Coroner's Finding: SNIECIKOWSKA Alicja

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 9th day of April and the 21st day of May 2020, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Alicja Sniecikowska.

The said Court finds that Alicja Sniecikowska aged 68 years, late of 2/41 Norman Terrace, Everard Park, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 1st day of September 2016 as a result of chronic obstructive pulmonary disease. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Ms Alicja Sniecikowska was born on 13 May 1948 and died at the Royal Adelaide Hospital on 1 September 2016 at the age of 68.

1.2. The cause of death was determined by a pathology review conducted by Dr Jane Alderman in discussion with Dr Stephen Wills, forensic pathologist, from Forensic Science South Australia1. In her report Dr Alderman suggested the cause of death as chronic obstructive pulmonary disease, or COPD. An autopsy was not required as the cause of death was clear from the medical notes. Based on the pathology review I find that the cause of Ms Sniecikowska’s death was chronic obstructive pulmonary disease.

Ms Sniecikowska's body was identified by Dr Jonathan Sivakumar2.

1 Exhibit C2 2 Exhibit C1

1.3. The reason for this inquest is that Ms Sniecikowska’s death falls within the definition of a ‘death in custody’ and is subject to a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003. Ms Sniecikowska was placed on a Level 1 Inpatient Treatment Order (ITO) on 31 August 2016. The ITO was not confirmed as per section 21(5)(a) of the Mental Health Act 2009 as Ms Sniecikowska died less than 24 hours later.

2. Background and medical history 2.1. There is little known about Ms Sniecikowska's background with most of the information obtained being from her friend, Ms Marysia Norman, and medical records from her general practitioner. Ms Norman was a close friend of Ms Sniecikowska's daughter and assisted her in the years prior to her death. Ms Norman provided a statement to the Court3. Ms Sniecikowska was of Polish descent and spoke little English. Approximately 15 years prior to her death she moved to Australia. Her daughter, who is also deceased, had been living in Australia. It appears however that her daughter committed suicide prior to Ms Sniecikowska's arrival, although the fact of the suicide is somewhat contradicted by Ms Sniecikowska's general practitioner who was under the impression that her daughter died in a car accident. Ms Sniecikowska had one grandchild but there is no evidence that she had any contact with the child. She had no other family in Australia aside from an aunt who has since passed away.

2.2. Ms Norman is of the opinion Ms Sniecikowska was an alcoholic: Every time Ms Norman saw her she would be intoxicated. Ms Norman also believed she was an extremely lonely lady. Ms Norman did her best to support her, regularly visiting her and keeping her company and assisting in cleaning the house. In 2013 Ms Norman made several arrangements for Ms Sniecikowska to visit her sister in Poland, but it never eventuated. Ms Norman said that Ms Sniecikowska missed the first flight and the second time she was en route she became intoxicated and incontinent and was admitted to a hospital in Kuala Lumpur. Ms Sniecikowska was caught smoking on a plane journey back to Australia: She was an extremely heavy smoker.

2.3. In the two years prior to her death, Ms Norman would accompany Ms Sniecikowska to the doctor acting as an interpreter. She stated that Ms Sniecikowska was a smart woman who enjoyed reading and doing Polish puzzles and perfectly understood 3 Exhibit C5

anything that was explained to her by way of an interpreter. On 31 April 2014 Ms Sniecikowska gave Ms Norman medical power of attorney.

2.4. Dr Monika Moy at the Kurralta Park Surgery had been Ms Sniecikowska's general practitioner from December 20044. Dr Moy stated Ms Sniecikowska suffered from COPD which is characterised by poor airflow, shortness of breath, cough with septum production and frequent infections. She had numerous hospital admission due to the exacerbation of her COPD; three of those admissions were in June and July 2016. She also suffered from hyperthyroidism and periods of incontinence. Dr Moy noted that Ms Sniecikowska's last known prescribed medications were thyroxine for hyperthyroidism, puffers including Ventolin, Spiriva, Symbicort for her COPD, thiamine and vitamin B tablets for alcohol abuse. She stated there was evidence to suggest that Ms Sniecikowska was not taking her prescribed medication. In 2013 Dr Moy was notified that Ms Sniecikowska suffered a cardiac arrest secondary to choking. Dr Moy stated in June 2013 Ms Sniecikowska was admitted to the RAH with a fracture to her cervical spine, C1 and C2. There were concerns about her mental capacity due to delirium, which is believed to be secondary to vascular dementia. An interim guardian was appointed on 21 June 2013, however the delirium resolved and she was found to have the capacity to make medical decisions.

2.5. Dr Moy submitted a review report to the Guardianship Board (now SACAT) on 16 August 2013. She expressed concerns about Ms Sniecikowska's mental capacity.

Dr Moy believed that, even with the advantage of a professional interpreter, Ms Sniecikowska had difficulty understanding medical advice and she would not follow Dr Moy's instructions. Dr Moy believed Ms Sniecikowska did not have the ability to look after herself or make reasonable decisions on her own, or alternatively did not have the desire to do so. Due to alcohol abuse, Dr Moy felt Ms Sniecikowska had some cognitive issues, particularly regarding her memory. She had referred Ms Sniecikowska to a geriatric memory clinic, but was unsure if she actually attended.

Dr Moy states Ms Sniecikowska was probably subject to the lowest level of intervention regarding her mental capacity and alcoholism over the years. Dr Moy felt she herself could have done more when Ms Sniecikowska failed to attend infrequent appointments. Dr Moy felt the system had failed Ms Sniecikowska, but does not 4 Exhibit C4

expand on this. The doctor also stated that Ms Sniecikowska was fatalistic and had some degree of a death wish, falling short of suicidal ideation. She stated: 'She passively was not trying to save herself.' Ms Sniecikowska was difficult to contact via telephone and Dr Moy was not prepared to visit her home. Dr Moy stated that Ms Sniecikowska drank herself to death. Despite Dr Moy's review report, Ms Sniecikowska was later assessed and found to have mental capacity, once the delirium secondary to alcohol abuse had lifted.

2.6. The interim guardianship order was revoked on 21 August 2013. Ms Sniecikowska was in receipt of care support, a fortnightly cleaner and support worker but she refused any more support beyond this and Ms Norman's usual visits.

3. The circumstances surrounding Ms Sniecikowska’s death 3.1. As stated earlier, Ms Sniecikowska had numerous hospital admissions for the exacerbation of her COPD. On 29 August 2016 Ms Sniecikowska attended at the Royal Adelaide Hospital (RAH). Hospital notes indicate that she had run out of inhalers five days prior to admission. At 5:36pm Ms Sniecikowska was admitted to the RAH presenting with ineffective exacerbation of the COPD.

3.2. Dr Joanne Eng-Frost5 stated that on admission Ms Sniecikowska denied any haemoptysis6, leg pain or chest pain. She was noted to have an increased respiratory rate of 24 with widespread wheeze and crackles. She was commenced on intravenous antibiotics and supplemental oxygen and underwent a chest X-ray. She was then transferred to the acute medical unit (AMU) at 9:30pm under the care of Dr Terence Glynn who had been the consultant physician in charge of her during previous hospital admissions.

3.3. Ms Sniecikowska had poor compliance with oxygen treatment, over-used puffers and continued to actively smoke. She signed an acknowledgement form with respect to taking responsibility for her behaviour when leaving the AMU for a cigarette, but agreed to nicotine patches and a nicotine inhaler when required.

5 Exhibit C3 6 Coughing up of blood

3.4. At around 6pm on 30 August 2016 a medical emergency team (MET) call was made for chest pain and acute oxygen desaturation to 64% on room air. It was felt that Ms Sniecikowska had type 2 respiratory failure secondary to exacerbation of the COPD, but pulmonary embolus and ischaemic cardiac events were also considered.

She was also suspected of a urinary tract infection and pull-up pads were provided in case of probable incontinence.

3.5. Ms Sniecikowska was reviewed by the ICU registrar who recommended repeat blood investigation and thoracic review for trial of non-invasive ventilation. She was subsequently reviewed by the thoracic RMO at 7:45pm. Following discussions with the respiratory consultant, Dr Antic, Ms Sniecikowska was deemed suitable to transfer to the thoracic ward for trial of bilevel positive air way pressure (BiPAP) with a nurse special assigned to her.

3.6. The BiPAP treatment was explained to Ms Sniecikowska via an interpreter. However, the treatment was not tolerated and she was resistant to the mask. She was returned to the ward and reviewed by the AMU registrar at approximately 9pm for ongoing fast respiratory rate.

3.7. Ms Sniecikowska's resuscitation status was clarified with her through the assistance of a Polish speaking nurse. She confirmed she did not want CPR or intubation, but was willing to trial BiPAP again. A MET call was made at 10:35pm due to low oxygen saturation of 78%. BiPAP was trialled again, but was met with resistance. The consequences of proceeding without BiPAP support, including worsening of the type 2 respiratory failure, drowsiness, infection and overall clinical deterioration were explained to Ms Sniecikowska and she accepted these risks.

3.8. Further MET calls were made on 31 August 2016 at 2:55am and 5:35am for low saturations at 77% and 67%. Ms Sniecikowska was managed conservatively with supplemental oxygen and on-ward based treatments. Medical notes indicate that she had poor tolerance of all mask-based interventions including oxygen, Ventolin nebules and BiPAP.

3.9. At around 5:10am a hospital note indicated that she refused to sleep in a 90 degree position and insisted on lying flat. At 5:25am she asked for a fresh air and a fan was provided. Dr Glynn and his team, including Dr Eng-Frost, reviewed Ms Sniecikowska

at 9:05am and 10am on 31 August 2016 and found her to be non-compliant with treatment and requesting to leave the ward for a cigarette.

3.10. She was assessed to be a significant risk to herself due to limited cognitive capacity secondary to hypoxia and was placed under the Level 1 ITO at 10:05am. Notes made by Dr Christina Valero indicated the reasons for the ITO as being unsafe for discharge, unsafe to leave the ward, and poor prognosis given inability to escalate treatment.

3.11. A computed tomography pulmonary angiogram (CTPA) had been requested to test whether she had pulmonary embolus, but this was not accepted by her. As such the CTPA was cancelled with a plan for continued conservative management. The gravity of her condition and high mortality risks were reiterated to her. She became agitated about using an oxygen mask. She was recorded as saying 'I need to die, and that's it'.

She finally agreed to endure an oxygen mask but continued to ask for cigarettes.

3.12. A copy of the Level 1 ITO was faxed to the Office of the Chief Psychiatrist at 4pm on 31 August 2016. Another MET call was made at 6:56pm. There was discussions regarding palliative care in case of further deterioration and it was decided that further MET calls would be ceased. A Polish interpreter was secured at 8:02pm to explain this to Ms Sniecikowska. Ms Sniecikowska indicated that she was willing to try the oxygen mask or BiPAP if required, but when trialled with the mask she was non-compliant after ten seconds.

3.13. At around 10:40pm Dr Jonathan Sivakumar reviewed Ms Sniecikowska and found her sitting up and agitated. The impression of her condition at the time was increased respiratory rate and diffused wheeze secondary to agitation.

3.14. On 1 September 2016 at 1:30am she was reviewed again by Dr Sivakumar for oxygen desaturation of 40%. She was assessed to be agitated causing her to remove nasal specs, but her oxygen saturation improved to 80-85% after oxygen was held near her face.

She was given 5mg of morphine subcutaneously, she settled and appeared comfortable and oxygen saturation levels were noted to be good at 3am and 4am.

3.15. At 5:10am on 1 September 2016 Ms Sniecikowska was very agitated with an oxygen saturation level of 65%. Staff attempted to administer an inhaler which was resisted and she was noted to be sweating profusely. Her pad and gown were changed to make her more comfortable, her breathing became more laboured, her upper teeth were

removed to clear airways and suction applied for excessive saliva. Her breathing slowed and appeared to stop at 5:35am. She was pronounced deceased by Dr Sivakumar at 5:42am.

4. Coronial investigation and conclusion 4.1. Detective Brevet Sergeant Melanie Ellis from the SAPOL Sturt Criminal Investigation Branch was the appointed investigating officer for this death in custody and provided a comprehensive report to the Court in relation to Ms Sniecikowska's death.7

4.2. I accept the opinion of Detective Ellis that the Level 1 ITO was appropriate and lawful given Ms Sniecikowska's condition at the time. I agree with her conclusion that Ms Sniecikowska was provided with the appropriate care and treatment and was treated with dignity by the medical professionals at the Royal Adelaide Hospital.

5. Recommendations 5.1. 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 21st day of May, 2020.

Deputy State Coroner Inquest Number 11/2020 (1672/2016) 7 Exhibit C9a