Coroner's Finding: WHATLEY Deborah Rose

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 Deborah Rose Whatley.

The said Court finds that Deborah Rose Whatley aged 55 years, late of Magill Lodge, 524 Magill Road, Magill, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 18th day of January 2018 as a result of ischaemic heart disease complicated by epilepsy, asthma and schizophrenia. The said Court finds that the circumstances of her death were as follows:

1. Introduction 1.1. Deborah Rose Whatley was born on 29 May 1962 and died on 18 January 2018 at the Royal Adelaide Hospital. She was 55 years old.

2. Cause of Death 2.1. A post-mortem examination including a full autopsy was performed by Specialist Forensic Pathologist, Dr Cheryl Charlwood, of Forensic Science South Australia on 23 January 2018. Dr Charlwood had reference to the Royal Adelaide Hospital case notes as well as the results of toxicology screening of Ms Whatley’s ante-mortem and post-mortem blood samples along with a macroscopic brain report prepared by

Professor Peter Blumbergs.1 Dr Charlwood deemed the toxicological findings not to be a factor in Ms Whatley’s death.2

2.2. An examination of Ms Whatley’s heart revealed the presence of ischaemic heart disease with moderate and severe calcified atheromatous stenosis in the left anterior descending coronary artery. Dr Charlwood’s opinion was that this condition alone could represent a valid cause of Ms Whatley’s death. An examination of Ms Whatley’s lungs revealed marked pulmonary oedema and congestion to the lungs with signs of early acute asthma. Ms Whatley’s epilepsy was capable of exacerbating her cardiac dysfunction.

2.3. In Dr Charlwood’s opinion, Ms Whatley’s cause of death was ischaemic heart disease complicated by epilepsy, asthma and schizophrenia3, and I so find.

3. Reason for inquest 3.1. A mandatory inquest into Ms Whatley’s death was required pursuant to section 21(1)(a) of the Coroners Act 2003 as she was the subject of an Inpatient Treatment Order (ITO) at the time of her death. A Level 1 ITO had been made pursuant to section 21 of the Mental Health Act 2009 by Dr Mei Shing Yee on 17 January 20184 and confirmed by psychiatrist Dr Russell Finlay on 18 January 2018.5 The treatment order was current at the time of Ms Whatley’s death and due to expire on 24 January 2018.

3.2. There are no concerns in relation to the lawfulness of custody.

4. Background 4.1. Ms Whatley was adopted by Bryan and Mavis Whatley when she was six weeks old.

At that time Ms Whatley’s adoptive parents had a biological son, Bruce.6

4.2. Ms Whatley lived with her family in Seaton Park before moving to Whyalla in 1967 and subsequently to Wales in the United Kingdom at the end of 1969 when she was seven years of age. Ms Whatley returned to live in Australia in March 1981, her brother 1 Exhibit C3a, Toxicology Summary Report of ante-mortem blood samples, Exhibit C3b, Toxicology Summary Report of post-mortem samples, Exhibit C4a, Report of Dr Peter Blumbergs 2 Exhibit C2a 3 Exhibit C2a 4 Exhibits C10 and C20c 5 Exhibit C20c 6 Exhibit C15

having moved back to Australia approximately six months earlier. Upon her return from the United Kingdom, Ms Whatley and her parents lived in Ingle Farm.

4.3. Ms Whatley moved into her own Housing SA unit at Ingle Farm in 2002 where she lived independently until May 2017. Throughout this period Ms Whatley had periods of detention in mental health facilities for treatment of her schizophrenia and she was engaged with the North Eastern Community Mental Health Team.

4.4. Initially Ms Whatley’s mother would visit her regularly at her unit in Ingle Farm, but over time Ms Whatley wanted to see less of her mother and within a year or so of living independently, Ms Whatley stopped letting her parents visit her.7

4.5. Ms Whatley’s brother was of the view that she initially seemed to cope living by herself and there was some partial rekindling of her relationship with her parents. However, over time Ms Whatley’s mental health seemed to deteriorate and she came to police attention in 2011. On 12 January 2011 Ms Whatley was accused of damaging property at a laundromat at Ingle Farm. On 23 April 2011 Ms Whatley was accused of assaulting a two-year-old child and an adult female at Ingle Farm in a two separate incidents. No criminal charges were pursued for any of these three incidents due to Ms Whatley’s intellectual disability.

4.6. Ms Whatley’s parents were unable to care for her due to their age and health and Ms Whatley’s brother lived interstate.

4.7. On 12 March 2015 Ms Whatley was placed under a Full Guardianship Order by the South Australian Civil and Administrative Tribunal.8 This order was confirmed on 15 April 20169 and remained in place until 30 March 2017 when it was varied to a Limited Guardianship Order.10 The Full Guardianship Order gave the Office of the Public Advocate responsibility for making decisions regarding Ms Whatley’s accommodation, health and lifestyle, whereas the Limited Guardianship Order meant that the Office of the Public Advocate only had decision making authority over accommodation decisions.

7 Exhibit C15 8 Exhibit C17 9 Exhibit C20b 10 Exhibit C20a

4.8. On 17 May 2017 Ms Whatley was moved from her Housing SA accommodation in Ingle Farm to a residential care facility in Magill on the referral of North Eastern Community Mental Health.11 From this point onwards staff at the facility cared for Ms Whatley with support from care workers at Uniting Care Wesley in conjunction with Eastern Community Mental Health Services12.

5. Medical history 5.1. Ms Whatley’s General Practitioner for 24 years, Dr Jennifer Cook-Foxwell, has provided a statement to the Court setting out Ms Whatley’s medical history in detail.13

5.2. Ms Whatley had a long history of mental illness and had suffered from an intellectual disability since birth. Ms Whatley’s communication was limited and her mental health and intellectual disability made it difficult for her to express herself at times.

Ms Whatley was also generally resistant to medical treatment and intervention.

5.3. Ms Whatley had been diagnosed with epilepsy by Dr Julian Kent, a psychiatric registrar at the Modbury Hospital, in 1982.14 In June 1982 Ms Whatley was diagnosed as having a borderline range of intelligence and agoraphobia.

5.4. On 19 October 1987 Ms Whatley was diagnosed with chronic schizophrenia15, although her brother notes that she displayed signs of escalating mental illness from about the age of 10.16

5.5. Ms Whatley was a smoker. When she moved to the supported residential facility in May 2017 she was smoking approximately 20 cigarettes per day which had reduced to less than 13 a day at the time of her death.17 Ms Whatley had chronic obstructive pulmonary disease (COPD). X-rays taken of Ms Whatley’s chest on 22 June 2016 were normal, although she had a chronic cough for years.18 11 Exhibit C1a 12 As Ms Whatley moved to a different catchment area her care was transferred from North Eastern Community Mental Health 13 Exhibit C16 14 Exhibit C16 15 Exhibit C16 16 Exhibit C15 17 Exhibit C1a 18 Exhibit C16

5.6. At the time of her death Ms Whatley was prescribed medications including an inhaler for her COPD, sodium valproate for her epilepsy and clozapine for her schizophrenia.19

6. Ms Whatley’s decline in health and detention 6.1. Ms Whatley was taken by ambulance to the Royal Adelaide Hospital from her accommodation on the evening of Tuesday 16 January 2018 due to reported abdominal pain, intermittent faecal incontinence and increased confusion. Ms Whatley was seen in the Emergency Department of the Royal Adelaide Hospital and was provided with antibiotics for a suspected urinary tract infection before being discharged back to her residential accommodation.20 Ms Whatley returned to her accommodation at 5:10am on Wednesday 17 January 2018 and went straight to bed.21

6.2. Ms Whatley’s psychotic behaviour seemed to worsen and at 5:06pm on 17 January 2018 she was taken by ambulance to the Royal Adelaide Hospital.22 Information provided by staff at Ms Whatley’s accommodation was that her mental state had been deteriorating over the past few weeks and she had been talking to herself, not sleeping, pacing the corridors and displaying persecutory delusions. At the time of her re-admission the results of the urine test taken from on 16 January 2018 were available and confirmed that she did not have a urinary tract infection.23

6.3. Following a review and assessment Ms Whatley was medically cleared by the emergency physicians for transfer to Glenside Hospital for further psychiatric treatment the following morning on 18 January 2018.

6.4. Dr Mei Shing Yee conducted a psychiatric review of Ms Whatley at the Royal Adelaide Hospital at about 11pm on Wednesday 17 January 2018. Dr Yee suspected that Ms Whatley may have been suffering a relapse of her schizophrenia and formed the view that she would need to remain in hospital for observation and treatment. Due to Ms Whatley displaying unpredictable and impulsive behaviours, a Level 1 ITO was instituted by Dr Mei Shing Yee which was confirmed the following day by psychiatrist 19 Exhibits C1a and C11 20 Exhibit C10 21 Exhibit C1a 22 Exhibit C1a; Royal Adelaide Hospital Notes (SAAS Notes) 23 Exhibit C10

Dr Russell Finlay.24 That treatment order was current at the time of Ms Whatley’s death.

6.5. On the morning of 18 January 2018, whilst still at the Royal Adelaide Hospital, Ms Whatley experienced a drop in her conscious state and was suffering from bladder and bowel incontinence. An emergency call was made and Ms Whatley was taken to the Resuscitation Unit in the Emergency Department for further evaluation.25 Ms Whatley was quite agitated and was given sedatives to enable staff to appropriately assess her condition.

6.6. Routine blood tests, a CT of Ms Whatley’s brain and a chest X-ray all returned unremarkable results. Notwithstanding her history of COPD, Dr Nguyen did not hear any evidence of lung obstruction and Ms Whatley’s oxygen saturation levels were appropriate. Ms Whatley was admitted for care under the general medicine team at the Royal Adelaide Hospital for further investigations to be carried out. The planned transfer to Glenside Hospital was cancelled.

6.7. Dr Van Vi Nguyen assessed Ms Whatley at about 3pm on 18 January 2018 shortly after the CT scan was performed. An electrocardiogram (ECG) showed a normal heart rhythm. During Dr Nguyen’s review Ms Whatley would intermittently sit up and not co-operate and remained agitated at times. Dr Van Vi Nguyen admitted Ms Whatley for care under the general medicine team. She could not go to Glenside because she was not medically stable at that stage.

6.8. Ms Whatley’s blood had a high acidity level, referred to as acidosis. This was thought to be the likely result of her having suffered a seizure.26

6.9. Ms Whatley was transferred to the general ward at 8pm on 18 January 2018.27 As Ms Whatley remained agitated, arrangements were made to have her allocated a special nurse on a one-on one basis.

6.10. Ms Whatley’s progress in the general ward was unremarkable and she was checked on regularly by nursing staff. Registered Nurse Chandri Polara checked on Ms Whatley at approximately 11pm on 18 January 2018 and noticed she was ‘off colour’ and did 24 Exhibits C10c and C20c 25 Exhibit C9 26 Exhibit C9 27 Exhibit C8

not appear to be breathing or to have a pulse.28 A medical emergency was called and attempts to resuscitate Ms Whatley continued for approximately 30 minutes.

Ms Whatley was intubated as part of the resuscitation attempts and blood was aspirated from her trachea. The team were unable resuscitate Ms Whatley and she was pronounced deceased by Dr Seon Ho Shin at 11:55pm on 18 January 2018. 29

7. Coronial investigation 7.1. Detective Brevet Sergeant Leon Rusak of the Eastern Adelaide Criminal Investigation Branch of SAPOL investigated the death of Ms Whatley and prepared a comprehensive report for the Court30. Detective Rusak’s investigation revealed that Ms Whatley was in lawful detention at the time of her death and that the circumstances surrounding her death were not suspicious and did not indicate the involvement of any third party.

7.2. Detective Rusak did not identify any matters of concern in relation to the care and treatment of Ms Whatley whilst at the Royal Adelaide Hospital. No concerns relating to Ms Whatley’s medical treatment have been raised by her next of kin.

8. Conclusions and recommendations 8.1. I find that Ms Whatley was in lawful detention at the time of her death. I further find that the care and treatment provided to Ms Whatley whilst at the Royal Adelaide Hospital was appropriate in the circumstances.

8.2. I make no recommendations in relation to 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 48/2020 (0129/2018) 28 Exhibits C6 and C7 29 Exhibit C8 30 Exhibit C20