Coroner's Finding: Rerich, Josef

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign King at Adelaide in the State of South Australia, on the 2nd day of December 2022 and the 11th day of April 2023, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Josef Rerich.

The said Court finds that Josef Rerich aged 78 years, late of Aldersgate Aged Care, 160 OG Road, Felixstow, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 1st day of July 2020 as a result of multi-organ failure complicating neck of femur fracture (operated) on a background of renal and cardiac failure, infective exacerbation of chronic obstructive lung disease and right cerebellar infarction. The said Court finds that the circumstances of his death were as follows:

1. Introduction, reason for inquest and cause of death 1.1. Mr Josef Rerich was born on 13 May 1942 and died on 1 July 2020 at the Royal Adelaide Hospital. He was 78 years old.

1.2. Mr Rerich’s death was a ‘death in custody’ as defined in the Coroners Act 2003 as he died whilst subject to a Level 1 Inpatient Treatment Order (ITO) imposed under the Mental Health Act 2009. The Coroners Court must hold an inquest to determine the cause or circumstances of a death in custody.

1.3. This inquest proceeded upon affidavits only, as no oral evidence was required.

1.4. A pathology review was undertaken by Dr Iain McIntyre of Forensic Science South Australia in consultation with forensic pathologist Dr Cheryl Charlwood. In the report Dr McIntyre proffered an opinion that the cause of Mr Rerich's death was multi-organ

failure, complicating neck of femur fracture (operated), on a background of renal and cardiac failure, infective exacerbation of chronic obstructive lung disease and right cerebellar infarction.1 I accept that opinion and I so find.

2. Background 2.1. Mr Rerich was born in Serbia, and he moved to Australia when he was 15 years of age.

He had continuous employment in the maintenance industry until he retired. Mr Rerich was married to Katerina and they had three sons, Robert, Cliff and Frank. He moved into the Aldersgate Residential Aged Care Home to be with her. He was there until his admission to the Royal Adelaide Hospital.

3. Medical history 3.1. Mr Rerich's medical history is set out in some detail in the SAPOL investigating officer's report2 and is summarised in the pathology review of Dr McIntyre and in the statement of Dr Holly Bills.3 The medical notes from Mr Rerich’s nursing home also contain a number of hospital discharge summaries.4

3.2. Mr Rerich suffered from chronic congestive heart failure, chronic pulmonary hypertension, chronic obstructive pulmonary disease, chronic kidney disease, chronic intermittent anaemia, multivalvular heart disease, atrial fibrillation, hypercholesterolaemia, postural hypertension and cholelithiasis. He also suffered from cognitive impairment, osteoporosis, and arthritis. Mr Rerich underwent surgery from an abdominal aortic aneurysm in 2009 and a perforated peptic ulcer in 2016. In April 2020 he had a right cerebellar ischemic stroke.

4. The circumstances surrounding Mr Rerich’s death 4.1. At about 10:30pm on 26 June 2020 Mr Rerich had an unwitnessed fall in his room at Aldersgate Residential Aged Care and struck the back of his head.

4.2. Mr Rerich was taken to the Royal Adelaide Hospital, where CT imaging revealed a stable right cerebellar infarction and a right neck of femur fracture, which was treated with a hemiarthroplasty. The surgery was uncomplicated, but Mr Rerich deteriorated, 1 Exhibit C2a 2 Exhibit C9 3 Exhibit C1a 4 Exhibit C10

developing acute on chronic renal failure, shortness of breath, drowsiness and delirium.

He became combative and violent and nursing staff could not take his observations or perform a bladder scan. He continuously attempted to climb out of bed, apparently unaware of his fractured hip, and attempted to pull out his urinary catheter and IV cannula.

4.3. On 28 June 2020, during a medical review, Mr Rerich yelled continuously and attempted to punch Dr Baig, an intern. Attempts to verbally de-escalate Mr Rerich were unsuccessful. Dr Baig discussed the case with Dr Fitzgerald, the resident medical officer, who recommended a Level 1 ITO to facilitate the administration of an intramuscular sedative with the use of restraint. This was imposed at 4:32am. A code black was called to facilitate the administration of 500mg of haloperidol, after which Mr Rerich was left unrestrained. The purpose of the ITO was to administer the intramuscular antipsychotic safely and legally to the patient, to maintain his health and to allow ongoing treatment to be provided5 and to prevent harm to Mr Rerich and to others.

4.4. Consultant psychiatrist, Dr Shane Ryan, reviewed Mr Rerich the following day. He confirmed the order, believing that Mr Rerich lacked the capacity to consent to treatment and that the ITO was necessary. Mr Rerich was then assessed by a consultant geriatrician, Dr Tewari and by orthogeriatric registrar, Dr Holly Bills, on 30 June 2020.

They regarded his prognosis as guarded.

4.5. In her affidavit, Dr Bills6 stated Mr Rerich was in multi-organ failure, had pulmonary oedema, bradycardia, progressive acute kidney injury and delirium. He was not to be fed by mouth, and it was considered unlikely that he would tolerate nasogastric feeding.

Registered Nurse Linda Russell cared for Mr Rerich throughout the night of 30 June 20207, during which Mr Rerich's breathing become agonal. Mr Rerich was certified life extinct at 1:14am on 1 July 2020 by Dr Isaac.

5 Exhibit C5 6 Exhibit C1a 7 Exhibit C3

5. Conclusion 5.1. Detective Brevet Sergeant Corbridge of the Eastern District Criminal Investigation Branch has provided a comprehensive report assessing the lawfulness of custody and the adequacy of the treatment received by Mr Rerich.8 There is no criticism made of the medical treatment received by Mr Rerich while at the Royal Adelaide Hospital. She expressed the view that the Level 1 ITO was valid and appropriate, and that the hospital staff complied with the requirements of the Mental Health Act 2009. I agree and so find.

5.2. 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 11th day of April, 2023.

State Coroner Inquest Number 17/2022 (1282/2020) 8 Exhibit C9