Coroner's Finding: Barry, Margaret Joan

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 10th day of June and the 23rd day of November 2021, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Margaret Joan Barry.

The said Court finds that Margaret Joan Barry aged 80 years, late of 69 Mitchell Street, Millswood, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 24th day of April 2019 as a result of right haemothorax due to bleeding right pleural adhesion with contributing apixaban anticoagulant therapy for atrial fibrillation and aortic valve replacement. The said Court finds that the circumstances of her death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Margaret Joan Barry was born on 7 August 1938 and died on 24 April 2019 at the Royal Adelaide Hospital. She was 80 years old.

1.2. Dr John Gilbert, specialist forensic pathologist from Forensic Science SA, performed an autopsy on 2 May 2019. His opinion as to the cause of death was right hemothorax due to bleeding right pleural adhesion with contributing apixaban anticoagulant therapy for atrial fibrillation and aortic valve replacement.1

1.3. This is a mandatory inquest2 pursuant to section 21 of the Coroners Act 2003 as, at the time of her death, Mrs Barry was subject to a Level 2 Inpatient Treatment Order (ITO) 1 Exhibit C2a 2 From 7 June 2021, following the amendment of section 21 of the Coroners Act 2003, if certified by a medical practitioner to have been a death due to natural causes, Mrs Barry’s death would not have resulted in a mandatory inquest

made on 5 April 2019 by Dr Paul Davis. A Level 1 ITO pursuant to section 21 of the Mental Health Act 2009 was initially made by Dr Bazzi on 29 March 2019.

2. Background and medical history 2.1. Margaret Barry was employed as a registered nurse and had four children. Her first child was stillborn and her three surviving children are Karen Barry, Tracey Reemst and Rebecca Barry. Her husband Kevin John Barry died on 12 October 1997.

2.2. Dr Gilbert notes that Mrs Barry had a medical history that included a transcatheter aortic valve implant in 2018 for an aortic valve incompetence, atrial fibrillation, a cardiac pacemaker, asthma, immunoglobulin G deficiency which made her prone to infections, Addison's disease, epileptiform seizures, drug allergies, recurrent urinary tract infections and bipolar affective disorder.3

2.3. Further information relating to Mrs Barry's medical history is contained in the affidavit of Dr Goodwin4, Mrs Barry's general practitioner in the final years of her life.

2.4. Her daughter Karen Barry5 states that Mrs Barry suffered with mental health issues, including depression and anxiety, for most of her life, and that following the death of her husband Kevin she suffered from asthma, heart valve issues and experienced a number of falls.

2.5. Karen Barry moved in to live with and care for her mother in 2005. She recalls that one of her mother's falls, in about mid-2015, resulted in a subdural haematoma.

2.6. Approximately one year before her death, Mrs Barry underwent a procedure to replace a heart valve, and suffered a minor stroke resulting in weakness down her right side. In mid-March of 2019, she had another fall and was admitted to hospital for five days.

2.7. Dr Rami Tadros was Margaret Barry's consultant physician.6 She presented with a headache and dizziness after the fall. The following day she had a CT scan. Mrs Barry was discharged on 24 March 2019. She was not subject to an ITO and there were no identified medical complications.

3 Exhibit C2a 4 Exhibit C8 5 Exhibit C1a 6 Exhibit C6

2.8. On returning home Mrs Barry became, as described by Karen Barry, ‘hyper and more manic’. She also had a urinary tract infection. After two nights of no sleep, they visited their general practitioner, Dr Goodwin, who recommended that she return to the Royal Adelaide Hospital.

3. Mrs Barry’s readmission to the Royal Adelaide Hospital 3.1. Mrs Barry was readmitted on 28 March 2019 presenting with confusion and worsening mania. It appeared to be due to the cessation of Mrs Barry's psychiatric medication, carbamazepine. Mrs Barry was described by Dr Tadros as extremely manic and it was decided she should be kept in hospital, despite being medically stable.

3.2. On 29 March 2019 Mrs Barry was placed on a Level 1 ITO by Dr Bazzi. That order was confirmed the following day by Dr Chiew, who was the psychiatrist on-call.

Mrs Barry continued to be unsettled, with signs of mania.

3.3. On 5 April 2019 a Level 2 ITO was made by Dr Paul Davis, to continue Mrs Barry's treatment. There had been some improvement, but she was still busy, elevated, disinhibited and adamant that she wanted to leave the hospital. The affidavit of Dr Davis summarises Mrs Barry's psychiatric care whilst in hospital.7

3.4. By 15 April 2019 there was significant improvement. The plan was to transfer Mrs Barry to the psychogeriatric ward at the Flinders Medical Centre. During this final admission Mrs Barry was treated for a urinary tract infection and experienced atrial fibrillation on 22 April 2019. That was attributed to a mis-dose of her heart rhythm medication Sotalol.

3.5. On the morning of 23 April 2019 Mrs Barry slipped whilst in the bathroom, but a nurse caught her before she fell to the ground. On that day she was mobilising quite well on a four-wheel walker.

3.6. In the early hours of 24 April 2019 Mrs Barry reported some discomfort in her breast area. She went back to sleep but in the morning complained of having had a bad night and being unable to sleep. It was noted that during the morning Margaret Barry was chatty and was moving around the ward on her walker.

7 Exhibit C7

3.7. Jade Livesey8, an enrolled nurse at the Royal Adelaide Hospital, describes providing one-to-one care for Mrs Barry on 24 April 2019 from 2:30pm. Mrs Barry complained to her of back pain at about 3:15pm. She also complained of dry retching. She then became agitated and appeared to throw herself on the floor, sustaining a small skin tear to her left elbow. Ms Livesey states that Mrs Barry did not hit her head or have any loss of consciousness.

3.8. Wayne Little9, a registered nurse, was also present. He stated that they were able to physically support Mrs Barry her as she slid down, and that she suffered a skin tear.

There was a small amount of blood visible near her left elbow.

3.9. Mrs Barry was transferred to a wheelchair and then back to bed. She was noted to be agitated and was given pain relief. Ms Livesey states that Mrs Barry poured lemonade over her head, saying that she was washing her hair.

3.10. At about 4pm Mrs Barry spoke to her daughter Karen, who arrived at the hospital at approximately 5pm. Mrs Barry asked for her to play some music and Karen arranged for Beethoven to be played to her mother. She said that she loved the music.

3.11. Mrs Barry died peacefully whilst Karen held her hand. Dr Bogatic declared Mrs Barry deceased at 6:10pm.

4. Discussion regarding cause of death 4.1. Dr Gilbert in his report10 states that the death was found to be due to massive blood loss with a right haemothorax of 1600ml which appeared to be arising from bleeding in or adjacent to a pleural adhesion between the lower lobe of the right lung and an inwardly protruding old displaced and healed fracture of the lateral aspect of the right seventh rib.

4.2. Dr Gilbert states that an obvious risk factor for a relatively spontaneous haemothorax was treatment with the anticoagulant apixaban. It is significant that there were no changes in blood pressure, oxygen saturation levels, pulse, or respiratory rate until Mrs Barry's final set of observations that took place at 2:10pm on the day of her death.

This suggests that significant blood loss had not occurred by that time. Dr Gilbert's 8 Exhibit C4 9 Exhibit C5 10 Exhibit C2a

opinion is that it is possible that the bleeding was initiated by traction on the adhesion caused by the fall at about 3:20pm and even by the dry retching, which was reported shortly before that, at 3pm.

4.3. Dr Gilbert has explained that although it is possible that the dry retching or fall contributed to the haemothorax, Mrs Barry was very fragile and the haemothorax could even have been caused spontaneously without any trauma, especially with her anticoagulant medication. Dr Gilbert is not critical of the use of anticoagulant medication, which was quite normal and appropriate.

5. Conclusions 5.1. Margaret Joan Barry was born on 7 August 1938 and died on 24 April 2019 at the Royal Adelaide Hospital. She was 80 years old.

5.2. Mrs Barry was in lawful detention at the time of her death.

5.3. The circumstances surrounding the death do not give rise to concerns relating to her care.

5.4. The cause of death of her death was right hemothorax due to bleeding right pleural adhesion with contributing apixaban anticoagulant therapy for atrial fibrillation and aortic valve replacement.

6. Recommendations 6.1. I make no recommendations 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 23rd day of November,2021.

State Coroner Inquest Number 6/2021 (0828/2019)