Coroner's Finding: Phillips, William Garnett

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of William Garnet Phillips, Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is William Garnet Phillips (Mr Phillips); b) Mr Phillips died in circumstances where he was frail and underweight; c) The cause of Mr Phillip’s death was bronchopneumonia; and d) Mr Phillips died on 30 January 2020 at the North West Regional Hospital, Burnie Tasmania.

Introduction In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Phillips’ death. The evidence includes:  Police Report of Death for the Coroner;  Affidavits as to identity and life extinct;  Affidavit of Dr Terence Brain, Forensic Pathologist;  Affidavit of Rhonda Irvine, the daughter of Mr Phillips and senior next of kin;  Medical records of Mr Phillips obtained from his general practitioner; and  Medical records of Mr Phillips obtained from the North West Regional Hospital

(NWRH).

Background Mr Phillips was born on 29 June 1937. He was aged 82 years, widowed, had two children, retired, and lived alone in Waratah, Tasmania.

Mr Phillips met and married Audrey Phillips in or about 1961 and they had two children; Lorraine and Rhonda. He worked as a rubber fitter at the Savage River Mine for

approximately 25 years. Audrey Phillips died in 1992. After her death Mr Phillips lived alone and generally in solitude. His daughter, Rhonda Irvine, says her father was a very proud man.

He did not want any assistance from either of his daughters or anybody else. He shared very little with them about his health.

General health The general practitioner’s records indicate Mr Phillips had a history of heart problems dating back to 1997 when he suffered an acute myocardial infarct. High blood pressure and cholesterol was diagnosed in 2001 and a heart murmur was diagnosed in 2004. In 2014 he suffered from sinus bradycardia (a slower than expected heartbeat) with a bifasicular block and in 2016 he suffered from the same condition along with a first-degree AV block. He was also diagnosed with a mild hearing impairment in 2012.

Mr Phillips was last prescribed iron tablets and tablets to treat reflux symptoms on 7 November 2019. Prior to those scripts he was provided with scripts for heart and cholesterol medication along with aspirin on 4 September 2019.

Ms Irvine says prior to Christmas 2019 her father appeared to be in reasonable health. His other daughter Lorraine visited him over the Christmas period and advised her sister their father did not seem well. He was eating well but not moving well. Lorraine saw him again when he visited her in Ulverstone on 5 January 2020 and she said he was much the same. A few days later Mr Phillips phoned Ms Irvine and she says he seemed okay on the phone and was joking with her. She spoke to him again a few days later about setting up a phone that her auntie and uncle had purchased for her father. He was reluctant to let her visit to set the phone up. He kept asking her to “just leave me alone” and “give me a couple of days”. Ms Irvine says she would give him a few days and call him again but she would receive the same response when she suggested setting up the phone.

Each time she called thereafter she says he sounded like he was deteriorating and she became worried. It got to the point where she says she could not understand him so she called her sister and they decided to attend his home in Waratah to check on him.

In the meantime Mr Phillips’ younger sister contacted Tasmania police as she was concerned for his welfare given his ailing health and isolation. She reported that in recent months she had visited Tasmania and spent time with Mr Phillips and observed he was in extremely poor health, would rarely eat and was significantly underweight. He constantly refused help and gave her the impression he had little care to continue living and was resigned to wasting away until he died.

On 13 January 2020 a home visit and assessment was conducted by an employee of My Aged Care which is a Commonwealth government organisation that helps people find and access aged care services they require. It was reported Mr Phillips refused all help however the employee reported similar concerns to those held by Mr Phillips’ sister. That organisation relies on consent and as that was not forthcoming all they could do was liaise with and assist Mr Phillips’ sister.

Tasmania police were advised by Mr Phillips’ sister that she spoke to him at 3.00pm each day so she could check on his welfare. On 22 January 2020 he failed to answer this call despite repeated attempts. He also failed to attend a medical appointment with a GP and as a result his sister telephoned Tasmania police but she, like his daughters, was unable to outline any known illnesses or medical history.

Circumstances of death At approximately 5.30pm on 22 January 2020 Sergeant Adam Spencer attended Mr Phillips’ address. No one could be raised so he gained entry through an unlocked internal door located inside an unlocked garage. Sergeant Spencer described the house as neat and says he found Mr Phillips in bed. Initially Mr Phillips appeared vague and unresponsive. He then advised Sergeant Spencer he was okay and he refused any assistance. Sergeant Spencer was unconvinced and asked Mr Phillips to stand up to determine if he could. Mr Phillips eventually did so but was significantly hunched over. He continued to refuse any help and said he was fine and that he wished to be left alone. When he stood up the Sergeant noted Mr Phillips was slight and he appeared to be malnourished. Sergeant Spencer left with the impression Mr Phillips had given up all hope and was waiting to die alone. Neighbours reported not seeing him for 3 weeks and believed he was away.

A paramedic from Ambulance Tasmania also attended and assessed Mr Phillips who again refused all assistance. Sergeant Spencer reported the paramedic agreed with his view of Mr Phillips’ general condition. Because Sergeant Spencer held significant concerns for Mr Phillips’ ongoing health and welfare, he recommended Mr Phillips be provided with appropriate care as a matter of priority. He made that recommendation in a referral he sent by email to a number of health organisations on the north-west coast including the Tasmanian Health Service.

A rural outreach worker from the organisation known as Rural Alive and Well Tasmania Inc., Mr Martin Dicker, attended Mr Phillips’ home on 23 January 2020 after receiving Sergeant Spencer’s referral. He accessed Mr Phillips’ home in the same manner as Sergeant Spencer. He found Mr Phillips sleeping on the floor. Mr Phillips did not want to speak to him and wanted to be left alone. Mr Dicker did however assist Mr Phillips by getting him some

water and Mr Phillips assured him he was not suicidal. Mr Phillips requested Mr Dicker leave so he left his card and that of Mensline and Suicide Callback. Mr Dicker consulted his team leader and then contacted Ambulance Tasmania as he believed Mr Phillips required a medical assessment.

When Ms Irvine, her son and her sister arrived at Mr Phillips’ home they found him on the floor in his bedroom. Again he refused all help and asked to be left alone. After a number of attempts to assist, which were all refused by Mr Phillips, they decided to leave and as they were doing so an ambulance arrived.

On arrival Mr Phillips was found lying on the floor by the ambulance officer. He was asleep.

He was woken by voice. Again Mr Phillips refused treatment saying “I just need one more night and then I will rest in peace”. He was questioned again about this and he indicated he wished to be left alone. The ambulance officer found 3 suicide business cards1 and a handwritten note from Mr Phillips’ daughter instructing him to call the men’s helpline when he is depressed. Mr Phillips was advised he would be taken to hospital for a mental health assessment. The ambulance officer also spoke to the general practitioner who advised Mr Phillips had an undiagnosed abdominal or gastrointestinal tract bleed. Mr Phillips was then advised police would attend to assist after which Mr Phillips became upset and said “fine I will come with you just get rid of the police as the town is going to talk about me”. One hour had elapsed between the time the ambulance officer arrived and when Mr Phillips agreed to attend hospital. As he was standing up he collapsed. Treatment was provided and he was stabilised on route to hospital and was able to converse with the treating ambulance officer.

On arrival at hospital he was examined and found to have a central stab wound. He was also hypothermic. Mr Phillips provided a history of opening cans with a knife and the wound was sustained in this manner. He denied suicidal intent. Ms Irvine says for as long as she can remember Mr Phillips had been known to open cans with a knife when he could not find the can opener or the can opener was not working. It did not surprise her he had injured himself in this way. She says he used to sit the can on the bench and place a knife tip down on the top of it and hit it with the other hand until it went through. When he went through the top he would then turn the can and cut around the top of it. He always used to sharpen his knives and so the knife he would have used would have been sharp. The wound was badly infected and weeping.

After being assessed in the emergency department Mr Phillips was transferred to a medical ward at 3.20am on 24 January 2020. The medical officer’s note indicates an incidental finding 1 At least 2 and possibly 3 of these cards had been left by Mr Dicker.

on examination showing an epigastric stab wound and treatment for what was considered to be urosepsis2 with associated rhabdomyolysis,3 acute renal impairment and hypernatraemia.4 The nursing notes for 25 January 2020 indicate Mr Phillips was unsettled but orientated and later disorientated to time and place. He was climbing out over the bed rails and taking his clothes off. On 26 January 2020 he fell from his bed. A CT of the brain organised after the fall detected no abnormalities; that is no head injury was sustained in that fall. A discussion was held with Mr Phillips’ family and it was agreed that should he deteriorate further he would be provided with palliative care. His condition continued to deteriorate and palliative care was commenced on 28 January 2020. He was declared deceased at 8.40pm on 30 January 2020.

Investigation The fact of Mr Phillips’ death was reported in accordance with the requirements of the Coroners Act 1995. His death was reportable because it was likely he had sustained 2 falls; one at home given he was found on the floor by the ambulance officer and one in hospital. In addition he was suffering from a stab wound. Accordingly his death was a reportable death within the meaning of that term as set out in the Coroners Act 1995.5 Mr Phillips’ body was formally identified by his daughter Rhonda Irvine, and then transported by mortuary ambulance to the Launceston General Hospital.

At that hospital, the experienced forensic pathologist Dr Terence Brain conducted a postmortem which included an examination of Mr Phillips’ body and a review of his medical records. In his report, Dr Brain expressed the opinion that the cause of Mr Phillips’ death was bronchopneumonia6 whilst being frail and underweight. Mr Phillips weighed 58 kg and is described by Dr Brain in his report as thin and wiry. Dr Brain examined the injury to Mr Phillips’ abdomen and found that it was a superficial stab wound. He also noted severe aortic atherosclerosis. The 2 falls and the stab wound were therefore not causative of death. I accept Dr Brain’s opinion.

2 Urosepsis is sepsis caused by infections of the urinary tract.

3 Rhabdomyolysis is a condition in which damaged skeletal muscle breaks down rapidly. Symptoms may include muscle pains, weakness, vomiting, and confusion. There may be tea-coloured urine or an irregular heartbeat. Some of the muscle breakdown products, such as the protein myoglobin, are harmful to the kidneys and may lead to kidney failure.

4 Hypernatraemia is a high concentration of sodium in the blood.

5 See s3 and the definition of reportable death particularly at paragraphs (a)(i)-(iii) and (iv) of that definition.

6 Bronchopneumonia is a form of pneumonia that affects the bronchi in the lungs. This condition commonly results from a bacterial infection, but viral and fungal infections can also cause it.

Conclusion I am satisfied, given Dr Brain’s opinion, Mr Phillips died from natural causes and he was frail and malnourished. Mr Phillips was offered assistance on a number of occasions in the weeks leading up to his death but he, as is his right, rejected each and every one of those offers. He stated on numerous occasions that he wished to be left alone. There is no evidence whatsoever to suggest he lacked the capacity to make an informed choice as to whether or not to accept assistance. It was only when, on 23 January 2020, the ambulance officer threatened to involve the police that Mr Phillips agreed to being taken to hospital for a medical assessment.

Comments and Recommendations The circumstances of Mr Phillips’ death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of Mr Phillips.

Dated 16 November 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner