Coroner's Finding: Reid, Betty Lorraine

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 Betty Lorraine Reid.

The said Court finds that Betty Lorraine Reid aged 84 years, late of Resthaven Paradise, 61 Silkes Road, Paradise, South Australia died at Paradise, South Australia on the 21st day of November 2020 as a result of Alzheimer’s disease with subdural haematoma from traumatic head injury as a contributing factor. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Mrs Betty Reid was born on 1 September 1936 and was 84 years of age when she died on 21 November 2020 at the Resthaven Nursing Home in Paradise.

1.2. A CT scan and external examination was undertaken at Forensic Science South Australia by Consultant Forensic Pathologist Dr Neil Langlois, whose opinion as to the cause of death, which I accept, was Alzheimer’s disease with subdural haematoma from traumatic head injury as a contributing factor.1

2. Reason for inquest 2.1. At the time of her death, Mrs Reid was subject to a guardianship order with special powers made by the South Australian Civil and Administrative Tribunal (SACAT), and 1 Exhibit C1a

her death was not from certified natural causes, so this was a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

3. Background and medical history 3.1. For 62 years Mrs Reid was married to her husband Iain, who was her carer at home until her admission to the nursing home.2

3.2. On 28 June 2019 Mrs Reid was admitted to the Lyell McEwin Hospital (LMH) due to behavioural and psychological symptoms of dementia. She remained there, medically stable, while she awaited a nursing home placement.

3.3. During this hospital admission an application was made to SACAT and, following an urgent interim hearing on 28 June 2019, orders were made for guardianship and urgent action special powers with directions to residence and authorising detention. These orders were to expire on the 19 July 2019.

3.4. On 11 July 2019 Mrs Reid was discharged from the LMH and admitted directly to Resthaven Nursing Home at Paradise to reside in the Memory Support Unit.

3.5. A full SACAT hearing was held on 17 July 2019 and a guardianship order was confirmed appointing her husband Iain Reid, and her daughters Julie Holyhirm and Dianne Reid, as limited guardians for accommodation and lifestyle decisions. This order had a review date of 15 July 2022.

3.6. A special powers order was also made with directions to residence and authorising detention with a review date of 16 January 2020. The special powers order was reviewed on 3 April 2020 and confirmed with a review date of 1 April 2021.

4. Events leading to death 4.1. On the evening of 1 November 2020, Mrs Reid had an unwitnessed fall in the nursing home dining room when she tripped over her four-wheel walker. She was admitted to the Modbury Hospital for treatment.

2 Exhibit C3

4.2. A CT scan revealed the presence of a right subdural haematoma and cortical contusions with no mass effect. There were also fractures of her right orbital floor region. She was not a candidate for surgical intervention.

4.3. On the morning of 2 November 2020 Mrs Reid was returned to Resthaven. By this time, she was reaching end stage dementia and her life expectancy was considered short. Her treatment was palliative in the light of her extremely poor prognosis.

4.4. Mrs Reid had a further fall on 17 November 2020. An incident report from the home indicates that she was found on the floor in her bedroom, face down with her legs still wrapped among bedsheets. It was noted there was some blood on the floor and a 2cm cut on her left eyebrow. She was hoisted from the floor to bed using the full sling lifter.

An ambulance attended and her wounds were treated, followed by neurological observations. No significant injuries were apparent.

4.5. From this time Mrs Reid was commenced on an end-of-life pathway, and she continued to deteriorate until she passed away on 21 November 2020.

5. Conclusion and recommendation 5.1. I agree with the conclusions of the SAPOL investigating officer, Detective Sergeant Rhett Vormelker, that the guardianship order with special powers was lawful and appropriate.

5.2. In my opinion, the standard of care afforded to Mrs Reid at her home and at the Modbury Hospital in the weeks prior to her death was proper and appropriate.

5.3. I make no recommendations.

Key Words: Death in Custody; Section 32 Powers; Head Injury 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 06/2024 (2376/2020)