Coroner's Finding: Kaczaniw, Iwan

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 Iwan Kaczaniw.

The said Court finds that Iwan Kaczaniw aged 93 years, late of Reynella Lodge Aged Care Facility, 7 Railway Terrace, Old Reynella, South Australia died at Old Reynella, South Australia on the 7th day of September 2020 as a result of general inanition on a background of cognitive impairment, congestive cardiac failure and chronic renal disease with contributing fractured neck of femur (operated). The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mr Iwan Kaczaniw was born on 5 September 1927 and died on 7 September 2020 at Reynella Village. He was 93 years of age.

1.2. A pathology review was undertaken by Dr Jane Alderman of Forensic Science South Australia and the suggested cause of death was ‘general inanition in a male with cognitive impairment, congestive cardiac failure and chronic renal disease and fractured neck of femur (operated)'.1 I find his cause of death to be ‘general inanition on a background of cognitive impairment, congestive cardiac failure and chronic renal disease with contributing fractured neck of femur (operated)’.

1 Exhibit C1a

2. Reason for Inquest 2.1. The contribution of the fractured neck of femur to the death of Mr Kaczaniw while he was under a guardianship order with special powers pursuant to Section 32(1)(b) of the Guardianship and Administration Act 1993, means that his death is a death in custody and requires a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

3. Background 3.1. At the time of his death Mr Kaczaniw’s wife was deceased, and he had an estranged daughter and a sister who resided in England. The investigating officer was unable to ascertain much detail about Mr Kaczaniw’s family or social background. Mr Kaczaniw was reportedly a very well-liked resident at Reynella Village

4. Guardianship Order 4.1. The South Australian Civil and Administrative Tribunal (SACAT) received an application for a guardianship order with special powers on 22 October 2018. The application was made by a social worker at the Flinders Medical Centre.

4.2. A full hearing in relation to that application was heard on 14 November 2018 and the Tribunal made a guardianship order appointing the Public Advocate as guardian, limited to accommodation and health care, with a special powers order authorising such force as may be reasonably necessary for the purpose of ensuring the proper treatment and care of Mr Kaczaniw.

4.3. From this date various other applications, variations and reviews of orders and powers granted by SACAT against Mr Kaczaniw occurred as set out in the affidavit I received from Ms Donna Attard2 of SACAT.

5. Mr Kaczaniw’s medical and recent residential history 5.1. Ms Heather Fraser, Residential Services Manager of Reynella Village at the time of Mr Kaczaniw’s residency, has provided an affidavit.3 She stated that Mr Kaczaniw came to reside at Reynella Village in 2019, whilst subject to the guardianship order.

2 Exhibit C3 3 Exhibit C2

5.2. The area where Mr Kaczaniw lived within the home was not a secure facility. There was no impediment to residents coming or going, but Mr Kaczaniw did not ever choose to leave.

5.3. When Mr Kaczaniw arrived at the home he had a long and complex list of medical conditions including dementia, depression, chronic pain, heart failure, post-traumatic stress, paranoia, type 2 diabetes, arthritis, asthma, COPD and cancer of the prostate. He needed assistance with all his daily living needs. Over time his ailments progressed, and his mobility worsened.

5.4. Ms Fraser states that Mr Kaczaniw was considered prone to falls but was unaware of his frailty. He never waited or asked for assistance. Measures were put in place to prevent falls and injury. Mr Kaczaniw had, but never used, a four-wheel walker. He had a lowered bed and floor mats with alarms which were not used as they became a hazard when Mr Kaczaniw tried to avoid them when he moved, creating further risk.

Hip protectors were worn but could not be worn in bed, and that was when he mostly tried to move unassisted.

5.5. Mr Kaczaniw had a number of unwitnessed falls in the latter half of 2020.

6. Circumstances leading to Mr Kaczaniw’s death 6.1. On 10 August 2020 Mr Kaczaniw had a fall at the home which resulted in a fracture to his right proximal femur, which was surgically repaired at the Flinders Medical Centre

(FMC).

6.2. Medical treatments at FMC are reported as being without complication, although Mr Kaczaniw acquired pneumonia whilst in hospital and was treated accordingly.

6.3. Hospital notes reflect that Mr Kaczaniw was placed on an inpatient treatment order (ITO) during this hospital stay on 14 August 2020 after a code black due to postoperative delirium, calling out and aggression toward staff.

6.4. An urgent application for special powers lodged with SACAT by FMC staff cited the need for ongoing treatment and investigation of a possible pulmonary embolism and the need for special powers to treat Mr Kaczaniw. These special powers were ultimately granted, and the granting of those special powers included the reasonable

use of force to ensure his care. The granting of these special powers removed the need for any continued ITO which was revoked 24 August 2020.

6.5. Mr Kaczaniw was discharged on 25 August 2020 back to his residence. After his return there were a further two unwitnessed falls.

6.6. Mr Kaczaniw became progressively weaker and his oral intake diminished. On 2 September 2020 comfort care measures were put in place.

6.7. Mr Kaczaniw passed away on 7 September 2020.

7. Conclusion and recommendation 7.1. I agree with the conclusions of the investigating officer that the guardianship order with special powers was lawful and appropriate.

7.2. In my opinion Mr Kaczaniw’s care and treatment at both Reynella Village and the Flinders Medical Centre was appropriate.

7.3. I make no recommendations.

Key Words: Death in Custody; Section 32 Powers 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 05/2024 (1802/2020)