Coroner's Finding: Oakley, Joseph Richard

FINDINGS and COMMENTS of Coroner Andrew McKee following the holding of an inquest under the Coroners Act 1995 into the death of: Joseph Richard Oakley

Table of Contents

Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Andrew McKee, Coroner, having investigated the death of Joseph Richard Oakley with an inquest held at Hobart in Tasmania, make the following findings.

Hearing Dates 8 December 2020 Appearances Counsel Assisting the Coroner: Senior Constable A Barnes Introduction

1. Mr Joseph Richard Oakley, aged 82 years, died on 24 April 2019 from atherosclerotic and hypertensive cardiovascular disease whilst a resident at the Roy Fagan Centre (RFC), situated at Kalang Avenue, Lenah Valley.

2. At the time of his death, Mr Oakley was the subject of an order made by the Guardianship and Administration Board in favour of Mr P Oakley.

3. The order was expressed in the following terms and remained in effect until 19 December 2021: “The Board Orders

1. That Paul Joseph Oakley be appointed as the Represented Person’s Guardian.

2. That the powers and duties of the Guardian are limited to decisions concerning;

(i) Where the Represented Person is to live either permanently or temporarily; and (ii) Providing consent to any reasonable measures required to convey the Represented Person to the place of residence as determined by the Guardian.

3. That the Order remains in effect to the 19th day of December 2021.”

4. I deemed that a public inquest was required to be held in respect of Mr Oakley’s death as he was a person ‘held in care’ under the Coroners Act 1995 (the Act).

5. In making the findings below I have had regard to the documentary evidence gained in the investigation into Mr Oakley’s death and note the following documents were tendered at the inquest:  Report of Death, Constable Aaron Wigg;  Life Extinct affidavit, Dr Graham Stevens;  Affidavit of identification, Constable Aaron Wigg;  Affidavit of identification, Mortuary Ambulance;  Post-mortem affidavit, Dr Donald Ritchey;  Property receipt, Tasmania Police;  Affidavit of Constable Wigg;  Affidavit of Constable Jaenke;  Affidavit of Donna French, senior next of kin;  Dr Anthony Bell’s report;  Medical records, Roy Fagan Centre;  Guardianship and Administration Board Order; and  Medical records, Royal Hobart Hospital.

6. As Mr Oakley was a ‘person held in care’, under the Act I am required to hold a public inquest.1 I am also required to report on the care, supervision or treatment of Mr Oakley while he was in care.

7. A ‘person in care’ under the Act is a ‘person detained or liable to be detained in an approved hospital within the meaning of the Mental Health Act 2013’. 2 The RFC is a specialised hospital operated by the Tasmanian Health Service to assess and treat older persons with psychiatric illness and / or cognitive impairment. The RFC is an approved hospital under the Mental Health Act 2013.

8. At the date of his death Mr Paul Oakley had made the decision Mr Oakley was to reside at the RFC. This decision was in accordance with order 2 of the Guardianship Order made on 20 December 2018.

9. I am satisfied that given the term of the Guardianship Order Mr Oakley was not free to leave the RFC. In fact on occasions he had left RFC and he was returned to the RFC. I am therefore satisfied that Mr Oakley was detained or liable to be detained at the RFC.

10. I note and agree with the comments made by Coroner McTaggart in her findings following the inquest into the death of Molly Jesse Smith, where she stated:3 1 Section 24 (b) of “the Act”.

2 Section 3 of “the Act”.

3 [2017] TASCD 444.

“The public policy rationale for the requirement in section 28(5) of the Act to report on the care, supervision or treatment is to ensure that the death of every person who is coercively held in any state run institution is carefully, independently and transparently examined.”4 She further stated: “It is therefore a question of fact as to whether the aspects of control or compulsion are present such that a person can be found to be detained, notwithstanding the absence of a formal order legitimising that detention”.5

11. As I have found that Mr Oakley is a person held in care under the Act I am required to report on his care, supervision and treatment at the RFC.

12. In compliance with that statutory obligation, I requested Dr Anthony Bell, an experienced medical practitioner attached to the Coroners Office, to review the care, treatment and supervision received by Mr Oakley at the RFC.

13. Dr Bell prepared a comprehensive report which was tendered at the inquest. Dr Bell, in that report, expressed the following opinion: “The care provided for PD since 2014 was of good standard and attentive. At the RFC management was aimed at providing symptom control and a safe environment. There was no cure and the goal was reasonable. There is no deficiencies in the management. The decision to move to palliative care to control symptoms at the end of life was a medically sound decision and supported by the family. PD remains a dreadful illness.

There are no medical issues raised by the case.”

14. I am satisfied that Dr Bell is qualified to express the opinions contained in his report, and I accept the opinions expressed by him in the report tendered as exhibit C11.

Background

15. Mr Oakley was born on 7 April 1936 at Hobart in Tasmania. He was one of seven children.

As a child, his family lived in different locations as his father was a policeman. Mr Oakley obtained employment at the Cadbury Chocolate Factory when he was 15 years of age. He remained in that employment until his retirement. By the time he had retired he had been appointed an assistant supervisor.

4 Ibid pg. 13.

5 Ibid pg. 14.

16. Mr Oakley met his wife, Margaret, in 1953 and they married in 1956. Mr and Mrs Oakley resided in Moonah. Their marriage produced three children.

17. Mrs Oakley predeceased Mr Oakley, dying in 2008.

Mr Oakley’s Medical History

18. Mr Oakley lived a healthy life. He was physically fit and did not suffer from any notable medical conditions until he was aged 50. At this time he was diagnosed with high blood pressure and cholesterol. Both conditions were treated with medication.

19. Mr Oakley’s health began to decline around 2005. He was diagnosed with the following conditions: a) Parkinson’s disease b) Macular degeneration c) Type 2 diabetes d) Atrial fibrillation e) Hyperthyroidism f) Hypertension

20. Mr Oakley underwent surgical procedures for his macular degeneration. In 2015 he ceased driving due to his eyesight.

21. During 2015 Mr Oakley’s family noted that he had begun to exhibit signs of dementia. Mr Oakley’s family made arrangements for support to be provided so he could remain living in his own residence.

22. Mr Oakley’s dementia progressed. He began suffering from falls due to his dementia and failing eyesight.

23. On 4 November 2018 Mr Oakley was admitted to Calvary Health Care at Lenah Valley. He had become unmanageable at his home due to worsening symptoms of Parkinson’s disease, which included falls, agitation and insomnia. Changes to his medication over the preceding months had not been effective.

24. On 12 November 2018 Mr Oakley was transferred from Calvary Health Care to the Royal Hobart Hospital.

25. On 13 November 2018 an emergency order was made by the Guardianship and Administration Board. As a result of that order Mr Oakley was transferred to the RFC.

26. Throughout the time that Mr Oakley resided at the RFC he attempted to leave the centre on a number of occasions.

27. Whilst residing at the RFC Mr Oakley had a number of falls. Mr Oakley’s motor and nonmotor skills had deteriorated.

28. By 21 February 2019 RFC were unable to prevent falls with cumulative injuries. Mr Oakley had advanced dementia along with a diminishing oral intake and he was becoming increasingly distressed.

29. Mr Oakley’s medical practitioner considered that small increments in medication may only increase the rate of falls.

30. After discussions with Mr Oakley’s son, he was commenced on sedation. Mr Oakley died on 24 February 2019.

Post-Mortem Examination

31. An external post-mortem examination was conducted by Dr C Lawrence. Dr Lawrence provided the following opinion as to Mr Oakley’s cause of death: “The cause of death of this 82 year old man, Joseph Richard Oakley, was atherosclerotic and hypertensive cardiovascular disease. Significant contributing factors were advance Parkinson’s disease with dementia and type two diabetes.

Mr Oakley has been placed by way of an order at the Roy Fagan Centre where he was cared for because of dementia on a background of advanced Parkinson’s disease and numerous falls. Staff believe [Mr] Oakley’s death was imminent however his death was reported to the Coroner because he was under a Guardianship Order.

He died on 24 February 2019.”

32. I accept Dr Lawrence’s opinion as to Mr Oakley’s cause of death.

33. I am satisfied, based on the entirety of the evidence before me, that there are no suspicious circumstances surrounding Mr Oakley’s death.

Summary of Formal Findings

34. I find, pursuant to section 28(1) of the Coroners Act 1995, that:

(a) The identity of the deceased is Joseph Richard Oakley;

(b) Mr Oakley died in the circumstances set out in this finding;

(c) Mr Oakley died as a result of atherosclerotic and hypertensive cardiovascular disease; and

(d) Mr Oakley died on 24 February 2019 at the Roy Fagan Centre, Lenah Valley, Tasmania.

Comments and Recommendations

35. I comment that, for the reasons contained in this finding, the care, supervision and treatment of Mr Oakley at the RFC was of a good standard and in no way contributed to Mr Oakley’s death.

36. I wish to acknowledge Senior Constable A Barnes’ efforts in preparing the file for inquest and for her helpful submissions.

37. In concluding, I convey my sincere condolences to Mr Oakley’s family.

Dated: 17 December 2020 at Hobart in the State of Tasmania Andrew McKee Coroner