Coroner's Finding: SOLTYS Marie Joyce

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 4th day of June and the 16th day of July 2020, by the Coroner’s Court of the said State, constituted of Paul Marvin Foley, Deputy State Coroner, into the death of Marie Joyce Soltys.

The said Court finds that Marie Joyce Soltys aged 78 years, late of 108/12-16 Durham Street, Glenelg, South Australia died at the Queen Elizabeth Hospital, 28 Woodville Road, Woodville, South Australia on the 13th day of September 2018 as a result of aspiration pneumonia complicating electroconvulsive therapy on a background of end-stage Lewy Body dementia and cerebrovascular disease. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Marie Joyce Soltys was born on 23 December 1939 and died on 13 September 2018 at the Queen Elizabeth Hospital. She was 79 years old. Mrs Soltys was formally identified by her daughter, Kathleen Felstead, at the Queen Elizabeth Hospital, on 13 September 20181.

1.2. A pathology review of Mrs Soltys’ medical records and clinical history was conducted by Dr Iain McIntyre on 17 September 20182. Dr McIntyre found that Mrs Soltys died from aspiration pneumonia complicating electroconvulsive therapy on a background of end-stage Lewy Body dementia and cerebrovascular disease, and I so find. Dr McIntyre noted a history including behavioural issues and hallucinations, insulin dependent 1 Exhibit C1, PD44 Identification of Deceased 2 Exhibit C2a, Pathology Review by Doctor Iain N McIntyre dated 17 September 2018

diabetes, atrial fibrillation, ischaemic heart disease, chronic congestive heart failure, hypertension, right side cerebrovascular accident, hypothyroidism, gastroesophageal reflux disease, osteoarthritis, migraine, angio-oedema to ACE inhibitor antihypertensives, and giant cell arteritis.

2. Reason for inquest 2.1. Mrs Soltys was placed on a Level 1 Inpatient Treatment Order (ITO) at 11:41am on 27 July 2018 by psychiatrist, Dr HanKyung Oh, pursuant to section 21 of the Mental Health Act 2009. The ITO was confirmed by psychiatrist, Dr Douglas Wilson, on 28 July 2018 at 2:12pm.

2.2. On 3 August 2018 Mrs Soltys was seen by psychiatrist, Dr Andrew Lawlor, who approved a Level 2 ITO at 12:21pm. The Level 2 ITO was revoked by Dr Jonathan Fry on 12 September 2018 at 9:50am as Mrs Soltys was near death and the order to detain and treat her was no longer required. Despite her death not occurring whilst under an ITO, Mrs Soltys’ 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 Soltys was subject to an ITO. As such this is a mandatory inquest pursuant to section 21(1)(a) of Coroners Act 2003.

3. Background and circumstances leading to hospitalisation 3.1. Mrs Soltys was diagnosed with diabetes at age 41 and was insulin dependent from that time. She had a stroke in 1998 which affected her left side. She had a history of cardiac issues and received two cardiac stents in 2011. Mrs Soltys had numerous other health issues.

3.2. Until approximately fourteen weeks prior to her death Mrs Soltys lived in her home at Glenelg. She was independent and looked after herself3.

3.3. On 6 June 2018 Mrs Soltys began having delusions that someone was trying to kill her.

She was admitted to the Ashford Hospital for tests and a CT scan. She was then transferred to Flinders Private Hospital and reviewed by a geriatrician. Antipsychotic 3 Exhibit C1a, Affidavit of Kathleen Felstead dated 13 September 2018

medication was prescribed. At this time she was diagnosed as suffering from Lewy body dementia.

3.4. Mrs Soltys was unable to remain in her own home and was placed at the Ananda Aged Care facility in Findon. Due to her delusions she refused oral medication. She suffered a hypoglycaemic episode and was found in an unresponsive state.

3.5. Mrs Soltys was admitted to the Queen Elizabeth Hospital on 26 July 2018. On 27 July 2018, Mrs Soltys was seen by psychiatrist, Dr HanKyung Oh and this is when she was placed on the Level 1 ITO due to her increased agitation and to ensure appropriate treatment4. As previously noted, Dr Douglas Wilson confirmed the ITO the following day.

3.6. On 3 August 2018 Mrs Soltys was reviewed by Dr Lawlor who found that Mrs Soltys’ mental state was deteriorating and she continued to refuse treatment. He found she was a risk to herself and others. At 2:28pm Dr Lawlor approved the Level 2 ITO5.

3.7. Mrs Soltys underwent Electro Convulsive Therapy (ECT) on 7 September 2018. Her daughter Kathleen described her as ‘a bit shaky’ following that treatment6.

4. Circumstances of death 4.1. On 10 September 2018 Mrs Soltys underwent a second course of ECT. Her daughter Kathleen described her as being ‘very confused and didn’t recognise her own name’ following this treatment7. By 5pm that day Mrs Soltys was non-responsive.

Mrs Soltys’ daughters consulted medical staff and a decision was made to move Mrs Soltys to palliative care.

4.2. As stated earlier, the Level 2 ITO was revoked by Dr Fry on 12 September 2018.

4.3. Mrs Soltys’ daughters, Kathleen and Tania, stayed with Mrs Soltys overnight on 12 September 2018. Mrs Soltys’ daughters were with her at 6:35am on 13 September 2018 when she ceased breathing. At 7:20am Mrs Soltys was declared deceased.

4 Exhibit C4, Affidavit of Dr HanKyung Oh dated 18 January 2019 5 Exhibit C5, Affidavit of Dr Andrew Lawlor dated 10 July 2018 6 Supra n.3 at paragraph 16 7 Supra n.3 at paragraph 17

5. Coronial investigation 5.1. Probationary Constable Daniel Pichl8 attended the Queen Elizabeth Hospital at about 8:20am on 13 September 2018 in relation to the death of Mrs Soltys. Probationary Constable Pichl observed the body of Mrs Soltys and made other observations at the Queen Elizabeth Hospital in accordance with standard procedures.

5.2. Brevet Sergeant Bradley Chapman attended the Queen Elizabeth Hospital at about 10:58am on 13 September 2018 and undertook the standard photographic procedures applicable to deaths where an ITO has been in place9.

5.3. Detective Brevet Sergeant James Watkins investigated the death in custody of Mrs Soltys and prepared a comprehensive report that was tendered to the inquest10.

Detective Watkins noted no issues of concern in relation to the detention, care and treatment of Mrs Soltys.

6. Conclusion and recommendation 6.1. From the medical records it is apparent that Mrs Soltys’ daughters were kept aware of and consulted about their mother’s treatment. I find that Mrs Soltys’ care and treatment at the Queen Elizabeth Hospital was appropriate. I find that the imposition of an inpatient treatment order was appropriate.

6.2. I have no recommendations to make in relation to the death of Mrs Soltys.

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 16th day of July, 2020.

Deputy State Coroner Inquest Number 61/2020 (1743/2018) 8 Exhibit C7, Affidavit of Probationary Constable Daniel Pichl dated 13 September 2018 9 Exhibit C8, Affidavit of Brevet Sergeant Bradley Chapman dated 23 November 2018 10 Exhibit C9, Final Report of Detective Brevet Sergeant James Watkins dated 16 July 2019