Coroner's Finding: Murphy, Phillip Robin

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 15th day of March and the 19th day of June 2024, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Phillip Robin Murphy.

The said Court finds that Phillip Robin Murphy aged 76 years, late of Lerwin Nursing Home, 67 Joyce Streeet, Murray Bridge, South Australia died at Murray Bridge, South Australia on the 18th day of February 2022 as a result of right lower lobe pneumonia on a background of frontotemporal dementia, chronic obstructive pulmonary disease and immobilisation due to pelvic and limb fractures due to recent falls. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mr Phillip Robin Murphy was born on 13 December 1945 and died on 18 February 2022 at the Lerwin Nursing home in Murray Bridge. He was 76 years of age.

1.2. An autopsy report by Dr John Gilbert, senior consultant forensic pathologist at Forensic Science South Australia, and based upon an external examination and CT scan, gives the cause of death as ‘right lower lobe pneumonia on a background of frontotemporal dementia, chronic obstructive pulmonary disease and immobilisation due to rib and pelvic fractures due to recent falls’.1 I find that to have been the cause of Mr Murphy’s death.

1 Exhibit C1a

2. Reason for Inquest 2.1. As Mr Murphy was under a guardianship order with special powers pursuant to Section 32(1)(b) of the Guardianship and Administration Act 1993, and his death is not from certifiable natural causes, Mr Murphy’s death was a death in custody which required a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

3. Background 3.1. Mr Murphy was married to Mrs Joy Ann Murphy who passed away in January 2021.

Mr Murphy had worked as a fitter and turner.

3.2. On 11 August 2020 he was admitted to the Lerwin Nursing Home in Murray Bridge by his wife, who was also his Power of Attorney. At the time of his admission, Mr Murphy had been diagnosed by a geriatrician with rapidly progressing fronto-temporal lobe degeneration syndrome, progressive aphasia and global cognitive deficit.

3.3. Mr Murphy also had the following medical conditions: left renal cell carcinoma; • diabetes mellitus; • hypercholesterolemia; • obstructive sleep disorder; • chronic obstructive airway disease (COPD); • osteoporosis; • left total knee replacement; and • osteoarthritis.

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3.4. Mr Murphy had minimal speech as a result of his medical conditions, and he did not have the ability to communicate with staff. He was prone to frequent falls and was under palliative care.

3.5. Mr Murphy was reviewed at the fall prevention meeting group, and strategies were implemented to reduce the risk of harm or injury. Strategies implemented include a ‘crash mat’ next to Mr Murphy’s bed, additional staffing, and separating Mr Murphy from other patients who had been involved in incidents with him.

3.6. On 13 November 2020, a Resuscitation Plan (7-step pathway) was endorsed by Mr Murphy’s wife and a medical practitioner. This plan stated that Mr Murphy was not to undergo any advanced treatment including CPR, invasive ventilation, or intensive care treatment or admission.

4. Guardianship Order 4.1. Once Mr Murphy’s wife died in January 2021, and his care facility was unable to contact friends or family to help make decisions for him, the Office of the Public Advocate was contacted.

4.2. A SACAT hearing was held on 4 March 2021 and Mr Murphy was placed on a Guardianship and Administration Order with special powers of detention, pursuant to the Guardianship and Administration Act 1993. The Public Advocate was appointed the Limited Guardian for Mr Murphy.

5. Circumstances of Mr Murphy’s death 5.1. On 7 February 2022 Mr Murphy had an unwitnessed fall in the aged care facility. He was able to mobilise with his walker after the fall, but he developed non-verbal signs of pain.

5.2. On 9 February 2022 Mr Murphy was transferred from Lerwin Nursing Home to the Murray Bridge Memorial Hospital. The reason was that Mr Murphy appeared to be experiencing pain following recent falls, he was sweating and had an irregular pulse.

5.3. Mr Murphy had a consultation with the on-duty doctor and was admitted for a CT scan of his chest, abdomen and spine, an x-ray of his hips and blood tests. These tests revealed early consolidation of his lungs, inflammatory markers, and a fracture of his right superior acetabulum. He was prescribed analgesia and antibiotics and discharged back to the Lerwin Nursing Home.

5.4. Mr Murphy had a further fall on 12 February 2022 when he was found on the floor next to his bed with a laceration to his left eyebrow and bruised knees. Following this, difficulty swallowing, and minimal oral intake were noted.

5.5. Comfort care measures were commenced on 15 February 2022, including cessation of non-essential medications.

5.6. On 18 February 2022 Mr Murphy was observed by Registered Nurse Tanath Hoff2 on a number of occasions during the early hours of the morning and his breathing interval was slowing. He died and was declared deceased later that morning.

6. Conclusion and recommendation 6.1. I agree with the conclusions of the SAPOL investigating officer, Senior Constable Amanda Jonas, that the guardianship order with special powers was lawful and appropriate.

6.2. In my opinion the care Mr Murphy received at both Lerwin Nursing Home and the Murray Bridge Memorial Hospital was appropriate.

6.3. 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 19th day of June, 2024.

State Coroner Inquest Number 19/2024 (0411/2022) 2 Exhibit C3