Coroner's Finding: Underwood, Richard

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 22nd day of February and the 14th day of April 2022, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Richard Underwood.

The said Court finds that Richard Underwood aged 97 years, late of 19 Jennifer Street, Rosewater, South Australia died at The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, South Australia on the 6th day of November 2019 as a result of respiratory failure attributed to aspiration pneumonia on a background of advanced dementia and a fractured neck of femur (operated) and a gastro-intestinal tract haemorrhage.

The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Richard Underwood was born on 23 August 1922 and he died on 6 November 2019 at the Queen Elizabeth Hospital.1 He was 97 years old.

1.2. A pathology review was conducted by pathologist Dr Iain McIntyre from Forensic Science South Australia2 on 11 November 2019 with the suggested cause of death being respiratory failure attributed to aspiration pneumonia in a man with advanced dementia and a fractured neck of femur, surgically repaired, as well as gastrointestinal tract haemorrhage. Dr McIntyre discussed his findings with pathologist Dr Neil Langlois who agreed with Dr McIntyre's conclusion. I accept the cause of death suggested in the pathology review and make a finding accordingly.

1 QEH 2 FSSA

1.3. This is a mandatory inquest pursuant to Section 21 of the Coroners Act 2003 as Mr Underwood's cause of death occurred whilst he was subject to a Level 2 Inpatient Treatment Order.3

1.4. A Level 1 ITO4 was made pursuant to Section 21 of the Mental Health Act5 2009 by Emergency Department medical officer Dr Rachael Cheng on 30 September 2019. That was confirmed by psychiatrist Dr Elizabeth Markwick on 1 October 2019. The order expired on 4 October 2019. A Level 2 ITO was made by Dr Sheikh Naveed on 4 October 2019. A copy of the Level 2 ITO was tendered at the Inquest.6

1.5. On 30 October 2019, psychiatrist Dr Asa Stobie revoked the Level 2 ITO.

Mr Underwood passed away on 6 November 2019. A neck of femur fracture was sustained whilst Mr Underwood was subject to the Level 2 ITO and that was one of the many conditions that were thought, in combination, to have led to his death according to the pathology review at FSSA.

1.6. Therefore, Mr Underwood's cause of death cannot be considered to have been from natural causes. Thus, it was mandatory to hold an inquest in relation to his death.

2. Background 2.1. Mr Underwood was born on 23 August 1922 in England. He met his wife Joan in approximately 1945. They remained married until his passing, a period of some 75 years. They had three children together, Adrian Underwood, Susanne Hare and Suzette Rugolo. He was a prisoner of war in Germany in World War II.7

2.2. In 1966 Mr Underwood, his wife and children migrated from England to Australia. For the last nine years of his life, Mr Underwood's daughter Ms Rugolo became his primary carer. She would visit the house a number of times a week to fulfil that role.

3. Mr Underwood’s medical history 3.1. Mr Underwood had been a patient at the Rosewater Family Practice since the year

4. He suffered from ocular hypertension and gastro-oesophageal reflux disease.8 3 ITO 4 Exhibit C9 5 MH Act 6 Exhibit C9 7 Exhibit C3, paragraph 19

8 GORD

In 2004 he was diagnosed with Bowen's Disease, a common superficial cancer of the skin.

3.2. Ms Rugolo provided an affidavit to the Inquest.9 She described the changes that she observed in her father's behaviour in September 2019.

3.3. On 30 September 2019, Ms Rugolo took her father to the Rosewater Family Clinic where he was seen by Dr Arief Wahab. Ms Rugolo advised the doctor about her father's behaviour. The doctor prescribed him with Valium, however, Mr Underwood refused to take it. During a conversation she was having with her father the afternoon of the doctor's visit, Ms Rugolo witnessed her father leave the house and attempt to enter the next-door neighbour's house. She contacted the South Australian Ambulance Service and her father was conveyed to the QEH for treatment.

3.4. Upon presentation there, Mr Underwood appeared agitated and was alluding to the fact that people were attempting to take his home from him. Medical investigations conducted following his presentation to the QEH, revealed that he may have been suffering from pneumonia and/or a urinary tract infection. He was agitated and uncooperative with staff and the treatment that they were trying to give him. As a result he was placed under the Level 1 ITO that I have referred to earlier.

3.5. At about 9:30pm on 30 September 2019, Mr Underwood was admitted to what is known as the Acute Medical Unit at the QEH for treatment. His treatment included the administration of antibiotics and some carrying out of further investigations into his condition. The medications that he was prescribed and administered with during his stay at the QEH are set out in some detail in the affidavit of Dr Paul Fitzgerald.10

3.6. On 4 October 2019, psychiatrist Dr Sheikh Naveed placed Mr Underwood on a Level 2 ITO. On 4 October 2019, still at the QEH, Mr Underwood sustained a fall resulting in a hip fracture. He had surgery to repair that on 12 October 2019. He suffered another fall in hospital on 16 October 2019 and struck his head, but did not sustain any serious injury.

4. Mr Underwood’s further decline in health and death 9 Exhibit C3 10 Exhibit C5, paragraph 11

4.1. After his last fall a plan commenced to locate a residential placement for Mr Underwood, however his physical state had deteriorated due to his falls, his poor oral intake, an increasing oxygen requirement and gastrointestinal bleeding. The medical team, in conjunction with Mr Underwood's family, pursued a pathway of palliative care from 30 October 2019. The Level 2 ITO was revoked that day as there was no need for that order given his palliative care.

4.2. I turn to the circumstances of Mr Underwood's passing. At about 9pm on 5 November 2019, registered nurse Bini Sahji first had contact with Mr Underwood during her shift change clinical handover. She was monitoring Mr Underwood hourly throughout her shift. At 6am on 6 November 2019 she noted that his condition had deteriorated. By 6:20am she noticed that Mr Underwood had stopped breathing. A doctor certified that Mr Underwood had passed away at 6:45am.

5. Conclusions and recommendation 5.1. Consistent with the conclusions of the investigating officer, Brevet Sergeant Kathryn Ghent and as detailed in her report11, the circumstances surrounding Mr Underwood’s death are not suspicious and do not indicate the involvement of any third party or concerns relating to his care. He was in lawful custody at the time of his fractured neck of femur under the MH Act. As already explained, as this injury was part of his cause of death, a mandatory Inquest was necessary.

5.2. I make no recommendations.

Key Words: Death in Custody; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 14th day of April, 2022.

Deputy State Coroner Inquest Number 25/2021 (2304/2019) 11 Exhibit C8