Coroner's Finding: Duthie, Norman Alec

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 18th day of December 2020 and the 29th day of March 2022, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Norman Alec Duthie.

The said Court finds that Norman Alec Duthie aged 96 years, late of Eldercare – Oxford, 35 Hulbert Street, Hove, South Australia died at Noarlunga Health Service, Alexander Kelly Drive, Noarlunga Centre, South Australia on the 14th day of May 2019 as a result of hospital acquired pneumonia on a background of advanced Alzheimer’s dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for inquest 1.1. Norman Alec Duthie was 96 years of age when he died on 14 May 2019 at the Noarlunga Hospital. A post-mortem examination of Mr Duthie’s remains was not necessary. A pathology review dated 22 May 2019 performed by Dr Iain McIntyre of Forensic Science South Australia (FSSA) describes Mr Duthie’s cause of death as ‘hospital acquired pneumonia in a man with advanced Alzheimer's dementia’.1 I accept that opinion and find that the cause of Mr Duthie’s death was hospital acquired pneumonia on a background of advanced Alzheimer’s dementia.

1.2. On 7 May 2019 Mr Duthie had been placed on a level 1 Inpatient Treatment Order (ITO) under the Mental Health Act 2009. An ITO involves the detention of the patient in an approved treatment centre. Mr Duthie was detained under the ITO in such a centre. The length of the ITO was for a period of seven days, expiring at 2pm on 1 Exhibit C1a

14 May 2019.2 The ITO had expired two hours prior to the time of Mr Duthie’s death.

While Mr Duthie’s death did not occur while the ITO was still in existence, his cause of death arose during the currency of the order. Accordingly, Mr Duthie’s death was a death in custody in respect of which an inquest was mandatory. These are the findings of that inquest.

1.3. It should be understood at the outset that there is absolutely no stigma attached to the imposition of an ITO which in this case, I find, was appropriately and lawfully imposed with Mr Duthie’s care and protection as its sole purpose.

2. Background 2.1. Mr Duthie was born in Adelaide at the Queen Victoria Hospital in 1923. Growing up he was one of five siblings, having two sisters and two brothers.

2.2. Mr Duthie was married with two daughters, one of whom is deceased. Ms Barbara McMahon, Mr Duthie’s surviving daughter, provided an affidavit to the Court.3

2.3. Mr Duthie worked as a mattress maker prior to the outbreak of the second world war.

On 23 May 1942, at the age of 18, he joined the Royal Australian Airforce as an aircraftsman. He was discharged as a warrant officer in 1946. In her affidavit, Ms McMahon states that her father did not like to speak about the war, but she understood that he had been a navigator in Lancaster bombers. His plane had crashed on one occasion as a result of which he sustained a back injury that he had for life.

2.4. Mr Duthie worked as a butcher until the age of approximately 50 years before becoming a manager at the Franklin Street Bus Station until his retirement at approximately 60 years of age.

2.5. Mr Duthie lived at Largs North with his family for approximately 12 years before moving to Seacliff during the 1960s. In 2000 Mr Duthie and his wife moved to the Elderly Citizens Home at Hove where they both resided until Mrs Duthie's death in

2013. Following his wife's death, Mr Duthie continued to live at the Elderly Citizens Home until moving into Oxford Eldercare, also at Hove, on 29 January 2019. He was initially moved to Oxford Eldercare for respite after a hospital admission during which he was diagnosed with early signs of dementia. Ultimately, Mr Duthie was accorded 2 Exhibit C7c 3 Exhibit C2

permanent residency at Oxford Eldercare. Mr Duthie was still a resident at Oxford Eldercare at the time of his death.

3. Mr Duthie’s medical history 3.1. From July 2002 Mr Duthie was under the care of a general practitioner, Dr Ignatius Budiman, at the Hove Surgery. Dr Budiman’s affidavit was tendered to the Court.4

3.2. Prior to 2002 Mr Duthie was diagnosed with ischaemic heart disease. In 2002 Mr Duthie had a myocardial infarction (heart attack) and was diagnosed with impaired fasting glycaemia.

3.3. In 2004 Mr Duthie was diagnosed with sleep apnoea necessitating the need for a CPAP machine.

3.4. In 2006 Mr Duthie underwent coronary artery bypass grafting and an aortic valve replacement.

3.5. In 2014 Mr Duthie was diagnosed with macular degeneration. In that same year he sustained a fractured neck of femur following a fall.

3.6. In 2015 Mr Duthie was diagnosed with congestive cardiac failure.

3.7. Mr Duthie’s heart condition led to a number of heart attacks and to congestive heart failure. The final heart attack prior to his death occurred in April 2019.

4. Mr Duthie’s decline in health 4.1. On 1 November 2018, Mr Duthie was diagnosed with dementia by Dr Dinesh Kunnusamy, a geriatrician. On 17 April 2019, Dr Budiman reviewed Mr Duthie at the request of the clinical nurse at Oxford Eldercare due to increasing levels of agitation towards other residents and staff members. On 6 May 2019, he was transferred from Oxford Eldercare to the Myles Ward at the Noarlunga Hospital.

4.2. On 7 May 2019 at the Noarlunga Hospital, Dr Eric Nguyen initiated an ITO following an assessment of Mr Duthie.5 The ITO was reviewed the following day on 8 May 2019 by psychiatrist Dr Raja Hiremani whose report was tendered to the Court.6 Dr Hiremani assessed Mr Duthie as lacking decision-making capacity due to dementia, 4 Exhibit C4 5 Exhibit C7c 6 Exhibit C3

delirium and impairment from Alzheimer's with behavioural and psychological symptoms of dementia. Dr Hiremani deemed Mr Duthie to be at significant risk, noting that he had had multiple code blacks called. As a result, the ITO was confirmed. No medication was prescribed to Mr Duthie at this time.

4.3. During his admission at Noarlunga Hospital, Mr Duthie developed urinary retention which was managed with catheterisation. A chest X-ray indicated that Mr Duthie had also developed pneumonia. Despite the administration of antibiotics, Mr Duthie's condition continued to decline and he developed renal failure.7

4.4. On 13 May 2019 Mr Duthie became short of breath and was no longer eating or drinking. In light of his declining condition, and following discussions with his daughter, the focus of his care became that of palliative care.

4.5. On 14 May 2019, after spending the majority of the day with Ms McMahon, Mr Duthie died in her presence. Mr Duthie was pronounced deceased by a medical practitioner at 4:20pm.

5. Conclusion and recommendation 5.1. The circumstances of Mr Duthie’s death were comprehensively investigated by Detective Brevet Sergeant Sebastian Brunt of the SAPOL Southern District Criminal Investigation Branch. The conclusion reached by Detective Brunt was that Mr Duthie’s care at the Noarlunga Hospital had involved appropriate treatment and medication. As well, he concluded that the imposition of the ITO had been appropriate. Having reviewed the evidence, I agree with those conclusions and have nothing further to add.

5.2. I make no recommendations.

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 29th day of March, 2022.

Deputy State Coroner Inquest Number 93/2020 (0967/2019) 7 Exhibit C7f, clinical progress notes of Noarlunga Hospital