Coroner's Finding: Osborne, Brian Thomas

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 16th day of March 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 Brian Thomas Osborne.

The said Court finds that Brian Thomas Osborne aged 89 years, late of 29/17 Zwerner Drive, Hallett Cove, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 27th day of July 2019 as a result of combined effects of cerebrovascular accident, pneumonia and chronic cardiac failure on a background of ischaemic heart disease and diabetes. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Brian Osborne was born on 22 July 1930 and died at the Flinders Medical Centre on 27 July 2019, at the age of 89 years.

1.2. A Forensic Science SA pathology review was undertaken by Dr Iain McIntyre. I accept the opinion expressed by Dr McIntyre, and find the cause of Mr Osborne’s death to have been the combined effects of cerebrovascular accident, pneumonia and chronic cardiac failure on a background of ischaemic heart disease and diabetes.1 1 Exhibit C2a

2. Reason for inquest 2.1. At the time of his death Mr Osborne was subject to a Level 1 Inpatient Treatment Order (ITO) under the Mental Health Act 2009. When the inquest was heard, his death was defined as a death in custody and was a mandatory inquest.2

2.2. Mr Osborne was initially transferred to the Flinders Medical Centre from Noarlunga Hospital at 9:33pm on 20 July 2019. On 22 July 2019, he was suspected to have suffered a stroke.

2.3. On 25 July 2019 Dr Lucy Pillay, the stroke registrar at Flinders Medical Centre, imposed a Level 1 ITO following a series of aggressive episodes and documented delirium.

2.4. On 26 July 2019, consultant psychiatrist Dr Bonita Lloyd visited Mr Osborne, who was asleep and did not wake to voice. Dr Lloyd confirmed the ITO, having regard to documented episodes of confusion and distress. The Level 1 ITO was then valid for seven days.

3. Background 3.1. Mr Osborne’s background has been obtained from the statement of his wife, Barbara Osborne, prepared with the assistance of the couple’s daughter, Karen and son, Chris.3

3.2. Mrs Osborne had known her husband for 65 years and they had been married for 63 years. Karen was born in 1957 and Chris in 1960.

3.3. Mrs Osborne sets out some of her husband’s medical conditions. She referred to a motorcycle accident in England when he was 19 or 20 years old, which resulted in a seriously broken right ankle and permanent injuries to his left hand; he had been a good boxer in England during World War II.

3.4. Mrs Osborne states her husband had many more recent health issues, starting with his first heart attack in 1979, from which he made a swift recovery. In 1994 the couple 2 From 7 June 2021, following the amendment of section 21 of the Coroners Act 2003, Mr Osborne’s death would likely have been certified by a medical practitioner to have been a death due to natural causes, and would not have required a mandatory inquest 3 Exhibit C3

resided in a caravan while travelling around Australia, when Mr Osborne suffered a second heart attack and spent a short time at Flinders Medical Centre.

3.5. As a result of the heart attack, the couple moved from their caravan to their final home together, a unit in Hallett Cove.

3.6. In 1997 Mr Osborne was diagnosed with type 2 diabetes. He managed the condition well, with exercise and medication.

3.7. During the early 2000s, Mr Osborne was diagnosed with polymyalgia after suffering extreme pain rendering him unable to lift his arms or dress himself. He was prescribed pain medication.

3.8. In 2003, he commenced regular injections of insulin to manage his diabetes.

3.9. Mrs Osborne began to notice a shift in her husband’s personality, which she attributed to the loss of his independence. However, he was good at managing his diabetes and, as Mrs Osborne said, was always very good at pulling himself together after tough periods.

3.10. Mr Osborne was diagnosed with glaucoma and early onset of macular degeneration in his right eye. Following various eye operations, including laser surgery, he lost sight in his right eye.

3.11. Mrs Osborne states most of her husband’s issues were generally attributed to diabetes or polymyalgia.

3.12. On 20 July 2019, Mr Osborne accompanied his wife to her appointment with their general practitioner, Dr Burns. He mentioned to Dr Burns that he had been suffering from a chest infection for about a week and Dr Burns advised him to go to hospital.

Mr Osborne attended Noarlunga Hospital that day, where he was admitted, and then transferred to Flinders Medical Centre.

3.13. On 21 July 2019, the family visited him and noted that he was happy and recovering well. Mrs Osborne advised Flinders Medical Centre staff of her husband’s wish that, if the situation arose, he was not to be resuscitated.

3.14. At 2am on 22 July 2019, Mrs Osborne received a call from the Flinders Medical Centre informing her that Mr Osborne had suffered a stroke.

3.15. Mrs Osborne states that from 25 July 2019, her husband’s condition continued to worsen. Her husband was no longer eating and drinking, and she told hospital staff that he would not want to have a feeding tube inserted, and he would fight against if this was done. On one occasion when she returned to the room there was a security guard present and she was told that Mr Osborne had been aggressive towards medical staff and was showing signs of delirium and confusion. On Friday 26 July 2019 Mrs Osborne arranged for a priest to attend and administer last rites. She and her children said their goodbyes and left the hospital, not expecting to see Mr Osborne alive again.

3.16. On 27 July 2019 Mrs Osborne observed her husband sitting in a chair, seemingly normal, coherent and happy to see them. She recalls him telling her that he had always loved her, before she left the room for a short time. When she returned, Mr Osborne was back in bed, appearing ‘out of it’ and struggling to breathe.

3.17. The family left and, upon return at about 9:30pm, were advised that Mr Osborne had died.

4. Medical history 4.1. Mr Osborne was a patient of Dr Steven Burns’ medical practice from 2001. His general practitioner until 2011 was Dr Karpinsky, after which he was treated by Dr Burns.4 Dr Burns referred him to several specialists over the years.

4.2. Dr Burns lists Mr Osborne’s numerous medical conditions as being type 2 diabetes, basal cell carcinoma, hypertension, diverticular disease, chronic obstructive pulmonary disease, osteoarthritis of the spine, B12 deficiency, polymyalgia and non-ST elevation myocardial infarction (N-STEMI) cardiac failure.

4.3. Mr Osborne was prescribed many medications. Dr Burns noted that although he felt depressed about disabling consequences of several of his conditions, Mr Osborne was never diagnosed with depression or any other form of mental illness.

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4.4. On 20 July 2019, Mr Osborne presented to Dr Burns for the last time, with shortness of breath. Given his various comorbidities, Dr Burns referred him to hospital, with a letter recommending inpatient treatment.

4.5. Given his extensive medical history, Dr Burns was not surprised to hear of Mr Osborne’s death one week later. If an ITO had not been imposed upon Mr Osborne, he would have completed a certificate of cause of death.

5. Mr Osborne’s admission to Flinders Medical Centre 5.1. Following his appointment with Dr Burns, Mr Osborne attended Noarlunga Hospital.

At around 8pm on 20 July 2019, he was transferred via ambulance to the Flinders Medical Centre, where was admitted to the cardiology unit, due to heart failure.

5.2. Dr Matthew Willcourt, a consultant neurologist at FMC states that at 1am on 22 July 2019, it was suspected that Mr Osborne had suffered a stroke.5 He was suffering acute dysphasia and slurring of speech with potential incoordination on his right side.

5.3. A CT scan confirmed a stroke, and Mr Osborne was transferred to the care of the stroke team and received thrombolytic treatment. In the early hours of 23 July 2019, he was transferred to the Intensive Care Unit.

5.4. Prior to the stroke, he had been suffering recurrent hypoglycaemic episodes due to being on insulin and having poor oral intake due to his heart failure. He was also noted to be vague and impulsive. This worsened after the stroke and he was unable to be fed or medicated orally.

5.5. Following the stroke he became unsettled and combative. On at least one occasion a code black was called as a result of Mr Osborne’s behaviour. He continually attempted to get out of bed and remove tubes and medical apparatus.

5.6. On 24 July 2019, family members told the doctors that it was Mr Osborne’s wish, and theirs, for him to be placed in palliative care. Mr Osborne’s doctors explained their belief that his conditions were not terminal and could potentially be reversed, possibly partially, with treatment. The family were happy for treatment to continue, provided that it did not require him to be moved back to the Intensive Care Unit.

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5.7. Dr Lucy Pillay, the stroke registrar, first saw Mr Osborne on that same day.6 She found him to be delirious and to have speech and swallowing difficulties due to the stroke. In consultation with the family it was agreed, as a temporary measure, to attempt feeding with a nasogastric tube.

5.8. Thereafter, Dr Pillay saw Mr Osborne once a day to check on progress and continually reassess Mr Osborne’s care goals, having a number of meetings with his family.

5.9. On 25 July 2019, an unsuccessful attempt was made to insert the nasogastric tube, and Mr Osborne declined a second attempt. Later that day, Mr Osborne gave Dr Pillay verbal approval to try again but then he physically resisted. She consulted with other clinicians, particularly speech pathology, and advised Mr Osborne’s family that, without the feeding tube, he could not be fed.

5.10. That afternoon Mr Osborne’s oxygen level dropped. He was agitated and unable to vocalise. Oxygen was successfully applied but when clinicians attempted to take arterial blood for a gas test, Mr Osborne became further agitated and aggressive, pulling off his oxygen mask and adopting a fighting stance. As she was unable to investigate or treat Mr Osborne, she discussed the situation with consultant Dr Willcourt and, with his approval, imposed a Level 1 ITO. The treatment plan, discussed and accepted by Mr Osborne’s family, was to treat potentially reversible causes of Mr Osborne’s condition.

5.11. On 26 July 2019, consultant psychiatrist Dr Bonita Lloyd confirmed the ITO. At 6pm that day, it was noted that Mr Osborne became increasingly agitated and short of breath.

His family stated that they wanted him to be moved to comfort care. Morphine was administered for breathing and agitation, and supplemental oxygen and antibiotics to alleviate his heart and chest issues.

5.12. Mr Osborne was maintained in comfort until he died at around 9pm on 27 July 2019.

He was certified deceased at 9:26pm.

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6. Coronial investigation 6.1. Due to Mr Osborne’s ITO, a police investigation was undertaken and Brevet Sergeant Rhys Williams from the Southern District Criminal Investigation Branch provided a final report.7 No issues of concern were identified in relation in relation to Mr Osborne’s care or the imposition of the ITO.

7. Conclusions 7.1. I find that Mr Osborne received appropriate care and treatment at the Flinders Medical Centre.

7.2. I find that the Level 1 Inpatient Treatment Order imposed on 25 July 2019 and confirmed on 26 July 2019 was lawful and appropriate.

7.3. I reiterate my finding that Mr Osborne’s cause of death was the combined effects of cerebrovascular accident, pneumonia and chronic cardiac failure on a background of ischaemic heart disease and diabetes.

8. Recommendations 8.1. I make no recommendations.

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 23rd day of November, 2021.

State Coroner Inquest Number 87/2020 (1535/2019) 7 Exhibit C12