Coroner's Finding: Hanson, Sungwaan

‘ FINDINGS of Coroner Andrew McKee following the holding

of an inquest under the Coroners Act 1995 into the death of:

SUNGWAAN HANSON

Contents

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Introduction

Record of Investigation into Death (With Inquest)

Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Andrew McKee, Coroner, having investigated the death of Sungwaan Hanson with an inquest held

at Hobart in Tasmania make the following findings.

Hearing Date

17 March 2021

Representation

Counsel Assisting the Coroner: Senior Constable A Barnes Introduction

On 27 May 2020 Sungwaan Hanson, aged 64, died at the Roy Fagan Centre Kalang Avenue, Lenah Valley. At the time of her death Mrs Hanson was the subject of a treatment order made by the

Mental Health Tribunal under the Mental Health Act.

Mrs Hanson's death is subject to the Coroners Act 1995 (the “Act”). The Act provides that an inquest must be held where a death occurs in Tasmania and the deceased person was, immediately before

their death, a person held in care.

Accordingly, an inquest in relation to her death was mandatory. The investigation and inquest focused upon her care, treatment and supervision whilst she was subject to that order at the Roy

Fagan Centre.

In making the findings below | am satisfied that this matter was comprehensively investigated and the relevant issues have been fully explored. | have taken into account and considered the evidence

tendered at the inquest namely:

. Cl — Police Report of Death;

. C2 — Affidavits of life extinct, Dr Fasnacht and Dr J Smith;

. C3 — Affidavit of identification, Constable M Reardon;

° C4 — Affidavit of identification, A Cordwell;

. C5 — Post-mortem report by Forensic Pathologist; Dr A Reid;

. C6 — Medical Records — Roy Fagan Centre;

. C7 ~ Medical Records — Royal Habart Hospital; . C8 — Affidavit of Ms B Van Steenis;

. C9 — Affidavit of Constable M Reardon;

. C10 — Affidavit of Constable L Brouwer; and

. CII ~ Report from the medical advisor to the Coranial Divison; Dr A Bell.

Having regard to the evidence | make the following findings pursuant to Section 28(|) of the Coroners

Act 1995:

a) The identity of the deceased is Sungwaan Hanson;

b) Mrs Hanson died in the circumstances set out in this finding;

c) The cause of Mrs Hanson's death was stage IVB metastatic adenocarcinoma of the rectum; and

d) Mrs Hanson died on 27 May 2020 at the Roy Fagan Centre, 54 Kalang Avenue, Lenah Valley.

Background

Mrs Hanson was born on 6 August 1955, in Thailand. She immigrated to Australia in February 1981.

There is no information available to me to allow me to comment on Mrs Hanson's life prior to her

immigrating to Australia.

Mrs Hanson moved to Tasmania in 1985. She married Mr C Hanson. Their marriage produced two

children. Their marriage ended in divorce.

Mrs Hanson was the primary carer of her children. She also held casual work in cafes and pizzerias.

Health

The evidence at the inquest disclosed that Mrs Hanson had a 35 year history of treatment resistant schizophrenia. Throughout her life she had been an inpatient of a number of psychiatric institutions

for almost 20 years.

As noted above she was the subject of a mental health order and resided at the Roy Fagan Centre.

Mrs Hanson had a number of medical conditions which are fully outlined in her medical records .Mrs

Hanson was a heavy smoker.

Mrs Hanson was noted to have intermittent per rectum blood loss. Given her mental health issues and cognitive impairment it was difficult for her treating medical practitioners to establish a clear

timeframe of her symptoms.

A per rectum examination was performed and a mass was identified. A CT scan of her abdomen and pelvis, which was performed on 12 November 2019, showed a tumour at the recto-sigmoid junction

with extension into surrounding tissues.

In conjunction with her guardian, Mental Health Services and the surgical services at the Royal Hobart Hospital - a decision was made that Mrs Hanson was not a suitable candidate for treatment.

This decision was primarily based on the distress such treatment would cause her given her mental

health and cognitive issues. It was decided she would be provided palliative treatment.

Mrs Hanson’s condition continued to deteriorate and she died on 27 May 2020.

Pursuant to Section 28(5) of the Act | am required to report on the care and treatment Mrs Hanson received at the Roy Fagan Centre. | note Mrs Hanson daughter, Ms B Van Steenis, who has sworn an affidavit as part of the investigation indicated she had no issues with the level of care provided to Mrs Hanson at the Roy Fagan Centre. | also requested Dr A Bell, an experienced medical practitioner to review the treatment and care provided to Mrs Hanson at the Roy Fagan Centre. Dr Bell in a report dated 2 February 2020 opined that the level of care and treatment provided to Mrs

Hanson at the Roy Fagan centre was of a good standard. | accept his opinion.

Post-Mortem A post-mortem examination was conducted by Forensic Pathologist, Dr A Reid. Dr Reid provided

the following cause of death:

“The cause of death of this 64-year-old Thai- Australian woman, Sungwaan HANSON, is Stage IVB

metastatic (hereditary) adenocarcinoma of the recturn.

Schizophrenia was another significant contributory condition.

This lady was compulsorily detained under the relevant mental health legislation due to the nature and degree of her schizophrenia (psychotic mental illness). She was under the care of Statewide Mental Health

Services and subject to guardianship by the Public Guardian Office.

A rectal tumour was diagnosed in November 2019. {t was palpable on rectal examination and was further

investigated by CT scan which showed locally advanced disease and probable metastases.

In consultation between Mental Health and Surgical Services with the oversight of the Public Guardian, it was determined that she would not tolerate further investigation or necessary treatment subject to the results of

any further investigation.

She was referred to Statewide Palliative Care Services and remained a patient detained at the Roy Fagan

Centre until she died in May 2020.” | accept Dr Reid’s opinion.

Comments and Recommendations

The evidence at the inquest outlined an appropriate standard of care for Mrs Hanson. The care and

treatment she received was entirely appropriate in the circumstances.

There is no need for me to make any other comments or recommendations.

| extend my condolences to the family and friends of Mrs Hanson.

Dated: 2. 5 i | 2021 at Hobart in the State of Tasmania.

Andy Kee Coroner’