Coroner's Finding: WILKS Deslandes

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 23rd day of April and the 18th day of June 2020, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Deslandes Wilks.

The said Court finds that Deslandes Wilks aged 79 years, late of Edercare Allambi, 86 Oaklands Road, Glengowrie, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 8th day of July 2017 as a result of pneumonia complicating ischaemic heart disease and dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for inquest 1.1. Deslandes Wilks was born on 6 November 1932 and died on 8 July 2017 at the Flinders Medical Centre. He was 79 years old. Professor Roger Byard conducted a post-mortem examination on Mr Wilks. This is referred to in Part 3 of this finding.

1.2. This is a mandatory inquest pursuant to section 21 of the Coroners Act 2003 as Mr Wilks had been on a Level 2 Inpatient Treatment Order1 at the time of his death that had been made pursuant to section 25 of the Mental Health Act 2009. That order had been made on 30 June 2017 and was due to expire on 11 August 2017. Mr Wilks had previously been placed on a Level 1 ITO on 25 June 2017. There are no concerns in relation to the lawfulness of custody.

1 ITO

2. Background 2.1. Mr Wilks was married to Janice Valmai Wilks. She described Mr Wilks as a good husband and a great dad. They had three children together, Karen, Katrina and Kylie.

Mr Wilks worked a variety of jobs, including as a baker and in sales. He worked for Cappo selling seafood before starting his own business selling seafood in Broken Hill and Mildura. Mr Wilks also sold pet food supplies.

3. Cause of death 3.1. An autopsy was conducted by Professor Roger Byard, forensic pathologist, from Forensic Science South Australia on 12 July 2017. Professor Byard's report was tendered at the inquest2. The suggested cause of death is pneumonia complicating ischaemic heart disease and dementia. I find that to have been the cause of Mr Wilks’ death.

3.2. Professor Byard noted the death was due to bilateral pneumonia complicating an established ischaemic heart disease, against a background of Alzheimer type dementia.

The behavioural changes reported could be attributed to the presence of Alzheimer type dementia. There were no other underlying organic diseases present which could have caused or contributed to death, and no evidence of trauma.

3.3. Other anatomical findings included amyloid angiopathy, mild thickening of the mitral valve, marked calcific atherosclerosis of the aorta with infrarenal ectasia, distal diverticular disease of the colon, nephrosclerosis of the kidneys, and moderate dorsal osteoarthritis.

3.4. Macroscopic and microscopic brain examinations were performed by Professor Blumbergs3. The neuropathological changes noted on microscopic analysis and abnormalities on macroscopic inspection were consistent with Alzheimer's disease.

4. Medical history 4.1. Mr Wilks' general practitioner was Dr Fook Wend Chan. In his statement4 Dr Chan stated that Mr Wilks' medical conditions prior to death included asthma and gout in 1988, a mild stroke in 2011 and high blood pressure in 2013. Mr Wilks developed mild 2 Exhibit C2a 3 Exhibits C3a and C3b 4 Exhibit C8

dementia in 2013. By 2015 he was officially diagnosed with Alzheimer's disease and was referred to the memory disorder clinic at the Repatriation General Hospital.

4.2. Janice Wilks described her husband starting to forget things. He was not turning taps off and ‘silly things like that’. He became increasingly physical with her.

4.3. Dr Chan treated Mr Wilks for his dementia condition in 2015 by prescribing risperidone to help him relax. He was displaying aggressive behaviour towards his wife. Dr Chan stated that this assisted to calm him down.

4.4. Mr Wilks was admitted to Eldercare Allambi Nursing Home in Glengowrie on 25 January 2017 and remained on risperidone. The dose was increased on 22 February 2017 when Mr Wilks became increasingly unsettled. Dr Chan is of the opinion that ceasing cigarette smoking contributed to Mr Wilks' irritation.

4.5. Mr Wilks' behaviour became increasingly difficult to manage, despite the increase to the dosage of medication. On 1 March 2017 he was noted as being threatening to the staff and trying to attack somebody with a fork. Dr Chan last saw Mr Wilks on 22 June 2017 at the nursing home. He had scabies rashes and was described as very uncooperative.

5. Mr Wilks’ admission to the Flinders Medical Centre and decline 5.1. Mr Wilks was then admitted to the Flinders Medical Centre the following day on 23 June 2017. He was transferred from the nursing home due to his aggressive behaviour, skin lesions, and a shortness of breath. He was diagnosed with a behavioural problem related to his dementia, scabies, dermatitis and pneumonia. He had previously been diagnosed with scabies on 9 June 2017 and treatments were commenced by his general practitioner whilst in the nursing home.

5.2. Mr Wilks was initially admitted under the care of geriatrician Dr Cheruvu and then from 1 July 2017 by Dr Gieroba5.

5.3. On 25 June 2017 Mr Wilks was placed on a Level 1 ITO by Dr Emma Adams in the context of confusion, aggression and agitation on a background of dementia. This order was confirmed by psychiatrist Randall Long on 26 June 2017. On 26 June 2017 5 Exhibit C7

Mr Wilks was admitted to the Flinders Medical Centre with increasing agitation and aggression.

5.4. A fall with a head strike occurred on 27 June 2017 and a CT scan of the brain shows no acute haemorrhage. Dr Gieroba thinks that this fall did not contribute to his death.

5.5. On 30 June 2017 the Level 1 ITO expired. Consultant psychiatrist Bonita Lloyd reviewed Mr Wilks' Level 2 ITO6. Dr Lloyd noted that Mr Wilks had a suspected delirium in the context of a respiratory tract infection, which led to a fluctuating mental state with periods of ongoing agitation and aggression. Mr Wilks was moaning but Dr Lloyd was unable to discern what he was saying. The order was confirmed and was due to expire on 11 August 2017.

5.6. From 30 June 2017 Mr Wilks was sedated and his delirium became increasingly apparent. His level of consciousness was fluctuating.

5.7. On 5 July 2017 Mr Wilks was reviewed by the Acute Care of the Elderly Team and he had slurred speech and was difficult to understand. Mr Wilks was not meeting nutritional requirements and invasive methods of treatment were not deemed appropriate. Geriatrician Dr Gieroba commented that in the days before his death Mr Wilks' pneumonia was improving. However, his shortness of breath worsened.

5.8. Mr Wilks was seen by a speech pathologist on 7 and 8 July 2017. There was a deterioration in the swallow function. He had poor oral intake, secondary to refusal, and deconditioning. He was a high aspiration risk. Mr Wilks developed a respiratory infection during admission, which was initially treated with antibiotics.

5.9. On 7 July 2017 Mr Wilks developed acute delirium and was difficult to rouse. After discussion with his daughter, comfort care was provided. Mr Wilks died on 8 July 2017.

5.10. The last person to see Mr Wilks alive was Registered Nurse Minghui Zhou. Prior to finishing her shift at 9:30pm on 8 July 2017, Ms Zhou checked on Mr Wilks. He was sleeping and breathing. As he was in comfort care she did not perform any observations7.

6 Exhibit C6 7 Exhibit C4

5.11. At about 9:30pm Registered Nurse Elizabeth Punu attended Mr Wilks' room. He had stopped breathing and had no pulse. Dr Alex Vidovic attended and declared Mr Wilks deceased at 11:30pm.

5.12. Dr Chan's opinion was that Mr Wilks' death was expected. He stated that when the brain does not work, all the other body parts shut down and stop working. That is the reason behind the very high mortality rate for dementia8.

6. Coronial investigation and conclusions 6.1. Mr Wilks’ death was subject to a coronial investigation by the Sturt Criminal Investigation Branch.

6.2. The investigating officer, Brevet Sergeant Monique Vickery, in her thorough report confirmed Mr Wilks was in lawful detention at the time of his death9. The circumstances surrounding the death are not suspicious and do not indicate the involvement of any third party or concerns relating to his care. I agree with the conclusion of this investigation.

7. Recommendations 7.1. 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 18th day of June, 2020.

Deputy State Coroner Inquest Number 18/2020 (1306/2017) 8 Exhibit C8 9 Exhibit C12a