Coroner's Finding: SWINGLER Yvonne Mary

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 21st day of May and the 2nd day of July 2020, by the Coroner’s Court of the said State, constituted of Brett Jonathon Dixon, Deputy State Coroner, into the death of Yvonne Mary Swingler.

The said Court finds that Yvonne Mary Swingler aged 86 years, late of 55 Blyth Street, Clearview, South Australia died at the Lyell McEwin Health Service, Haydown Road, Elizabeth Vale, South Australia on the 2nd day of December 2017 as a result of multiorgan failure due to sepsis. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Yvonne Mary Swingler was born on 15 October 1931 and died on 2 December 2017 at the Lyell McEwin Hospital. Mrs Swingler was 86 years old.

1.2. Mrs Swingler's clinical history and medical case notes were reviewed by Dr Iain McIntyre and discussed with Dr Steven Wills, forensic pathologist, of Forensic Science South Australia. In his pathology review report1 Dr McIntyre provided the cause of death as multi-organ failure due to sepsis, and I so find.

1.3. Mrs Swingler’s death was the subject of a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as she had been detained on an Inpatient Treatment Order (ITO) pursuant to section 21 of the Mental Health Act 2009 at the time of her death. That order, made by Dr Bahman Zarrabi of the Lyell McEwin Hospital, 1 Exhibit C2a

commenced on 28 November 2017 and was confirmed on the same day by psychiatrist Dr Andrew Rosser. The ITO was due to expire on 5 December 2017.2 There are no concerns in relation to the lawfulness of Mrs Swingler's custody.

2. Background and medical history 2.1. Mrs Swingler was mother to five children with her husband Francis; three sons, Steven, Peter and Leon and two daughters Margaret and Susan.3 Mrs Swingler's husband passed away in 1973 of kidney failure and four years later in 1977 her son Peter passed away in an industrial accident at the age of 22 years. Mrs Swingler lived for a number of years at a house in Clearview and once her son Steven reached adulthood, he remained living at the house in Clearview to care for her. She received a widow pension when her husband died and then subsequently the age pension when she turned 60.

2.2. In 2010 Mrs Swingler had a fall and started to lose her mobility. Her son Steven observed that Mrs Swingler seemed to lose interest in leaving the house at around this time and he took care of her, completing tasks such as shopping and banking. Steven Swingler became his mother’s official carer in 2012.

2.3. Mrs Swingler had been diagnosed with dementia in February 2017 and suffered from hypertension with multiple previous strokes4. Between 26 September and 13 October 2017 Mrs Swingler was treated at the Royal Adelaide Hospital for a stroke after presenting following a fall. During her time at the Royal Adelaide Hospital she developed leg weakness, was incontinent and became more dependent for movement.

2.4. Mrs Swingler was transferred to the Modbury Hospital for the purposes of inpatient rehabilitation before being released on 9 November 2017 into the care of the Oakwood Aged Care facility5. Steven Swingler reported that his mother had a few falls after she was released into the care of the Oakwood Aged Care facility and staff had reported that his mother had been difficult to manage because she was refusing to eat and drink and was becoming delusional. When Steven Swingler visited his mother at the aged care facility he noticed himself that she seemed confused and she told him that staff were trying to poison her.

2 Exhibit C10a 3 Exhibit C1a 4 Exhibit C6 5 Exhibit C12

3. Mrs Swingler’s decline in health and death 3.1. Mrs Swingler was admitted to the Modbury Hospital in the early hours of 23 November 2017, arriving by ambulance. Mrs Swingler had been admitted due to a change in her behaviour and her paranoia. This behaviour had first been observed on 11 November 2017, two days after her early release from hospital into the care of the aged care facility. In terms of the falls at the aged care facility, she experienced three falls on 11, 15 and 17 November 2017 respectively.

3.2. Mrs Swingler was transferred to the Lyell McEwin Hospital on 24 November 2017 as it was expected that she would require a longer hospital stay than was possible at Modbury Hospital.

3.3. Dr Siti Mohd Nawi assessed Mrs Swingler on 28 November 2017 and continued to monitor her on a daily basis until 1 December 2017. On 28 November 2017 Mrs Swingler was assessed by a psychiatrist at the Lyell McEwin Hospital, Dr Bahman Zarrabi.6 Mrs Swingler was disorientated, unsure what day it was, where she was and what her month of birth was. She appeared paranoid and expressed concern that hospital staff wanted to kill her so they could steal her money. She was refusing to eat or drink because she believed the food was poisoned. Mrs Swingler admitted to being thirsty and, at the encouragement of the psychiatrist, took a few sips of her milkshake before stating that it was poison and refusing to drink anymore.

3.4. Dr Zarrabi assessed Mrs Swingler as having experienced a rapid decline in her mental state with a clear mental impairment consistent with delirium and acute confusion. He suspected that Mrs Swingler's recent stroke and her age may have contributed to these conditions, however this was not ultimately confirmed. Dr Zarrabi made a Level 1 ITO on 28 November 2017.

3.5. Dr Mohd Nawi observed Mrs Swingler was combative and refusing to take anything by way of mouth, including medication. As the Level 1 ITO had been implemented Mrs Swingler was administered an intravenous drip in an effort to keep her hydrated and to provide medications to manage the symptoms of her psychosis.

3.6. On 29 November 2017 Mrs Swingler developed swelling on the right side of her neck resulting in the performance of a CT scan on 30 November 2017. That CT scan showed inflammation of her right salivary gland. Mrs Swingler was diagnosed with a bacterial 6 Exhibit C5

staphylococcus infection in her bloodstream and sepsis. Dr Mohd Nawi suspected that the infection was triggered by Mrs Swingler's lack of oral intake and the presence of staphylococcus in the mouth. Intravenous antibiotics were provided to Mrs Swingler7.

3.7. On 1 December 2017 Dr Mohd Nawi noticed a marked deterioration in Mrs Swingler's condition. She had less energy than previously observed, but still remained combative.

Her heart rate was rapid due to her infection and attempts to provide her with sustenance through a feeding tube proved unsuccessful as she pulled the feeding tube out.

3.8. Given her overall frailty, deteriorating health and her comorbidities including stoke, dementia and infection, it was agreed, in consultation with her son, that Mrs Swingler was not for resuscitation. Invasive intervention was deemed to be futile and neither Dr Mohd Nawi nor Mrs Swingler's son thought it appropriate to force further treatment on her. The focus at that point was to make Mrs Swingler as comfortable as possible during the time she had remaining.

3.9. On 2 December 2017 Enrolled Nurse Naomi Cappelluti was performing routine observations on Mrs Swingler when she noticed her blood pressure was very low.8 Nurse Cappelluti sought assistance from another Registered Nurse, Jessica Flaherty9, and a code blue was called resulting in a medical response team attending to assess Mrs Swingler. Given that Mrs Swingler was not for CPR she was placed on palliative care on the basis that no medical response team would attend if there was further deterioration in her condition.

3.10. Nurse Flaherty provided Mrs Swingler with morphine and all other medications and intravenous fluids were ceased. Nurse Cappelluti checked on Mrs Swingler at 7:25pm on 2 December 2017 and observed that Mrs Swingler had died. She was formally declared deceased by Dr Yong Cheng Chi at 7:40pm.

4. Coronial investigation 4.1. Detective Brevet Sergeant Craig Metschke of the Holden Hill Criminal Investigation Branch of SAPOL investigated the death of Mrs Swingler and prepared a comprehensive report for the State Coroner10.

7 Exhibit C11 8 Exhibit C3 9 Exhibit C4 10 Exhibit C10

4.2. Detective Metschke’s investigation determined that Mrs Swingler was in lawful detention at the time of her death and that the circumstances of her death were not suspicious and did not indicate the involvement of any third party. The investigation did not identify any issues of concern regarding the treatment of Mrs Swingler at either the Modbury Hospital or the Lyell McEwin Health Service.

4.3. No concerns were raised by Mrs Swingler's next of kin. In his statement dated 18 May 2018 Mrs Swingler's son expressed the following in relation to his mother's care in the final days of her life: 'I was really pleased with the medical care that was provided to my Mum. I believe they really looked after her and I have nothing but praise for them. I think they did their best effort to look after her.' 11

5. Conclusions and recommendations 5.1. I find that Mrs Swingler was in lawful detention at the time of her death and that her detention had no bearing on her death. I further find Mrs Swingler received an appropriate level of care and treatment during her admissions to both the Modbury Hospital and the Lyell McEwin Health Service.

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 July, 2020.

Deputy State Coroner Inquest Number 47/2020 (2455/2017) 11 Exhibit C1a