Coroner's Finding: OLIVER Ian 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 16th day of April and the 28th day of May 2020, by the Coroner’s Court of the said State, constituted of Simon James Smart, Deputy State Coroner, into the death of Ian Arthur Oliver.

The said Court finds that Ian Arthur Oliver aged 81 years, late of 6 Myora Crescent, Mildura, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 27th day of February 2017 as a result of haemorrhage from metastatic squamous cell tumour of the right axilla. The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Ian Arthur Oliver was born on 29 October 1935 and died on 27 February 2017 at the Royal Adelaide Hospital. He was 81 years of age.

2. Cause of Death 2.1. Mr Oliver’s medical records and case notes were reviewed by Dr Iain McIntyre from Forensic Science South Australia in consultation with Dr Stephen Wills, forensic pathologist. A post mortem examination of Mr Oliver’s remains was not necessary to establish a cause of death. The pathology review report1 provided by Dr McIntyre suggested the cause of death as haemorrhage from metastatic squamous cell tumour of the right axilla. I find that to have been the cause of Mr Oliver’s death.

1 Exhibit C2a

3. Reason for inquest 3.1. Mr Oliver’s death was the subject of a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mr Oliver had been detained on an Inpatient Treatment Order (ITO) at the time of his death. The Level 1 ITO had been made pursuant to section 21 of the Mental Health Act 2009.

3.2. The Level 1 ITO had been instituted on 21 February 2017 by Dr Wu Xiaowen and was confirmed on 22 February 2017 by Dr Tammy Nowack. The ITO was current at the time of Mr Oliver’s death and was due to expire on 28 February 2017.

3.3. There are no concerns in relation to the lawfulness of Mr Oliver’s detention.

4. Background 4.1. Mr Oliver lived in Mildura and had been married to his wife Marie who died in 2010 from disseminated lung cancer.2 He had three sons: Michael, Glen and Lincoln.

Mr Oliver preferred to use the name ‘Mike’ Oliver.

4.2. Mr Oliver had a complex medical history3 that included Type 2 diabetes, chronic obstructive lung disease, asthma, ischaemic cardiomyopathy with quadruple bypass surgery, chronic congestive cardiac failure, an ejection fraction of 11% in 2016, hypertension, chronic renal failure, nasal keratoacanthoma which was biopsied in 2015, peripheral vascular disease, gastroesophageal reflux disease, hypothyroidism, osteoarthritis and an implanted pacemaker. Mr Oliver was a smoker.

4.3. The pathology review conducted by Dr McIntyre in March 2017 referred to a ‘past medical history’ that included ‘axillary metastatic squamous cell carcinoma 2015 (operated)’.4 Dr McIntyre provided an amended pathology review report in April 2020.5 In that document the reference to the 2015 operation has been removed following a further review of the case notes which disclosed it had been included in error.

4.4. On 2 September 2016 Mr Oliver attended a consultation with his general practitioner, Dr Amarnarth Bhat, at which he reported a lump under his right arm that had been causing him pain.6 2 Exhibit C8 3 As described by his general practitioner, Dr Bhat, Exhibit C9 4 Exhibit C2a 5 Exhibit C2b 6 Exhibit C9

4.5. On 8 September 2016 an ultrasound was performed of the right axilla which showed a large irregular solid lesion and a node adjacent to this.

4.6. On 27 October 2016 Mr Oliver attended a consult with oncologist Dr Krishna Rachakonda regarding the lump. On 3 November 2016 a decision was made to perform a biopsy.7

4.7. On 1 December 2016 Mr Oliver attended a further consult with Dr Rachakonda and reported significant pain down his right arm.

4.8. On 19 January 2017 Mr Oliver was advised by Dr Rachakonda that anaesthetics had declined surgery in Mildura due to the risks involved and Mr Oliver was referred to the Peter MacCallum Centre in Melbourne. A decision was made by Mr Oliver’s family to change the referral to the Royal Adelaide Hospital due to the difficulties getting Mr Oliver to Melbourne in such a frail state.

4.9. On 17 February 2017 Mr Oliver was admitted to the Royal Adelaide Hospital under the management of oncologist Dr Richard Smith for pain management and treatment of the right fungating axillary mass. Mr Oliver remained in hospital until his death. Imaging showed a large ulcerating primary mass lesion in the right axilla with metastatic spread and a small right pneumothorax, and a cavitary lesion at the apex of the right lung. A biopsy confirmed the diagnosis of squamous cell carcinoma. Mr Oliver’s other comorbidities precluded surgery.8

4.10. Chemotherapy was considered, but deemed inappropriate due to the presence of metastases9. Palliative radiotherapy was refused and palliative care was instituted.

5. Mr Oliver’s detention and decline in health 5.1. On 21 February 2017 Mr Oliver became delirious, disorientated and agitated causing a code black which necessitated the imposing of a Level 1 ITO under the Mental Health Act 2009. This behaviour was uncharacteristic of Mr Oliver. He was described by his son Michael Oliver as ‘pretty placid’.10 Mr Michael Oliver described the care at the Royal Adelaide Hospital as ‘amazing’.11 7 Exhibit C7 8 Thyroid dysfunction, diabetes mellitus (Exhibit C8); Cardiomyopathy, NYHA Class 3 dyspnoea and frailty (RAH Case Notes); Widespread lung metastases causing his right lung to collapse (Exhibit C5) 9 Final Separation Summary, Dr Richard Smith at 27 February 2017 10 Exhibit C1b, page 5 11 Exhibit C1b, page 7

5.2. On 26 February 2017 a bleed was observed from the right axilla that resisted all attempts to stop it. It was thought that the tumour had invaded the blood vessels.

5.3. At 4:40am on Monday 27 February 2017 Enrolled Nurse Kimberlee Fenner attended Mr Oliver’s room and changed his dressings.12 She left the room and when she returned Mr Oliver was no longer breathing. Mr Oliver was certified deceased by Dr Zachary Richards at 4:58am that day.

6. Coronial investigation and conclusion 6.1. Mr Oliver’s death in custody was investigated by Detective Brevet Sergeant Mark Bischoff of the Eastern Adelaide Criminal Investigation Branch of SAPOL.13 It was Mr Bischoff’s conclusion following that investigation that Mr Oliver’s detention under the Mental Health Act 2009 had been lawful. In addition, Mr Bischoff concluded that Mr Oliver received the appropriate level of care and attention from both Tristar Medical in Mildura and at the Royal Adelaide Hospital.

6.2. I agree with the conclusions of the investigating officer in the matter. In addition, I conclude that the circumstances surrounding the death are not suspicious and do not indicate the involvement of any third party. I have no concerns relating to Mr Oliver’s care.

7. Recommendations 7.1. I have no recommendations to make 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 28th day of May, 2020.

Deputy State Coroner Inquest Number 14/2020 (0360/2017) 12 Exhibit C3 13 Exhibit C12a