Coroner's Finding: NIXON Viola Daphne

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 11th 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 Viola Daphne Nixon.

The said Court finds that Viola Daphne Nixon aged 92 years, late of 1A Main Street, Hahndorf, South Australia died at Noarlunga Hospital, Alexander Kelly Drive, Noarlunga Centre, South Australia on the 27th day of October 2018 as a result of decompensated congestive cardiac failure secondary to haemophilus influenzae lower respiratory tract infection. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Viola Daphne Nixon was born on 5 October 1926 and died on 27 October 2018 at the Noarlunga Hospital. She was 92 years old.

1.2. Following Mrs Nixon’s death, Dr Dimitri Niarchos from the Queen Elizabeth Hospital completed a ‘Death Report to Coroner - Medical Practitioner’s Deposition’ on 28 October 2018. In that report, he provided his opinion that the cause of Mrs Nixon’s death was decompensated congestive cardiac failure secondary to haemophilus influenzae lower respiratory tract infection.1 I accept Dr Niarchos’ opinion and find that to have been the cause of Mrs Nixon’s death.

1 Exhibit C11, Noarlunga Hospital Casenotes

2. Reason for inquest 2.1. Mrs Nixon was placed on a Level 1 Inpatient Treatment Order (ITO) at 2:34pm on 18 October 2018 by a medical practitioner, Dr Miriam Cursaro, pursuant to section 21 of the Mental Health Act 2009. The ITO was confirmed by psychiatrist, Dr Andrew Rosser, on 19 October 2018 at 11:06am.2 When Mrs Nixon died on 28 October 2018 the ITO had lapsed. The ITO was allowed to lapse as Mrs Nixon was by then receiving comfort care and no longer resistant to treatment.3 Despite her death not occurring whilst under the ITO, Mrs Nixon’s death is still regarded as a death in custody as ‘the death occurred, or the cause of death, or possible cause of death, arose, or may have arisen’ whilst Mrs Nixon was subject to an ITO. As such this is a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003.

3. Background 3.1. Prior to her admission to an aged care facility Mrs Nixon had lived at Murray Bridge in her own home. She was assisted by Domiciliary Care along with friends who aided with shopping, bill payments, transport and gardening.

3.2. On 19 June 2015 Mrs Nixon was admitted to respite care at Infin8 Care Hahndorf. At the time of admission Mrs Nixon was noted to suffer from dementia, hypertension, atrial fibrillation, chronic obstructive pulmonary disease, heart disease, dysphagia, anxiety, high cholesterol, urinary incontinence and asthma.4

3.3. On 29 June 2017 Mrs Nixon was taken to the Royal Adelaide Hospital as her oxygen saturations had decreased. She left the Royal Adelaide Hospital on 2 July 2017 with a diagnosis of lower lobe pneumonia.

3.4. On 6 August 2015 Mrs Nixon was admitted to Infin8 Care Hahndorf as a permanent resident. Over time her health declined further and she became more susceptible to colds and flu.5

3.5. In her last six months at the nursing home Mrs Nixon’s dementia related behaviours, such as altercations, worsened along with her compliance with the regime of medication.

2 Exhibit C9a Detective Brevet Sergeant Liouxeese Hadley dated 6 April 2019 3 Exhibit C3, Affidavit of Dr Tsung Han Woo dated 31 December 2018 4 Exhibit C5, Affidavit of Kasandra Melville dated 5 December 2018 5 Exhibit C4, Affidavit of Renee Paterson dated 7 November 2018

3.6. On 29 and 30 August 2018 Mrs Nixon was reviewed by a Residential Care Outreach Team from the Flinders Medical Centre. A recommendation was made to transfer Mrs Nixon to the Flinders Medical Centre if her behaviours escalated further.

3.7. Mrs Nixon had two admissions to the Myles Ward at Noarlunga Hospital in September

2018. The Myles Ward caters for patients with severe behavioural and psychological symptoms of dementia. Mrs Nixon’s first admission to the Myles Ward was from 5 to 15 September 2018. This followed an initial admission to the Flinders Medical Centre on 2 September 2018. She was admitted as she was displaying aggressive behaviour and refusing care at the nursing home. Dr Amalia Spiliopoulou was responsible for Mrs Nixon on this occasion. Her admission concerned dementia related complications with no underlying delirium. Mrs Nixon was discharged on 15 September 2018 to her nursing home.

3.8. On 21 September 2018 Mrs Nixon was again admitted to Flinders Medical Centre in response to her unmanageable behaviours and medication non-compliance. It was considered she was a danger to herself and others.

4. Mrs Nixon’s decline in health 4.1. Mrs Nixon last presented to the Noarlunga Hospital on 28 September 2018. This was Mrs Nixon’s second admission to the Myles Ward. Mrs Nixon exhibited challenging behaviour toward staff.6 Mrs Nixon was increasingly agitated, displaying physically and verbally aggressive behaviour, was refusing care and not complying with her medication. These were unfortunate manifestations of her illness.

4.2. By 18 October 2018 Mrs Nixon’s behaviour escalated and she was severely noncompliant. An ITO was put in place to enable medication administration and patient control.

4.3. Around mid-October Mrs Nixon became more wheezy and low in oxygen. Mrs Nixon was found to be suffering haemophilus influenza which can cause pneumonia. The medical team had a telephone discussion with a daughter of Mrs Nixon about her mother’s future care. On 25 October 2018, a meeting was held with Mrs Nixon’s daughter to discuss her mother’s end of life care. At that time Mrs Nixon was extremely 6 Exhibit C2, Affidavit of Maricor Vargas dated 10 April 2019

non-compliant. It was explained that the focus should be on comfort care for Mrs Nixon. Her daughter agreed with that approach.7

4.4. From 26 October 2018 Mrs Nixon was to be treated for comfort care only and not for resuscitation. She continued to deteriorate. On the evening before her death Mrs Nixon was to be checked every 15 to 30 minutes. At 11:10pm on 27 October 2018 Mrs Nixon was checked and was breathing. At 11:20pm Registered Nurse Vargas and another nurse attended to administer pain relief medication. At that time Mrs Nixon showed no signs of life. Nurse Vargas noted that Mrs Nixon was not breathing and she had no pulse.8 Myles Ward at Noarlunga Hospital did not have medical cover on the evening of 27 October 2018 and as such Mrs Nixon’s death was not formally certified until 8:53am the next morning, 28 October 2018, by Dr Dimitri Niarchos.9

5. Coronial investigation and conclusions 5.1. Detective Brevet Sergeant Liouxeese Hadley of SAPOL’s Coronial Investigation Section investigated the death in custody of Mrs Nixon and prepared a comprehensive report.10 Detective Hadley found that Mrs Nixon’s detention at the hospital was appropriate in the circumstances. In addition, no issues were identified with Mrs Nixon’s treatment whilst under the Inpatient Treatment Order. I agree with the conclusions expressed by Detective Hadley.

5.2. I have no recommendations to make in relation to the death of Mrs Nixon.

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 63/2020 (2072/2018) 7 Exhibit C3, Dr Tsung Han Woo dated 31 December 2018 8 Exhibit C2, Maricor Vargas dated 10 April 2019 9 Exhibit C1a, Dimitri Niarchos dated 28 October 2018 10 Exhibit C9, Detective Brevet Sergeant Liouxeese Hadley dated 6 April 2019