Coroner's Finding: Elliott, Ronald Arthur

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 14th day of December 2023 and the ?? day of January 2024, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Ronald Arthur Elliott.

The said Court finds that Ronald Arthur Elliott aged 80 years, late of ACH Yankalilla, 175 Main South Road, Yankalilla, South Australia died at Yankalilla, South Australia on the 4th day of July 2020 as a result of aspiration pneumonia on a background of severe oropharyngeal dysphagia and chronic obstructive pulmonary disease complicated by fractured left neck of femur (operated). The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Ronald Arthur Elliott was born on the 11 October 1939, and died on the 4 July 2020 at his residential care facility, Yankalilla Centre Residential Living.1 He was 80 years old.

1.2. This was a mandatory inquest pursuant to Section 21 of the Coroners Act 2003 as Mr Elliott was a protected person under the Guardianship and Administration Act 1993 at the time of his death.

1.3. Mr Elliott had undergone surgery to his left hip at the Flinders Medical Centre2 on 16 June 2020 following an unwitnessed fall on 12 June 2020. He was discharged from hospital on 20 June 2020, but was re-admitted ten days later due to a deterioration in 1 Yankalilla

2 FMC

his condition. He was treated for aspiration pneumonia and electrolyte disturbance.

According to his wishes he was transferred back to his residential care facility to be with his wife, who also resided there. He passed away on 4 July 2020.

2. Cause of death 2.1. The medical case notes from Yankalilla and the FMC were reviewed by Dr Alexandra Yuill of Forensic Science SA3 and discussed with forensic pathologist, Dr Karen Heath.

In the pathology review report4 the suggested cause of death is stated as ‘aspiration pneumonia in a man with severe oropharyngeal dysphagia and chronic obstructive pulmonary disease complicating fractured neck of femur (operated)’.

3. Guardianship Order 3.1. Dona Attard, Deputy Registrar of the Community Stream of the South Australia Civil and Administrative Tribunal,5 has provided an affidavit in relation to the guardianship orders in place at the time of the death of Mr Elliott.6

3.2. Ms Attard states that on 1 July 2020, a guardianship order with special powers was made appointing the Public Advocate as limited guardian of Mr Elliott. This order was made as a result of an urgent application to SACAT by a social worker at the FMC. A medical report and supporting letter were provided to the tribunal in support of the application, which established that Mr Elliott had a diagnosis of moderate fluctuating delirium on the background of cognitive impairment. The guardianship order was in place at the time of Mr Elliott’s death.7

4. Background 4.1. Mr Elliott became a permanent resident at Yankalilla on 23 April 2019.8 He shared a room with his wife, Brenda Elliott, who suffered from severe dementia. Mr Elliott described his wife Brenda as beautiful and the most important person in his life. He was her carer for ten years until he became too unwell to care for her at home and she was transferred to Yankalilla. He is quoted as saying ‘I just want to be with Brenda

3 FSSA 4 Exhibit C1a

5 SACAT 6 Exhibit C6, Annexure DA3 7 Exhibit C6, page 3 8 Exhibit C3, page 2

and spend time together’. Mr Elliott was born in England. He joined the Royal Navy as a young man and became a sonar operator on a navy submarine. He married his first wife, Anne, and they had two sons together, Martin and Keith, before separating.

Mr Elliott later worked on cargo vessels and ‘toured the world’. It was while docked in Port Lincoln that Mr Elliott met Brenda. He migrated to Australia in 1980 and they were married in June of that year. Mr Elliott continued in the merchant navy. He described himself as a happy person with a good sense of humour and dedicated to Brenda.9

5. Medical history 5.1. In relation to Mr Elliott’s medical history, the Court received into evidence the statement of Mr Elliott’s general practitioner,10 Dr Spassova.11

5.2. Dr Spassova had been Mr Elliott’s regular GP since July 2014. At that time Mr Elliott had already been diagnosed with squamous cell carcinoma of the tongue, with nerve damage which caused persistent drooling and slurred speech. Mr Elliott suffered from hypertension, hyperlipidaemia, degenerative arthritis, atrial fibrillation, chronic obstructive airways disease and avascular necrosis of the right hip.12

5.3. Dr Spassova states that, initially, Mr Elliott was able to provide adequate care for his disabled wife. However, his ability to do so gradually declined due to progression of his pain, restricted mobility and reduced strength. Accordingly, his wife transferred to Yankalilla. Mr Elliott was accepted as well after he was hospitalised following a fall in the bath.

5.4. Mr Elliott’s condition gradually declined from January 2019 when he was diagnosed with pneumonia, which resulted in him becoming frail, despite carefully managed food and supplement intake.13 In May 2020 he was hospitalised again with respiratory distress and was found to have left-sided pleural effusion, possibly infective but with suspicion of underlying malignancy.

9 Exhibit C9

10 GP 11 Exhibit C7 12 Exhibit C7, page 2 13 Exhibit C7, page 3

6. Circumstances leading to death 6.1. On 12 June 2020 Mr Elliott had an unwitnessed fall in his room. He was tended to by Ms Tish Belle, an enrolled nurse, who then called for the registered nurse on duty.

Mr Elliott refused transfer to hospital and was transferred to his bed using a lifter.

6.2. It appeared to Ms Belle that Mr Elliott may have tripped on the wheel of his wife’s bed, as he had pulled the bed linen off the bed in an apparent attempt to avert the fall.14 He was prescribed pain relief to no effect. Accordingly, an ambulance was called at 8:40pm and Mr Elliott was transferred to the FMC.

6.3. Mr Elliott had a history of falls and ambulated with the assistance of a walking stick.

He needed reminders to use the walking stick, however, and to wear his call pendant.15

6.4. After being diagnosed with a fracture of his left femur, Mr Elliott underwent left hip hemiarthroplasty. This was complicated by streptococcal bacteraemia, pneumonia and electrolyte disturbance.16

6.5. The surgeon who performed this operation was Dr David Worsley.17 Dr Worsley noted that Mr Elliott’s surgery and immediate post operative recovery was uneventful.18 He did however note that femoral neck fractures in Mr Elliott’s age group have a high mortality rate, approximately 25% at 30 days and close to 50% at one year.19 Further, Dr Worsley opined that Mr Elliott had a degree of pneumonia present when he first presented to hospital after the fall, and that it is more likely that the pneumonia caused the fall than the other way around.20

6.6. Mr Elliott was discharged back to Yankalilla after his surgery, but was readmitted to hospital on 30 June 2020 after his condition further deteriorated.21 Efforts to improve his condition were unsuccessful and Mr Elliott was returned to Yankalilla on 3 July 2020 for palliative care22 after expressing clearly his wishes to cease treatment and to 14 Exhibit C2, page 2 15 Exhibit C2, page 3 16 Exhibit C7, page 4 17 Exhibit C4 18 Exhibit C4, page 2 19 Exhibit C4, page 3 20 Exhibit C4, page 3 21 Exhibit C7, Discharge summary; Exhibit C5, page 1 22 Exhibit C5, page 3

be reunited with his wife in his last days.23 His wishes were discussed with his Public Advocate guardian, Emily Thwaites, who was supportive of the plan for comfort care.

6.7. Mr Elliott was kept comfortable with the usual palliative care medications until his death, which was declared by Dr Law at about 4:30am on 4 July 2020.24

7. Coronial investigation 7.1. Detective Sergeant Rhett Vormelker, formerly of the Coronial Investigation Section, provided a report to the State Coroner.25 He expressed the view that the special powers orders are valid, appropriate and timely given the short life expectancy of Mr Elliott.

He opined that the Public Advocate was most certainly required to protect the interests of the deceased and to make medical and other decisions on his behalf.

7.2. He also noted that there was no suggestion that the care received by Mr Elliott at Yankalilla, the FMC or by his GP was anything less than appropriate.26

7.3. Detective Sergeant Vormelker also considered whether appropriate strategies were in place to mitigate Mr Elliott’s risk of falls. He referred to the fact that the facility undertook a site inspection of the room after the fall took place and concluded that the room was not cluttered. While there were some suggestions for improvements, Brenda Elliott did not want these improvements made and her wishes in that regard were respected.27

8. Conclusions 8.1. I refer to the pathology review conducted by FSSA. I find that Mr Elliott’s cause of death was aspiration pneumonia on a background of severe oropharyngeal dysphagia and chronic obstructive pulmonary disease complicated by fractured left neck of femur (operated).

8.2. I find that there are no concerns in relation to the lawfulness of the orders made by SACAT. The orders were necessary to facilitate the proper medical treatment of 23 Exhibit C7, page 4 24 Exhibit C3, page 4 25 Exhibit C8 26 Exhibit C8, page 16 27 Exhibit C8, page 16

Mr Elliott, and to allow him to pass peacefully with his wife at Yankalilla in accordance with his expressed wishes.

8.3. I find the care and treatment Mr Elliott received whilst subject to these orders was appropriate.

8.4. I have no recommendations to make in this matter.

Key Words: Death in Custody; Section 32 Powers In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 19th day of January, 2024.

Deputy State Coroner Inquest Number 13/2023 (1308/2020)