Coroner's Finding: Campbell, Nancy

FINDINGS of Coroner Olivia McTaggart following the holding of an inquest under the Coroners Act 1995 into the death of:

NANCY CAMPBELL

Contents

Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Nancy Campbell with an inquest held at Hobart, Tasmania, make the following findings: Hearing Dates 11 March 2022 Representation Assisting the Coroner: A Barnes Findings pursuant to section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Nancy Campbell; b) Mrs Campbell died in the circumstances set out in this finding; c) The cause of Mrs Campbell’s death was sepsis with septic shock due to ascending cholangitis; and d) Mrs Campbell died on 22 June 2019 at the Mersey Community Hospital, Launceston in Tasmania.

Evidence in the investigation

1. In making the above findings, I have had regard to the evidence gained in the comprehensive investigation into Mrs Campbell’s death. The documentary evidence tendered at inquest comprised the following exhibits:  Police report of death;  Medical certificate of death;  Affidavit of Michael Campbell, son of Mrs Campbell;  Mental health treatment order;  Records of Uniting AgeWell Strathdevon nursing home;

 Medical records – Tasmania Health Service; and  Medical report of Dr Anthony J Bell, coronial medical consultant.

Background

2. Nancy Campbell was born on 14 December 1936 in Bridgenorth in the Tamar Valley and was 82 years of age at the time of her death. She was the second youngest of five sisters. She was a retired primary school teacher and was single, having separated from her husband many years before her death. There are two sons of the marriage, Michael and Stephen.

3. From 2005 until 2018 she lived by herself independently. In October 2018 she was assessed as needing full-time care due to a deterioration in her health, and she moved into Strathdevon nursing home voluntarily. She did not have a history of mental illness before commencing residence at the nursing home.

4. After moving into the nursing home Mrs Campbell’s son, Michael, noticed that his mother was becoming markedly delusional, paranoid and verbally abusive. She would become irrationally fixated upon certain ideas and make statements such as that the government was listening in on her conversations. She also started refusing to take her medication as she believed that the staff were giving her the wrong medication which was killing her.

5. Mrs Campbell became subject to mental health assessment, resulting in a three month inpatient admission to the Spencer Clinic between 28 February 2019 and 30 May 2019.

During her admission, she was diagnosed with and treated for delusional disorder. Her treating medical practitioners sought and were granted involuntary orders under the Mental Health Act 2013 on the basis that she lacked decision-making capacity and required treatment. It is apparent that Mrs Campbell was fixated upon leaving the facility in a taxi and travelling to Launceston, and was not co-operative with medication changes. Although she remained with significant delusions as the admission progressed, it appears that she became more compliant with her medication.

6. During her admission to the Spencer Clinic, Mrs Campbell also underwent an MRCP (Magnetic Resonance Cholangiopancreatography) examination which revealed the presence of gallstones and sludge (build-up of various compounds in the gallbladder), but no inflammation or issues requiring urgent treatment.

7. Upon discharge, Mrs Campbell remained subject to a treatment order under the Mental Health Act. The order, and the subsequent order existing at the time of her death, required Mrs Campbell to be treated with medication (primarily antipsychotic medication) as specified, to undergo medical assessment, and to attend appointments with Mental Health Services. The treatment orders authorised Mrs Campbell to be detained, if necessary, in an approved facility for the purposes of receiving her treatment. In relation to her gallstones, the discharge plan indicated that surgical intervention was not required at that time but that, once returned to the nursing home, she would have a specialist review relating to the possibility of an elective cholecystectomy (gallbladder removal). Upon her return to the nursing home, she underwent the specialist review, with the specialist advising against removing her gallbladder due to the high risk of death associated with the procedure. Further, Mrs Campbell did not have symptoms at that stage from her condition.

8. At the time of her death, Mrs Campbell was a person “held in care” under the Coroners Act 1995 because she was subject to a treatment order (the First Renewal of Treatment Order) pursuant to the Mental Health Act 2013 which rendered her “liable to be detained” in an approved hospital. This treatment order commenced on 7 June 2019 and expired on 6 December 2019.

9. Being a person in this category, I was required by section 24(1)(b) of the Coroners Act to hold a public inquest into Mrs Campbell’s death and, in addition to my usual functions, to report on her care, supervision and treatment whilst she was a person held in care as required by section 28(5) of the Coroners Act.

Circumstances surrounding death

10. On 21 June 2019 Mrs Campbell told her son, Michael, about some pains in stomach or chest but it did not appear to him to be causing her significant difficulty.

11. On 22 June 2019 the patient was vague, lethargic and complained of pain in the upper chest. She was taken to the Mersey Community Hospital. The presentation indicated severe bacterial septicaemia with a high risk of dying with no particularly effective treatment. Intravenous fluids and antibiotics were administered with no effect.

Unfortunately, Mrs Campbell passed away that same day.

12. Dr Shamim Parvez issued a medical cause of death certificate for Mrs Campbell, correctly determining that she died of natural causes. Dr Parvez listed “sepsis with septic shock due to ascending cholangitis” as the condition directly leading to death. The

doctor listed antecedent causes as common bile duct stricture and cholelithiasis (gallstones). I accept the doctor’s conclusions regarding cause of death.

Care, supervision and treatment of Mrs Campbell

13. Dr A J Bell reviewed the psychiatric and medical treatment and care received by Mrs Campbell as part of the coronial investigation. Dr Bell concluded in his report that the medical and psychiatric care was appropriate.

14. I am satisfied that the care that Ms Campbell received whilst subject to orders under the Mental Health Act was of a good standard. Unfortunately, she succumbed to sepsis originating from infection of the biliary tree, a problem to which she was susceptible due to her pre-existing condition. Her death could not have been reasonably prevented.

15. Further, it was entirely appropriate in the context of Mrs Campbell’s entrenched delusional disorder for her to be subject to involuntary orders under the Mental Health Act. She did not have the capacity to make decisions about her medical treatment by virtue of her delusional thought processes and she satisfied the treatment criteria under that Act.

16. The circumstances of Mrs Campbell’s death are not such as to require me to make any recommendations pursuant to section 28 of the Coroners Act 1995.

Acknowledgements I am grateful to Senior Constable Alisha Barnes for her excellent preparation of this inquest and her appearance at the inquest hearing.

I convey my sincere condolences to the family and loved ones of Mrs Campbell.

Dated: 18 March 2022 at Hobart in the State of Tasmania Olivia McTaggart Coroner