Coroner's Finding: Kettlestring, Jacqueline Collette

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INQUEST INTO THE DEATH OF JACQUELINE COLLETTE KETTLESTRING [2025] SACC 3 Inquest Findings of her Honour Coroner Giles 31 March 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of Jacqueline Collette Kettlestring, a 64-year-old woman who died while subject to a care and protection order imposed after she experienced advanced symptoms of Alzheimer’s dementia.

Held:

1. Jacqueline Collette Kettlestring, aged 64 years of Hackham West, died at Flinders Medical Centre on 1 October 2021 as a result of acute bronchopneumonia complicating Alzheimer's dementia with head injury.

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MR D EVANS Hearing Date/s: 28/02/2025 Inquest No: 06/2025 File No/s: 2119/2021

INQUEST INTO THE DEATH OF JACQUELINE COLLETTE KETTLESTRING [2025] SACC 3 Introduction Jacqueline Collette Kettlestring was born on 25 September 1957 and died on 1 October 2021 at the age of 64 years.

An autopsy was undertaken at Forensic Science South Australia by Dr Deborah Gomes, anatomical pathology registrar, and supervised by Dr Stephen Wills, forensic pathologist.

The resultant post-mortem report stated the cause of Mrs Kettlestring’s death as ‘acute bronchopneumonia complicating Alzheimer’s dementia with head injury’.1 I find this to have been the cause of Mrs Kettlestring’s death.

Reason for Inquest The contribution of the head injury to the death of Mrs Kettlestring, while she was under a guardianship order with special powers pursuant to Section 32(1)(b) of the Guardianship and Administration Act 1993, meant that her death was a death in custody requiring a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

Background and medical history Mrs Kettlestring was married to Mr Phillip Kettlestring and together they had two children.

In the years preceding her death, Mrs Kettlestring had been diagnosed with ischaemic heart disease (having suffered Type 2 NSTEMI in February 2021), osteoporosis, coeliac disease and gastrointestinal-oesophageal reflux disease.

In 2015, at the age of 57, she was diagnosed with early onset Alzheimer’s dementia with behaviours and psychological symptoms. Over time, Mrs Kettlestring’s dementia presented with aggression, wandering, intrusiveness and resistance to care. This presented challenges for her carers.

Mrs Kettlestring began to experience seizures in October 2020 and, from that time, was medicated for seizures.

On 23 May 2021 Mrs Kettlestring was taken to the Flinders Medical Centre by ambulance. The medical notes record that she had experienced a deterioration in her activity with lethargy and reduced engagement levels.2 It was noted that she was behaviourally aggressive towards her husband who had been caring for her up until this time. Doctors tried reducing Mrs Kettlestring’s seizure medication to address the increased lethargy, but there was minimal improvement. It was determined that Mrs Kettlestring’s dementia was progressing.3 1 Exhibit C1a 2 Exhibit C5c, page 1 3 Exhibit C5c, page 2

[2025] SACC 3 Coroner Giles

G 2 Mrs Kettlestring was admitted to the Flinders Medical Centre and, after a few days, transferred to the Repatriation General Hospital’s Advanced Dementia Unit where she was given a permanent placement in a secured area, with freedom of movement within the area.

A functional capacity assessment from August 2021 found Mrs Kettlestring to have deficits in attention, problem solving, judgment and planning.4 She had severe expressive and receptive aphasia. Her speech was no longer comprehensible, and she was not able to express her needs through words. Her dementia caused her to experience agitation, physical and verbal aggression, restlessness, anxiety and wandering.5 Restraints had been used to deal with activities of daily living. Four staff were required to deal with her personal needs as she would exhibit physically violent behaviours due to her dementia.

She was found to require ongoing 24-hour specialised care as she had progressed to high needs.6 While at the Dementia Unit, a multidisciplinary approach was adopted in an effort to minimise symptoms and improve Mrs Kettlestring’s quality of life. Her treatment consisted of environmental and behavioural interventions in combination with psychotropic medications.7 A gradual improvement in dementia behaviours was achieved, however there was a continual decline over time in functional abilities.

Mrs Kettlestring was recorded as having numerous unwitnessed falls. She was subject to multiple multidisciplinary fall reviews to try and mitigate her falls risk. However, despite various fall prevention measures being implemented, she continued to have falls which were attributed to non-modifiable factors, namely her cognitive dysfunction, and medications for the management of behavioural and psychological symptoms of dementia.8 Mrs Kettlestring had a seven-step pathway in place, which was updated in May 2021 and stated she was not for any treatment aimed at prolonging life. In particular, she was not for CPR or intubation. Her seven-step pathway allowed for treatment of simple reversible illnesses with antibiotics (including IV). A further notation in her medical records under the heading ‘Resuscitation Order’ stated: ‘not for up transfers to FMC. However, family will consider an up-transfer in case of fracture NOF. Not after urgent CT brain after a fall. For conservative management in case of intracranial bleed post fall. Focus should be on preserving her dignity.’9 SACAT orders On 13 February 2020 the South Australian Civil and Administrative Tribunal (SACAT) dealt with an application in respect of Mrs Kettlestring under the Guardianship and 4 Exhibit C5e, page 5 5 Exhibit C5e, page 7 6 Exhibit C5e, page 10 7 Exhibit C5g, page 2 8 Exhibit C6, page 1238; Exhibit C5g, page 2 9 Exhibit C5g, page 1

[2025] SACC 3 Coroner Giles

G 3 Administration Act 1993.10 SACAT considered that Mrs Kettlestring did not have mental capacity, and appointed Mr Kettlestring as her administrator and her limited guardian.

On 16 November 2020 SACAT dealt with another application in respect of Mrs Kettlestring, this time brought by a social worker from the Flinders Medical Centre.11 On this occasion, SACAT concluded that Mrs Kettlestring required additional orders for her health and safety and the health and safety of others. SACAT made orders continuing the placement of Mrs Kettlestring under the care of Mr Kettlestring, and new orders including that Mr Kettlestring decide where she was to reside and authorising her to be detained there.12 The use of necessary force was authorised to assist in the care of Mrs Kettlestring given the aggressive aspect of her dementia.

On 5 July 2021 SACAT reviewed Mrs Kettlestring’s case. It was concluded that there were proper grounds for the orders made in 2020 to remain in place.13 The orders remained in place until the time of Mrs Kettlestring’s death.

Circumstances leading to Mrs Kettlestring’s death On the afternoon of 8 September 2021 Mrs Kettlestring was found to have had an unwitnessed fall. She was assisted up and began to hit and bite the staff assisting her.

She was combative and was able to walk independently once up. Neurological observations were stable. Later that night, Mrs Kettlestring had another fall, again with no injuries found.

By 10 September 2021 Mrs Kettlestring had returned to her usual activities of daily living, however she was angry and refusing food.

On the morning of 11 September 2021, Mrs Kettlestring was found lying on the floor in the doorway of her bathroom. She was examined by Dr Lucy Atkinson who found no obvious head swelling or laceration, and no signs of basal skull fracture.14 A complete body examination was conducted, and no new injuries were noted. Mrs Kettlestring experienced vomiting and she was prescribed IV antibiotics to avoid aspiration pneumonia.15 Several hours later Mrs Kettlestring was noted to appear drowsier than usual but given her seven-step pathway and resuscitation order, no further investigations were undertaken other than routine bloods.

In the days that followed Mrs Kettlestring declined further with fluctuating consciousness and poor oral intake which was supplemented by IV fluids. She was diagnosed with prolonged hypoactive delirium.16 10 Exhibit C4 at [10] 11 Exhibit C4 at [11] 12 Exhibit C4 at [12] 13 Exhibit C4 at [13] 14 Exhibit C6, page 1256 15 Exhibit C6, page 1303; Exhibit C5g, page 2 16 Exhibit C5g, page 2

[2025] SACC 3 Coroner Giles

G 4 On 18 September 2021 Mr Kettlestring made the difficult decision to withdraw active care.17 Mrs Kettlestring died in the afternoon of 1 October 2021 surrounded by family.18 Conclusion and recommendations I find the guardianship order with special powers was valid at the time of Mrs Kettlestring’s death.

The standard of care afforded to Mrs Kettlestring was appropriate in what were very challenging circumstances.

I make no recommendations.

Keywords: Death in Custody; Section 32 Powers; Alzheimer's Disease; Head injury 17 Exhibit C6, page 1385 18 Exhibit C6, pages 1512-1516