Coroner's Finding: Donato, Anthony

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 28th day of February and the 22nd day of May 2024, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Anthony Donato.

The said Court finds that Anthony Donato aged 85 years, late of Calvary Flora McDonald Residential Aged Care, 206 Sir Donald Bradman Drive, Cowandilla, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 22nd day of April 2021 as a result of blunt craniocerebral trauma following a fall. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Anthony Donato was born on 19 October 1935 and died on 22 April 2021 at the Royal Adelaide Hospital at the age of 85 years.

1.2. A pathology review was undertaken by Dr Erin O’Connor, Medical Practitioner at Forensic Science South Australia, and discussed with Professor Roger Byard AO, Senior Specialist Forensic Pathologist. The cause of death provided in Dr O’Connor’s subsequent report1 is ‘blunt craniocerebral trauma following a fall’, and I so find.

2. Reason for inquest 2.1. Mr Donato’s death is deemed a death in custody pursuant to the Coroners Act 2003, as at the time of his death Mr Donato was under a guardianship order with special powers pursuant to Section 32(1)(b) of the Guardianship and Administration Act 1993, and his 1 Exhibit C1a

cause of death was not a natural cause. Thus, this was a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

3. Background 3.1. Mr Donato and his wife had two children, Catherine Turner2 and Allison Harris.3 He worked in the building and manufacturing industry for most of his life.

3.2. Mr Donato’s wife died in 2000. Prior to being placed into an aged care facility he had resided by himself in a two-bedroom unit in Leabrook.

4. Mr Donato’s medical history 4.1. Mr Donato had a complex medical history which included: Dementia; • Mild renal failure; • Hypertension; • Thoracic and aortic aneurysm; • Essential right tumour; • GORD (Gastro-oesophageal reflux disease); • Eczema; • Anxiety; • Osteoarthritis; • Sleep apnoea; • Cervical spondylosis; • Acute renal failure; • Falls; • Postural dizziness; • Vertebral crush fracture in lower back; and • Previous dislocation in left shoulder.

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4.2. Mr Donato began exhibiting symptoms of dementia approximately five or six years prior to his death. He was first treated for cognitive impairment on 28 April 2017.

An MRI scan revealed Mr Donato had moderate vascular damage to his brain.

2 Exhibit C5 3 Exhibit C6

Dr Robert Culver, geriatrician, concluded that he was exhibiting mild symptoms of dementia.

4.3. During subsequent consultations, the last being 1 September 2020,4 Dr Culver concluded that Mr Donato’s dementia had progressed.

5. Guardianship order 5.1. As a result of Mr Donato’s continuing decline, a guardianship order application was filed.

5.2. Following a hearing on 30 October 2020, the South Australian Civil and Administrative Tribunal (SACAT) made a limited guardianship order pursuant to section 29 of the Guardianship and Administration Act 1993. Mr Donato’s daughters, Ms Turner and Ms Harris, were appointed his joint limited guardians. Their roles and duties were limited to accommodation, treatment and giving or withholding consent to the use of chemical restraint only.

5.3. SACAT also granted Ms Turner and Ms Harris, as joint guardians, special powers of detention pursuant to section 32 of the Act.

6. Transfer to Calvary Flora McDonald House 6.1. On 26 October 2020 Mr Donato was transferred to the Calvary Flora McDonald House, a facility for residents requiring special care such as aged care, dementia care and short-term assisted living.

6.2. Among other assessments undertaken to assist in the formulation of his care plans, Mr Donato was assessed as a medium risk of having falls.

7. Circumstances of Mr Donato’s death 7.1. On Tuesday 20 April 2021 at about 9:30pm, Mr Mark Araojo,5 a personal carer, checked on Mr Donato, finding him in bed asleep.

7.2. Upon his next check at approximately 10:15pm, Mr Araojo found Mr Donato face down on the floor with a large pool of blood around his face. His injuries were managed with the assistance of nursing staff whilst an ambulance was called.

4 Exhibit C8 5 Exhibit C2

7.3. Upon their arrival SA Ambulance Service personnel found Mr Donato’s conscious state to be deteriorating.

7.4. Mr Donato was taken to the Royal Adelaide Hospital where he was admitted and overseen by Dr Alice O'Connell, a general physician consultant.6 A CT scan revealed a multicompartmental intracranial acute haemorrhage.

7.5. Dr O’Connell described in her affidavit that Mr Donato’s injuries were consistent with the reported (unwitnessed) fall and that the bleeding on Mr Donato’s brain was considered a terminal event with no options for effective treatment. Mr Donato was in respiratory distress and was not responding to voice or light touch. In the face of his apparently non-survivable brain injury, Mr Donato was provided with end-of-life medications on an as-needed basis.

7.6. Mr Donato was declared life extinct in the early hours of 22 April 2021.

8. Conclusion and recommendation 8.1. I agree with the conclusions of the SAPOL investigating officer, Detective Brevet Sergeant Christopher Butler, that the guardianship order with special powers was lawful and appropriate.7

8.2. In my opinion Mr Donato’s care and treatment at both Calvary Flora McDonald House and the Royal Adelaide Hospital were appropriate.

8.3. I make no recommendations.

Key Words: Death in Custody; Section 32 Powers; Nursing Home; Fall In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 22nd day of May, 2024.

State Coroner Inquest Number 09/2024 (0803/2021) 6 Exhibit C4 7 Exhibit C12