Coroner's Finding: Hammond, Peter Joseph

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 14th day of July and the 22nd day of December 2022, by the Coroner’s Court of the said State, constituted of Naomi Mary Kereru, Coroner, into the death of Peter Joseph Hammond.

The said Court finds that Peter Joseph Hammond aged 66 years, late of 37 Albert Street, Clarence Gardens, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 29th day of June 2020 as a result of inanition and probable respiratory tract infection complicating Alzheimer's dementia. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Peter Joseph Hammond was born on 16 February 1954 and died on 29 June 2020 at the Flinders Medical Centre (FMC). He was 66 years of age.

1.2. A pathology review was conducted by Dr Iain McIntyre of Forensic Science South Australia (FSSA). His suggested cause of death was ‘inanition and probable respiratory tract infection complicating Alzheimer's dementia’.1 Dr McIntyre discussed his findings with forensic pathologist Dr Stephen Wills, who agreed with his conclusions.

1.3. I find this to be the cause of Mr Hammond’s death.

1 Exhibit C2a

2. Reason for Inquest 2.1. Mr Hammond was the subject of a Level 3 Inpatient Treatment Order (ITO) pursuant to section 29 of the Mental Health Act 2009 at the time of his death.

2.2. In law this meant that Mr Hammond’s death was a death in custody within that meaning of the expression of the Coroners Act 2003. This inquest was therefore a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003.

2.3. The reason for the imposition of the ITO will be detailed below.

3. Background 3.1. Mr Hammond was married to his wife Tracy for 30 years. In 2015 he was diagnosed with Alzheimer's dementia which was initially managed at home under the care of a geriatrician. In the latter half of 2018 Mr Hammond’s condition became so severe that he required inpatient care.

3.2. In November 2018 Mr Hammond was admitted to the Royal Adelaide Hospital (RAH).

He was suffering from extreme behavioural and psychological symptoms relating to his Alzheimer’s dementia, namely severe agitation, distress and aggression.

Mr Hammond was diagnosed as having a rare Tier 7 form of Alzheimer’s dementia, the most extreme form.

3.3. On 29 November 2018, a Level 1 ITO was issued which was confirmed on 30 November 2018. A subsequent Level 2 ITO was issued on 6 December 2018.

3.4. On 18 December 2018 Mr Hammond was transferred to the Acute Older Persons Mental Health Unit at Ward 18B of the FMC.

3.5. On 12 March 2020 the South Australian Civil and Administrative Tribunal (SACAT), on application from the medical practitioners at FMC, confirmed a Level 3 ITO for a further 12 months. That order was due to expire on 10 March 2021 and was in force at the time of Mr Hammond's death.

3.6. Due to the severity of Mr Hammond's condition it was not possible to move him to an aged care facility. Mr Hammond was considered to be a danger to himself and others and he remained an inpatient in the acute Ward 18B until his death.

3.7. On 17 April 2020 a chest X-ray was performed and Mr Hammond was found to be suffering from pneumonia. Medications were administered to treat his pneumonia, but those medications exacerbated his dementia and his condition in general. Nevertheless, he appeared to recover.

3.8. On 25 May 2020, Mr Hammond suffered an unwitnessed fall and again on 18 June

2020. On the latter occasion, he appeared to have injured his left hip. It was difficult to investigate the injuries sustained by the fall due to Mr Hammond’s resistance.

Therefore, an X-ray was not performed. It was considered around this time that Mr Hammond was moving into the terminal stage of his Alzheimer’s dementia.

3.9. On 25 June 2020, a week after the fall injuring his left hip, Mr Hammond was found to be febrile, hypoxic, tachypneic and tachycardic. It was noted that Mr Hammond had reduced oral intake of both food and fluids, and a discussion was held with Mrs Hammond. It was agreed a palliative approach would be taken.

3.10. On 28 June 2020, Mr Hammond's breathing became laboured. Mrs Hammond, who had visited her husband almost every day of his inpatient admission, was contacted and attended. Mrs Hammond stayed overnight and into the morning. Mr Hammond was kept comfortable and died peacefully at 6:45am on 29 June 2020.

4. Conclusion 4.1. Mr Hammond was lawfully and appropriately the subject of the Level 3 ITO at the time of his death, and I so find. Mr Hammond was suffering from a terminal illness and had reached the end stage of that illness.

4.2. Consistent with the conclusions of the investigating officer, Detective Brevet Sergeant Peter McGradey, I find that Mr Hammond's care and treatment at FMC was appropriate and that there were no suspicious circumstances or third-party involvement.

5. Recommendation 5.1. I make no recommendations.

Key Words: Death in Custody; Inpatient Treatment Order; Alzheimer’s Disease In witness whereof the said Coroner has hereunto set and subscribed her hand and Seal the 22nd day of December, 2022.

Coroner Inquest Number 16/2022 (1260/2020)