Coroner's Finding: Perkins, Ann

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 Ann Perkins.

The said Court finds that Ann Perkins aged 77 years, late of Charles Young Residential Care Centre, 53 Austral Terrace, Morphettville, South Australia died at Morphettville, South Australia on the 10th day of January 2022 as a result of general inanition on a background of dementia, chronic subdural haematoma and a right fractured neck of femur (operated). The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Mrs Ann Perkins was born on 1 June 1944 and died on 10 January 2022 at the Charles Young Aged Care Facility in Morphettville. She was 77 years of age.

1.2. A pathology review was undertaken by Dr Alexandra Yuill, medical practitioner at Forensic Science South Australia and discussed with Dr Stephen Wills, forensic pathologist. I find the cause of Mrs Perkins’ death to be as suggested in the pathology review, namely, ‘general inanition on a background of dementia, chronic subdural haematoma and right fractured neck of femur (operated)’1 .

2. Reason for inquest 2.1. Mrs Perkins’ death is deemed a death in custody pursuant to the Coroners Act 2003, as at the time of her death she was under a guardianship order with special powers of 1 Exhibit C1a

detention pursuant to section 32(1)(b) of the Guardianship and Administration Act 1993, and her cause of death was not a natural cause as the fractured neck of femur was a contributing cause. For these reasons, this was a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

3. Background and medical history 3.1. Mrs Perkins was married to Reginald Perkins, and they had two children, Tania and Russell. Mrs Perkins had a career in retail.2

3.2. Mrs Perkins and her husband lived in Shepparton, Victoria for approximately 19 years.

3.3. Mrs Perkins’ husband first noticed a decline in her memory and behaviour in approximately 2016.

3.4. On 28 August 2019, Mrs Perkins was discharged from the Aged Psychiatric Assessment and Treatment Team (APATT) in Shepparton, Victoria with a diagnosis of dementia - probable Lewy body dementia. It was at this time that Mrs Perkins and her husband relocated to Adelaide to be closer to family.

3.5. On 6 January 2020 Mrs Perkins attended the Flinders Medical Centre (FMC) Memory Clinic. The clinic summary noted Mrs Perkins' presentation was ‘in keeping with likely neurodegenerative dementia process of at least moderate severe stage’.3

3.6. Mrs Perkins was referred to the Community Geriatric Team for further assessment. On 10 March 2020, the FMC Community Geriatric Team conducted a home assessment.

3.7. On 6 May 2020, Mrs Perkins was admitted to Noarlunga Hospital in relation to severe malnutrition in the context of a neurodegenerative condition.

3.8. Mr Perkins had noted an increase in aggression towards him and he was no longer able to provide the high level of care Mrs Perkins required.

3.9. During the hospital admission Mrs Perkins was diagnosed with Lewy body dementia and referred to the Geriatric Evaluation and Management (GEM) Clinic for future management.

2 Exhibit C4 3 Exhibit C5

3.10. Mrs Perkins was discharged from hospital and admitted to Charles Young as a respite resident on 19 May 2020.

3.11. Mrs Perkins was listed as having the following medical conditions: malnutrition; • dementia; • thrombocythemia; • vitamin D deficiency; and • urinary incontinence.

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3.12. On 2 June 2020, she transitioned to become a permanent resident at the Charles Young Aged Care facility.

3.13. By July 2020, staff members at the facility had noted the following behaviours of concern associated with her dementia: paranoid delusions with violent and distressing themes; • hallucinations; • resistance to care; • medication non-compliance; and • intrusive behaviour with physical aggression •

4. Guardianship order 4.1. On 28 July 2020 an application was made to the South Australian Civil and Administrative Tribunal (SACAT) by the manager of her supported residential facility.

4.2. A full hearing was held on 9 September 2020 and SACAT made a special powers order authorising residence and detention of Mrs Perkins.

4.3. The order was reviewed on 8 April 2021 on the papers and the special powers order was confirmed with a review date of 7 April 2022.

5. Circumstances leading to Mrs Perkins’ death 5.1. On 20 December 2021 Mrs Perkins sustained an unwitnessed fall at the nursing home and was sent to the Royal Adelaide Hospital, where she was diagnosed with a fracture

of the right neck of femur and a stable left-sided subacute on chronic subdural haematoma.

5.2. She underwent surgery on her hip on 22 December 2021.

5.3. Mrs Perkins was discharged on 28 December 2021 and returned to the Charles Young Aged Care facility.

5.4. Upon Mrs Perkins' return to Charles Young, she began to deteriorate and was not eating or drinking. Staff at the facility liaised with her treating doctors who made changes to her medication to assist.

5.5. On 6 January 2022, Mrs Perkins was commenced on a palliative care plan and on the evening of Monday, 10 January 2022 she passed away peacefully.

6. Conclusion 6.1. I agree with the conclusions of the SAPOL investigating officer, Detective Brevet Sergeant Shenae Klose, that the guardianship order with special powers was lawful and appropriate.

6.2. In my opinion the care provided to Mrs Perkins at both Charles Young and the Royal Adelaide 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 18/2024 (0087/2022)