

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 Eric Arthur Maggs.

The said Court finds that Eric Arthur Maggs aged 85 years, late of 2 Cardigan Street, Angle Park, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 26th day of March 2019 as a result of ischaemic heart disease.

The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Eric Arthur Maggs was born on 30 September 1933 and died on 26 March 2019 at the Royal Adelaide Hospital. He was 85 years of age.

1.2. A post mortem examination of Mr Maggs’ remains was conducted by Dr Neil Langlois, forensic pathologist, at Forensic Science South Australia on 28 March 2019. In his report1 of that examination Dr Langlois determined that Mr Maggs’ cause of death was ischaemic heart disease, and I so find. Dr Langlois noted significant findings including severe narrowing of the dominant right coronary artery, cardiomegaly, myocardial fibrosis, mucopurulent material trachea, emphysema and a swollen right lower leg. Dr Langlois did not find pneumonia, pulmonary emboli or cirrhosis of the liver.

1.3. At the time of his death Mr Maggs was subject to a Level 1 Inpatient Treatment Order (ITO), pursuant to section 21 of the Mental Health Act 2009. The order was authorised by an Emergency Medicine Registrar, Dr Joshua Lightfoot, at 4:38am on 26 March 1 Exhibit C2

2019.2 As this order was still active at the time of Mr Maggs’ death, his was a death in custody and a mandatory inquest was required pursuant to section 21(1)(a) of the Coroners Act 2003.

2. Background 2.1. Mr Maggs was born in Prospect, South Australia. He was profoundly deaf from birth.

His parents were also deaf.3 Mr Maggs attended Townsend House from the age of 6 to 15 years. At Townsend House Mr Maggs learned sign language. He met his wife-to-be, Rosemary, at Townsend House and they were married in 1959. In 1961, they bought a house in Renown Park. They had three boys, Trevor, Wesley, and Adrian. Their sons have some hearing, but still require a sign interpreter for communication.

2.2. Mr Maggs was a Christian, a very good father and a family man. He did not drink or smoke. He was very active and healthy until his older age. He was a resourceful handyman. Mr Maggs was employed as a carpenter/cabinet maker, a brush maker and a landscape gardener. He retired from the latter job with the Housing Trust in 1993. In retirement Mr Maggs was happy at home.

2.3. At about the time he retired Mr Maggs had back problems from previous heavy lifting.

He utilised pain medication for this. Some medications caused allergic reactions due to his sensitive skin. From 2001 Mr Maggs used a walking frame to assist mobility.

He was otherwise generally healthy until about 2010. In 2015, he started to develop dementia which gradually worsened.

2.4. In June 2018 Mr Maggs suffered a fall resulting in a hairline fracture to his knee. He was admitted to the Queen Elizabeth Hospital for a week, then to St Margaret’s Hospital followed by the Hampstead Rehabilitation Centre. During rehabilitation prostate issues led to the use of a catheter. His son Adrian suggests Mr Maggs’ dementia worsened during this time and may have caused depression.

2.5. A decision was made to place Mr Maggs into formal care as home care was too difficult.

On 11 September 2018 Mr Maggs was admitted to the Linsell Lodge Aged Care Facility at Angle Park. The plan was to return Mr Maggs home once his health improved.

Unfortunately, his health did not improve. Mr Maggs was not happy at Linsell Lodge.

2 Exhibit C8a 3 Exhibit C1a

In November 2018, he returned home for a week, but suffered issues related to his dementia. Mr Maggs could not recall or understand what was happening. He returned to Linsell Lodge where he was seen regularly by a visiting general practitioner, Dr Beng Hee Ong.4

2.6. Mr Maggs had several falls at the nursing home. His family were updated as to his issues and from January 2019 Mr Maggs was permanently in a wheelchair.

2.7. On 16 March 2019 Mr Maggs was admitted to the Queen Elizabeth Hospital after he developed a whole-body rash. The rash covered his entire body and was the result of the medication, cephalexin. He was placed on alternative medication. Mr Maggs became upset and angry.

2.8. As Linsell Lodge did not have staff with sign language ability, Mr Maggs could not communicate with them and was effectively voiceless. He loved talking by signing and that was taken away from him at Linsell Lodge. His son Adrian stated that Mr Maggs wanted to go home, felt like he was in jail, and wanted to die. On 26 March 2019 Mr Maggs’ wife and son, Wesley, met with Linsell Lodge staff with an interpreter to find a better way to manage Mr Maggs and his dementia.5

3. Mr Maggs’ decline in health 3.1. At 9:16pm on 25 March 2019 Mr Maggs was admitted to the Royal Adelaide Hospital with difficulty breathing. Mr Maggs wrote on paper that he had sharp chest pain that was worse with breathing. Tests revealed Mr Maggs’ organs were not receiving sufficient blood flow and there was a high risk of death even with optimum treatment.6 Attempts were made to source an Auslan interpreter, but one was not available until business hours the following morning.

3.2. In the early hours of 26 March 2019 Mr Maggs was removing his oxygen mask causing his oxygen levels to drop significantly. Mr Maggs was refusing oxygen and becoming delirious so at 4:38am Dr Lightfoot authorised the Level 1 ITO to assist in Mr Maggs’ treatment. Mr Maggs continued to be resistant to treatment following imposition of the 4 Exhibit C6 5 Exhibit C5 6 Exhibit C4

ITO and assistance was required. At 8am that morning Dr Lightfoot considered that Mr Maggs was critically unwell and treatment options were limited.

3.3. On 26 March 2019 Mr Maggs was attended to by Nurse Scott Crockart.7 Mr Crockart described Mr Maggs as erratic and hard to control. Mr Maggs was given sedation so that observations could be made. At about 8:30am an interpreter attended to assist with communication. A further interpreter was required to assist due to Mr Maggs’ erratic behaviour. Mr Crockart stated that Mr Maggs at one stage signed that he wanted to die.

At 10:30am Mr Maggs grabbed at his chest with one arm. His arms were not restrained at that time. Mr Crockart found Mr Maggs’ heartbeat to be ‘really slow’.

3.4. Following a meeting at Linsell Lodge Mr Maggs’ family went to visit him at the Royal Adelaide Hospital. Mr Maggs was unhappy, agitated and depressed. Adrian Maggs was told that Mr Maggs had to have his arms restrained. His son Adrian explained that ‘having his arms restrained would have been like someone taking his voice away. He was not a violent man, but had become very frustrated that no-one could help him’.8

3.5. Mr Maggs’ condition deteriorated and he was declared deceased at 10:45am by Dr Jarred Fairbanks.

4. Coronial investigation 4.1. Detective Brevet Sergeant Shane Pickering of the Western District Criminal Investigation Branch of SAPOL investigated the death in custody of Mr Maggs and prepared a comprehensive report.9 Detective Pickering noted no issues of concern arising from his investigation.

4.2. Adrian Maggs’ statement was tendered to the Court. In that statement, he expresses concern over his father’s arms being restrained and the impact that had on his ability to communicate. Similarly, being the only deaf person in Linsell Lodge would have been frustrating to Mr Maggs due to his inability to communicate with fellow residents.

4.3. It is an unfortunate aspect that sometimes restraints must be utilised when elderly dementia patients exhibit out of character behaviours that impact upon their treatment.

In the case of Mr Maggs and other deaf and mute patients, arm restraints will have 7 Exhibit C3 8 Supra n 4, at paragraph 15 9 Exhibit C8, Final Report of Detective Brevet Sergeant Shane Pickering dated 26 September 2019

greater impact on their ability to communicate and therefore their levels of frustration.

However, it is apparent that at all times staff at the Royal Adelaide Hospital did their best to assist Mr Maggs in dealing with his poor prognosis. They did all they could to communicate with Mr Maggs on his final night using notes and they sought an interpreter as soon as they were available in the morning. Any restraint used would have been utilised only if necessary to ensure Mr Maggs received proper treatment.

5. Conclusions 5.1. I therefore find that the care and treatment received by Mr Maggs’ whilst detained at the Royal Adelaide Hospital was appropriate in the circumstances, as was the imposition of the Inpatient Treatment Order to allow Mr Maggs to receive the treatment he required.

5.2. 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 2nd day of November, 2020.

Deputy State Coroner Inquest Number 71/2020 (0611/2019)