Coroner's Finding: Collis, Mary

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

MARY COLLIS

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 Mary Collis 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 Mary Collis; b) Mrs Collis died in the circumstances set out in this finding; c) The cause of death was pulmonary embolus; and d) Mrs Collis died on 15 June 2020 at the Launceston General Hospital, 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 Collis’s death. The documentary evidence tendered at inquest comprised the following exhibits:  Police and hospital reports of death for the coroner;  Affidavits confirming life extinct and identification;  Post-mortem report of Dr Terrence Brain, forensic pathologist;  Medical records – Deloraine Medical Centre;  Medical records – Tasmania Health Service;  Affidavit of Davina-Lee Collis, daughter of Mrs Collis;

 Affidavit of Constable Connor Pask;  Mental health treatment order – Mental Health Tribunal;  Medical report of Dr Anthony J Bell, coronial medical consultant.

Background

2. Mary Collis was born Mary Stamford on 2 February 1947 in Launceston to John and Phyllis Stamford. She had three siblings and lived her whole life in Tasmania. Mrs Collis met and married Maxwell Collis in 1974. They had three children together, and moved to Westbury. Mr Collis passed away in 2012, and Mrs Collis continued to live in the family home in Westbury until her death. At the time of her death, she was aged 73 years. Prior to her decline in health before her death, Mrs Collis is described by her family as having been fit and active most of her life. She suffered longstanding bipolar affective disorder, for which she was medicated and remained stable. She also suffered type 2 diabetes and had been treated with insulin since 2013.

3. At the time of her death, Mrs Collis was a person “held in care” under the Coroners Act 1995 because she was subject to a treatment order pursuant to the Mental Health Act 2013 which rendered her “liable to be detained” in an approved hospital. Being a person in this category, I was required by section 24(1)(b) of the Coroners Act to hold a public inquest into her 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

4. Mrs Collis had regular contact with her children until her death. Her daughter Davina Collis, spoke to her mother at home on Friday 1 May 2020. Davina said that Mrs Collis was her normal self and they spoke about her recent fall.

5. On Saturday 2 May 2020 Mrs Collis was visited by her other daughter, Joanne Taylor, and her granddaughter Brittany Taylor, who delivered her some groceries. They returned the next day to see her again and when they left she was asleep in her chair.

6. On Monday 4 May 2020, Mrs Collis’s son, Robert Collis, spoke with her when he was leaving for work at about 5.30am. He observed her to be sleeping in a chair by the fire at this time, something that was not unusual.

7. Later that day, Mrs Collis had an appointment with the podiatrist and was to be collected by the Westbury community car. When that service was unable to contact her at the house, they called her general practitioner who in turn, telephoned Davina.

8. When Davina arrived at her mother’s house, Mrs Collis was in an unconscious state with police officers and ambulance paramedics attending to her. She was taken to the Launceston General Hospital (LGH) where she was placed in the intensive care unit.

She was assessed as being in a hyperosmolar hyperglycaemic state (HHS) exacerbated by urosepsis, likely precipitated by cessation of diabetic medications and a large intake of sugared drinks in the days prior to admission. She suffered other associated conditions, including acute kidney injury. Standard intensive care management was implemented (intubation, ventilation, haemodialysis) with gradual corrections of the HHS. Unfortunately, despite optimal medical therapy, minimal improvement of her state of consciousness or mental state was seen and severe critical illness myopathy was noted.

9. On 26 May Mrs Collis was reviewed by a consultant psychiatrist. The possibility of depression with catatonia was raised. Electroconvulsive therapy (ECT) was considered a possible treatment option at this time, although she subsequently showed some signs of recovery.

10. On 4 June, a second opinion was obtained from a consultant psychiatrist regarding administration of ECT. However, a repeat MRI scan of the brain was normal and neurological review suggested psychogenic stupor was unlikely in view of an abnormal

EEG.

11. On 5 June, an urgent circumstances treatment order and interim treatment order under the Mental Health Act were granted in order to administer ECT to Mrs Collis in order to try and halt her deterioration. In the afternoon of that day, ECT was commenced.

Further ECT was administered on 8 June and 10 June.

12. Psychiatric review on 11 June found improved neurology with spontaneous eye opening, fixed gaze and a cough reflex. On that day a treatment order was made until 11 December 2020. The order required Mrs Collis to be treated with medication as specified, to undergo medical examinations, and to undergo up to nine ECT treatment sessions as directed by the treating psychiatrist. The treatment order authorised Mrs Collis, if necessary, to be detained in an approved facility for the purposes of receiving treatment.

13. Unfortunately, Mrs Collis’s condition further deteriorated over the following days and ECT was cancelled after discussions with the anaesthetist. After consultation with Mrs Collis’s family, active treatment was withdrawn and she passed away on 15 June 2020.

14. Dr Terry Brain, forensic pathologist, conducted a post-mortem examination of Mrs Collis on 17 June 2020. He concluded that the cause of the death was pulmonary embolus with contributory factors being hyperosmolar ketoacidosis and acute renal papillary necrosis. In short, Mrs Collis’ death was the result of natural causes.

Care, supervision and treatment of Mrs Collis

15. Dr Anthony Bell, coronial medical consultant, reviewed the medical treatment received by Mrs Collis. Dr Bell stated in his independent report that Mrs Collis’s complex medical case was well managed. Further, he was of the opinion that ECT therapy was a reasonable treatment option in the circumstances. He noted that studies showed that in patients with bipolar major depression, ECT is superior to pharmacotherapy and can lead to remission of a catatonic state.

16. I accept the opinion of Dr Bell and find that the care, supervision and treatment of Mrs Collis whilst at the LGH, including whilst subject to orders under the Mental Health Act, was of a good standard in all respects.

17. The circumstances of Mrs Collis’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 Collis.

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