Deceased
Raymond Albert Daly
Demographics
90y, male
Date of death
2020-07-12
Finding date
2021-03-25
Cause of death
aspiration pneumonia, vascular dementia, ischaemic heart disease, congestive cardiac failure and chronic renal failure
AI-generated summary
Raymond Albert Daly, aged 90, died of aspiration pneumonia complicated by vascular dementia, ischaemic heart disease, congestive cardiac failure and chronic renal failure whilst a resident at the Roy Fagan Centre under a guardianship order. He had experienced progressive behavioural deterioration related to his advancing dementia, requiring management of aggression with antipsychotic and sedative medications. In his final days, he declined medications for cardiac failure and developed lower limb oedema. He was managed palliatively and died peacefully with staff present. The coroner found no suspicious circumstances and was satisfied the care and treatment provided at the facility was of an appropriate standard. No clinical errors or preventable factors were identified.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
FINDINGS of Coroner Simon Cooper following the holding of an inquest under the Coroners Act 1995 into the death of:
Contents
Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the death of Raymond Albert Daly with an inquest held at Hobart in Tasmania make the following findings.
Hearing Date 12 March 2021 Representation Counsel Assisting the Coroner: J Ansell Introduction
Mr Daly died on 12 July 2020 aged 90 years, whilst a patient at the Roy Fagan Centre, Kalang Avenue, Lenah Valley.
At the time of his death, Mr Daly was the subject of an order made under the provisions of the Guardianship and Administration Act 1995. Accordingly, an inquest in relation to his death was mandatory. The inquest focused upon his care, treatment and supervision whilst he was subject to that order at the Roy Fagan Centre.
On the basis of the evidence tendered at the inquest I make the following formal findings pursuant to Section 28(1) of the Coroners Act 1995: a) The identity of the deceased is Raymond Albert Daly; b) Mr Daly died in the circumstances set out further in this finding; c) The cause of Mr Daly’s death was aspiration pneumonia, vascular dementia, ischaemic heart disease, congestive cardiac failure and chronic renal failure; and d) Mr Daly died on 12 July 2020 at the Roy Fagan Centre, 54 Kalang Avenue, Lenah Valley.
Mr Daly was born in what is now the suburb of Fern Tree, near Hobart on 28 January 1930.
He was one of 10 children of Martin and Dorothy Daly.1 He described that four of his siblings would sleep in one bed and six in the other.2 1 Exhibit C7 2 Exhibit C7
Mr Daly grew up on a farm that had cows and horses. At the age of five he would get up at 5.00am with his brother; their mother would give him a piece of bread with jam in his hand and they would proceed to the paddocks to round up the cows. Mr Daly attended the local school at Fern Tree where he was an avid reader.3
In 1954 he married his wife Dorothy, with whom he had four children.
Mr Daly met his second wife, Sue, in the late 1970s at a dance hosted by a group known as ‘Parents without Partners’. Mr Daly and Sue married on 10 June 1978. Mr Daly became a stepfather to three children. Mr and Mrs Daly were married for 41 years. Their marriage ended with her death shortly before Mr Daly’s on 11 April 2020.
Reportedly, Mr Daly enjoyed socialising with their friends, being involved in the community particularly at St Helens (the RSL), dressing up for community events and going out for meals, particularly Chinese.4
During his working life Mr Daly worked in heavy machinery. He was a crane driver and also drove taxis and buses.6
Mr Daly liked to be called Ray, liked jokes and to be the centre of attention.7 Health
Mr Daly’s health matters of note included gout, vitamin D deficiency, cellulitis, back pain, vertigo and diabetes8. As he aged, Mr Daly developed advanced vascular dementia with behavioural problems, ischaemic heart disease, congestive cardiac failure, atrial fibrillation, chronic kidney disease, gout, obesity and back pain. He was fitted with a permanent pacemaker.9
Following behavioural changes in 201410, Mr Daly’s dementia developed over a 3–5 year period, which resulted in what was described as the coarsening of his personality.11 3 Exhibit C7 4 Exhibit C7 5 Exhibit C7 6 Exhibit C1 7 Exhibit C7 8 Exhibit C6 9 Exhibit C5 10 Exhibit C9 11 Exhibit C5
In February 2020, Mr Daly had 3-4 falls within a two week period12 and began to show clear symptoms of agitation and psychosis. His condition did not improve and in May 2020, due to his behaviour, there was a meeting for guardianship and that was awarded to the Public Guardian (Tas).13 Circumstances of Death
In the months prior to his death, Mr Daly was aggressive and was managed both at the Royal Hobart Hospital and the Roy Fagan Centre.14
Initially transferred to the Roy Fagan Centre in June 2020, Mr Daly was transferred back to the Royal Hobart Hospital due to his aggressive behaviour, both verbal and physical15.
Mr Daly spent two weeks at the Royal Hobart Hospital, however because his behaviour did not improve and due to difficulties with staff, he was transferred back to the Roy Fagan Centre on 29 June 2020.16
The Roy Fagan Centre were able to provide Mr Daly with an empty ward which he had to himself in an attempt to assist with the management of his behaviour17.
Initially, upon that transfer in June 2020, Mr Daly was able to walk with the assistance of two staff members and a walking frame. This however changed dramatically with his health. His medical records indicate that after 6 July 2020, Mr Daly remained in bed.18
Mr Daly began to refuse to take his medications for congestive cardiac failure. He soon developed lower limb oedema. Mr Daly was given clonazepam and haloperidol in an attempt to ameliorate his distress and treated palliatively.19
On 12 July 2020 at approximately 4.40am, Roy Fagan staff went into Mr Daly’s room. Mr Daly was seen to have a large amount of excess secretion in his mouth. The secretion was suctioned. No attempts of CPR were conducted by staff as Mr Daly was in palliative care and had clearly indicated his wish not to be revived.20 12 Exhibit C9 13 Exhibit C10 14 Exhibit C5 15 Exhibit C1 16 Exhibit C1 17 Exhibit C1 18 Exhibit C1 19 Exhibit C5 20 Exhibit C1
The fact of Mr Daly’s death was reported in accordance with the requirements of the Coroners Act 1995. Police attended, inspected his body and his room and arranged for formal identification. After that occurred, Mr Daly’s body was taken to the mortuary at the Royal Hobart Hospital where highly experienced forensic pathologist, Dr Christopher Lawrence, examined his body, and arranged for a CT scan to be conducted. A review of the results of the scan showed clear evidence of left upper lobe pneumonia as well as evidence of ischaemic heart disease.
I am satisfied that Mr Daly died from a chest infection. He was, I note, suffering vascular dementia and heart disease at the time of his death.22
There are no suspicious circumstances surrounding his death. I am quite satisfied that the care and treatment he received at the Roy Fagan Centre was of an appropriate standard.
Comments and Recommendations
In the circumstances there is no need for me to make any further comment or recommendations.
In concluding, I convey my sincere condolences to the family of Mr Daly.
Dated: 25 March 2021 at Hobart in the State of Tasmania.
Simon Cooper
CORONER 21 Exhibit C1 22 Exhibit C5
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