Coroner's Finding: VOIVODICH Guido

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 28th day of September 2020 and the 30th day of June 2021, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Guido Voivodich.

The said Court finds that Guido Voivodich aged 84 years, late of 1 Main Street, Hahndorf, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 23rd day of April 2019 as a result of general inanition on a background of end-stage dementia and a fractured neck of femur (operated). The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Guido Voivodich was born on 30 July 1934 and died at the Royal Adelaide Hospital on 23 April 2019, aged 84 years. A Forensic Science SA pathology review by Dr Iain McIntyre suggests that the cause of death was general inanition in a man with end-stage dementia and a fracture to the left neck of the femur, operated.1

1.2. Mr Voivodich's death is considered a death in custody, as defined in the Coroners Act

2003. He had been subject to a Level 2 Inpatient Treatment Order (ITO) from 22 February 2019 until 2pm on 5 April 2019. Although the ITO had expired 18 days prior to his death, the fall resulting in the fractured femur, which contributed to his decline, occurred on 28 March 2019 while he was still under that ITO. His death is subject to a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003.

1 Exhibit C2

2. Background and medical history 2.1. Mr Voivodich's background is detailed in the affidavit of his wife, Loretta Voivodich.2 Mr Voivodich was born in Zadar in Croatia on 30 July 1934. He fled Croatia with his family and arrived in Australia when he was 16 years of age. He worked hard through his life, running the Heathfield General Store for 14 years prior to his retirement at the age of 81 years. He and his wife had moved to Hahndorf about three years prior to his death and he used to enjoy taking regular walks down the Hahndorf main street.

2.2. Mr Voivodich's medical history is summarised in the statement of Dr Ga Jin Kim, who stated that Mr Voivodich had known medical history of end-stage dementia, pulmonary embolism in 2014, renal impairment and ischaemic heart disease.3 His medical records also included a myocardial infarction over 20 years prior to his death, benign prostatic hypertrophy with laser prostatectomy in 2012, renal cell carcinoma and psoriasis.

3. Mr Voivodich’s decline in health and hospitalisation 3.1. According to his wife, in the 12 months prior to his death, Mr Voivodich's health started to decline as he had difficulty putting shoes and clothes on, and he showed increasing signs of irritability. Prior to his admission to hospital in January 2019, Mr Voivodich was not taking any prescription medication and was only taking nutritional supplements.

3.2. On 24 January 2019 Mr Voivodich was walking the streets of Hahndorf in extreme heat; the maximum temperature recorded at the nearby Mt Barker weather station was 44.5°C.4 He was conveyed by ambulance to the Royal Adelaide Hospital after a neighbour found him wandering the streets, apparently confused. He was admitted to the Royal Adelaide Hospital due to severe confusion, agitation, and posing a risk to himself and others.

3.3. On 1 February 2019, Dr Georgina Minns placed Mr Voivodich on a Level 1 ITO for seven days, which was extended for two further periods, each of seven days.5 2 Exhibit C3 3 Exhibit C4 4 Source, Bureau of Meteorology 5 Exhibit C13

3.4. Dr Paul Davis, a senior consultant psychiatrist at the Royal Adelaide Hospital, assessed Mr Voivodich on 22 February 2019 and determined that he should be placed under a Level 2 ITO.6

3.5. Dr Davis took into account that Mr Voivodich was confused and disorientated, wandering around the ward lashing out in an aggressive manner at the staff, needing some physical redirection and gentle restraint for reasons of his safety. He required injection of sedating medication to settle his behaviours, and Dr Davis determined that he was unable to appreciate his own medical predicament and was incapable of giving or refusing consent due to delirium on a background of dementia. The ITO was confirmed on 22 February 2019, to expire on 5 April 2019 at 2pm.

3.6. On 8 March 2019, following extensive discussions with his family, balancing the risks and benefits of the anticoagulation medication, Mr Voivodich was prescribed the anticoagulation medication, Apixaban, to treat his clinical pulmonary embolism. The pulmonary embolism was not proven, due to Mr Voivodich’s inability to cooperate with the scanning procedures. His medical records indicate that during these weeks in hospital there were multiple code blacks and Medical Emergency Team (MET) calls to assist Mr Voivodich, due to his agitation and aggression.7 There was also a gradual deterioration in his gait, and falls as described by Dr Kim. It was decided not to pursue complex imaging for his deteriorating gait, as gait disturbances and falls are common symptoms in advanced dementia, sedation would be required for meaningful imaging, and Mr Voivodich was unlikely to be a candidate for invasive interventions.

3.7. On 28 March 2019, whilst still under the Level 2 ITO, Mr Voivodich suffered a fall.

Enrolled nurse Laraine Gordon was caring for Mr Voivodich.8 She was allocated to ‘special’ the patient, which means he was the only patient that she was caring for on that shift. At 3pm Ms Gordon wanted to take Mr Voivodich's blood pressure. His blood pressure was observed to be in the lower range compared to an earlier reading and he showed signs of fatigue. Ms Gordon recalls that she had planned to encourage bed rest after this. Mr Voivodich had been sitting on the bed while she was measuring 6 Exhibit C6 7 Exhibits C4 and C10 8 Exhibit C5

his blood pressure and, as she was removing the arm cuff, he lurched forward, tripped over his own foot and landed on the ground. She had been beside him and there were no other witnesses. Medical staff were called.

3.8. Dr Kim and his intern attended to examine Mr Voivodich after the fall. Dr Kim noted that Mr Voivodich was severely agitated and grimacing, with shortening and external rotation of the left leg, typical findings for a neck of femur fracture.9 An X-ray demonstrated a left neck of femur fracture.

3.9. Mr Voivodich was taken to theatre on 31 March 2019, 72 hours after his anticoagulation medication was ceased. His surgery was uneventful and there were no obvious complications. On 1 April 2019, an attempt was made at early physiotherapy input but was aborted, due to Mr Voivodich experiencing severe pain.

3.10. His condition declined over the two to three weeks post-surgery. He was bed-bound with decreased oral intake, urine output and bowel activities. After discussions with his treatment teams and senior staff members, it was concluded that his decline was likely to continue as Mr Voivodich was not able to participate in rehabilitation due to his severe end stage dementia.

3.11. On 17 April 2019, following discussions with his family, it was decided to progress to palliative care. Mr Voivodich died on the evening of 23 April 2019 surrounded by his wife and family.

4. Conclusion 4.1. I find the cause of Mr Voivodich’s death to have been inanition on a background of end-stage dementia and a fractured neck of femur (operated).

4.2. My conclusions are consistent with the conclusions of the investigating police officer, Brevet Sergeant Kirtland.10 Mr Voivodich was under a valid and appropriately imposed Level 2 ITO as at 28 March 2019, the date of the fall which contributed to his decline.11 9 Exhibit C4 10 Exhibit C9 11 Exhibit C12

The circumstances surrounding the fall are not suspicious and do not indicate a want of care. The care otherwise provided at the Royal Adelaide Hospital was appropriate.

4.3. 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 30th day of June, 2021 State Coroner Inquest Number 84/2020 (0822/2019)