Coroner's Finding: Saberton, Linda Eileen

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 Linda Eileen Saberton.

The said Court finds that Linda Eileen Saberton aged 73 years, late of Cottage Grove, 150 Reynella Road, Woodcroft, South Australia died at Woodcroft, South Australia on the 17th day of March 2022 as a result of fractured neck of femur (operated) on a background of Alzheimer’s dementia. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Linda Eileen Saberton was born on 9 April 1948 and died on 17 March 2022 at Eldercare Cottage Grove facility in Woodcroft. She was 73 years of age.

1.2. A pathology review was undertaken by Dr Erin O’Connor, medical practitioner at Forensic Science South Australia and discussed with Professor Roger Byard. The stated cause of death was ‘fractured neck of femur (operated) on the background of Alzheimer’s dementia’,1 and I so find.

2. Reason for inquest 2.1. The contribution of the fractured neck of femur to the cause of death of Mrs Saberton, while she was under a guardianship order with special powers of detention pursuant to 1 Exhibit C1a

Section 32(1)(b) of the Guardianship and Administration Act 1993, means that her death was a death in custody as defined in the Coroners Act 2003 and required a mandatory inquest pursuant to Section 21 of that Act.

3. Background 3.1. Mrs Saberton was born in London and had one sibling. She moved to Australia with her family in 1961.

3.2. Mrs Saberton married her husband Eric in 1967. They had three children together.

3.3. During her life, Mrs Saberton worked various jobs, the last one being with Hills Industries where she worked in the roles of teller machine operator and senior production scheduler. She enjoyed netball, was a cub leader, and as her children got older, they got into junior motocross. They travelled extensively around the world and Australia.

3.4. The family moved to New South Wales for approximately 11 years, returning to Adelaide in 2017.

4. Mrs Saberton’s medical history 4.1. Mrs Saberton was diagnosed with Alzheimer’s dementia of the logopenic aphasia variety in 2012 whilst still living in New South Wales. She underwent treatment at the Prince of Wales Hospital.

4.2. After returning to Adelaide in 2017, Mr Saberton initially cared for his wife, but this became increasingly difficult due to the progression of her Alzheimer’s dementia and associated symptoms.

4.3. Mrs Saberton was placed into a respite facility but was soon transferred to the Queen Elizabeth Hospital (QEH), and then into St Margaret's Rehabilitation Centre which forms part of the QEH.

4.4. Mrs Saberton was ultimately transferred to the Eldercare Cottage Grove facility in Woodcroft. Mrs Saberton arrived at Eldercare Cottage Grove on 14 September 2018 for a period of respite, before transitioning to permanent care on 28 September 2018.

4.5. Mrs Saberton is recorded to have had the following medical conditions at that time of her admission to Eldercare Cottage Grove: Alzheimer's disease; • progressive aphasia relating to her Alzheimer’s disease; • decreased communication skills; • gastro-oesophageal reflux disease; • non-insulin dependent diabetes mellitus type 2; • macular degeneration; • obstructive sleep apnoea; • incontinence; • high cholesterol; • sinusitis; • asthma; • depression; • anxiety; and • osteoarthritis.

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5. Guardianship order 5.1. The South Australian Civil and Administrative Tribunal (SACAT) received an application for a guardianship order for Mrs Saberton on 28 August 2018. At an interim hearing on 29 August 2018 the Tribunal made an interim guardianship order appointing Eric Saberton as full guardian.

5.2. Following a full hearing on 19 September 2018 SACAT made a guardianship order appointing Eric Saberton and Barbara Ann Saberton as guardians, limited to accommodation and healthcare. A special powers order was also made authorising detention, and reasonable force for treatment and care.

5.3. The orders were reviewed and confirmed on a number of occasions and remained valid as at the date of Mrs Saberton’s death.

6. Circumstances of Mrs Saberton’s death 6.1. During her residency at Eldercare Cottage Grove, Mrs Saberton unfortunately had a large number of falls. Mrs Saberton was independently mobile, often walking for extended periods in the memory support unit. However, due to her advanced

Alzheimer’s dementia, she was unsteady on her feet. Mrs Saberton required clear verbal prompts with one step directions to reduce confusion. She was unable to manage a mobility frame as this was a two-step process which, due to her dementia, she was unable to implement.

6.2. After a fall in July 2019, it was recommended by her geriatrician to trial a soft helmet during the day to reduce risk of head trauma. This continued to be implemented until the time of her death. Additionally, Mrs Saberton had regular vision reviews.

6.3. A fall in May 2021 resulted in a fractured left neck of femur requiring surgical repair.

This resulted in increased frailty.

6.4. On 28 February 2022 Mrs Saberton was walking with a relative in the home when her foot became trapped in a trolley, and she fell. This resulted in a fractured right neck of femur, requiring surgical repair.

6.5. Following that surgery, Mrs Saberton was discharged on 7 March 2022 and returned to Eldercare Cottage Grove. Mrs Saberton was in general decline from this time and was placed on a palliative care plan.

6.6. Mrs Saberton passed away on 17 March 2022.

7. Conclusion 7.1. Mrs Saberton’s family drew to my attention concerns they had about aspects of her treatment. In particular, her family assert they had to advocate strongly for her to be taken off risperidone, and once she came off the risperidone, she reportedly markedly improved. Other concerns drawn to my attention include an occasion upon which she was given too much pain medication and appeared like she was in a coma due to the large dose, as well occasions leading up to her death where she was given inadequate pain medication and appeared to be in pain and agitated.

7.2. Mrs Saberton’s husband mentioned occasions when the care provided to his wife appeared to be substandard as a result of what he perceived to be lower staffing to patient ratios than were ideal to provide the required level of support.

7.3. I have had regard to the comments of Mrs Saberton’s family and acknowledge the additional stress and trauma that must have caused to them. I do find however that

those concerns, while important, are not directly related to the cause of Mrs Saberton’s death.

7.4. In the course of the coronial investigation the SAPOL investigating officer, Detective Brevet Sergeant Alex Grimaldi, did not identify any deficiencies in the care provided to Mrs Saberton.

7.5. I agree with the conclusions of the investigating officer that the guardianship order with special powers was lawful and appropriate.

7.6. I make no recommendations.

Key Words: Death in Custody 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 21/2024(0627/24)