Coroner's Finding: Procter, Sheelagh Patricia

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 Sheelagh Patricia Procter Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Sheelagh Patricia Procter (Ms Procter); b) Ms Procter died after she fell and fractured her right neck of femur which was surgically repaired; c) Ms Procter’s cause of death was pulmonary thromboembolus due to deep vein thrombus; and d) Ms Procter died on 26 February 2020 at Hobart, Tasmania.

Introduction In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Ms Procter’s death. The evidence includes:  The Police Report of Death for the Coroner;  Tasmanian Health Service (THS) Death Report to Coroner;  Affidavits as to identity and life extinct;  Report of the forensic pathologist Dr Donald Ritchey;  Affidavit of Ms Daphne Nordin;  Medical records of Ms Procter obtained from her general practitioner; and  Medical records of Ms Procter obtained from THS.

Background Ms Procter was born on the 3 November 1952. She arrived in Tasmania in 1964 as an immigrant from England with her parents, George Anderson Procter and Myra Edith Procter and her sisters Daphne Nordin and Kathleen Fabinyi. For most of Ms Procter’s life she resided at an address in Montrose.

Ms Procter worked as a laboratory assistant in her early 20s before being granted a disability pension. She did not marry and does not have any children. Neither did she smoke or consume any alcohol.

Health Medical records suggest Ms Procter was delayed developmentally and it is likely she sustained a convulsion around the age of 6 years. She received speech therapy from this time until she migrated to Tasmania at the age of 12. In 1971 she reached the second year of matriculation but obtained no level III subjects although she obtained a credit in level II mathematics at Elizabeth Matriculation College. As at March 1979 she had not sustained employment since she worked for a few days at the Silk and Textile Factory as a lab assistant and then in the mailroom with the Postmaster General’s Office. Ms Procter was subsequently granted a disability pension.

In 1972 she was referred to Clare House by the Vocational Guidance Department of the Commonwealth Employment Service because they were having difficulty in placing her in employment. Psychological testing was conducted as was an EEG1. The employment as a lab assistant then commenced but Ms Procter was dismissed due to her inability to assimilate instructions, she required constant reminders and was very slow in her work. She had difficulty in developing interpersonal relationships. Since that time she participated in regular therapeutic sessions with respect to her mental health and also with a speech therapist. She was also assessed by the John Edis Hospital.

In 1973 she was accepted into a secretarial course and for further speech therapy. Again it was noted she had great difficulty in forming relationships with the other students and it was this which ultimately resulted in her refusing to continue in that course later that year. In May the next year an attempt was made to place her in the Australian Government Public Service but that failed because it was said she lacked insight, was quite unaware of time responsibilities and 1 An electroencephalogram (EEG) is a noninvasive test that records electrical patterns in a person’s brain.

The test is used to help diagnose conditions such as seizures, epilepsy, head injuries, dizziness, headaches, brain tumors and sleeping problems.

once again there were difficulties with personal relationships and her belief she was the subject of mockery. The Australian Department of Social Security and Ms Procter made many approaches to a number of employers thereafter without success.

It appears from reports on file there were difficulties between Ms Procter and her parents; particularly her mother. She became estranged from her sisters who subsequently left the family home. She had few friends and limited social contacts.

From 1982 to 1997 she was reviewed at regular intervals by staff at Gavitt House which is a community mental health facility that assesses, diagnoses and treats adults with mental illness. In 1995 she suffered a grief reaction after her father died in January of that year. She was not coping well because of what was described as a solitary, lonely existence. By May of that year her mental state had improved.

In more recent times she visited her general practitioner, Dr McLeod, but very rarely. To 8 July 2019 she had only seen him on 9 occasions in the previous 7 years. The only medication Dr McLeod prescribed was an antibacterial cream no doubt because of her unwillingness to take medication which is referred to below.

In 2019 there was some contact with community mental health services. In January of that year Ms Procter was having difficulties with her Telstra account. Dr McLeod referred her to a social worker who reported by March she had met with Ms Procter on a number of occasions and had gone to a Telstra shop with Ms Procter to discuss her concerns. It appears the dispute concerned Ms Procter wanting quarterly not monthly bills. As the visit to the Telstra shop did not satisfy Ms Procter’s concerns a complaint was made at the end of February by the social worker, on Ms Procter’s behalf, to the Telecommunications Ombudsman. The ombudsman sent the complaint back to Telstra who attempted to deal with the complaint over the telephone however that call had to be taken in the social worker’s office because Ms Procter did not give out her number. That call did not proceed well because Ms Procter refused to provide details establishing her identity over the telephone. The social worker reported Ms Procter understood her complaint could not proceed unless she was willing to provide these details and so she agreed to the complaint being finalised. Subsequent letters in April and May from the social worker to Ms Procter asking whether she required any further assistance went unanswered.

Then in July 2019 there was contact between Ms Procter and the Old Person’s Mental Health Service. The referral to that service was made because of Ms Procter’s fixed beliefs which affected her ability to access the community and the telephone. Intervention included a police welfare check however she was discharged from follow-up because she was assessed and

considered to be “not certifiable under the Mental Health Act 2013” which was supported by her general practitioner, the police and evidence that she managed to live unassisted at her home. There was evidence she was a eating well and she was fit. She was able to attend the Glenorchy shopping centre for supplies. When assessed she was neatly dressed and groomed and was wearing clean clothes appropriate for a winter’s day. She refused to speak to anyone about her mental health. In addition staff were able to see in her laundry window and her premises were not cluttered or in squalor. The house appeared to be clean and tidy.

Accordingly because of these factors and Ms Procter’s wish not to engage with this service she was discharged.

Circumstances Leading to Ms Procter’s Death On the 15 February 2020 Ms Procter was taken to the Royal Hobart Hospital by ambulance after she collided with another pedestrian in the Elizabeth Street Mall in Hobart and fell. Ms Procter did not provide a next of kin and therefore the hospital did not have the contact details of her sisters. Ms Procter was assessed and found to have an acute fracture of the neck of the right femur. There were concerns Ms Procter was incapable of consenting to the surgery which was initially discussed with her on 16 February 2020 and to which she subsequently consented.

On 17 February 2020 the orthogeriatric consultant, Dr Beaumont, discussed with Ms Procter her options which were surgical versus conservative management. It was noted Ms Procter was able to retain information with respect to the risks and benefits of each treatment modality and she was able to express her decision. In addition Dr Beaumont spoke to her general practitioner Dr McLeod. He believed Ms Procter was capable of consenting but he believed she would refuse to engage with any mental health services. On the basis of Dr Beaumont’s discussion was Ms Procter and her discussion with Dr McLeod she considered Ms Procter capable of consenting to the surgery. Accordingly Ms Procter underwent a right hip hemiarthroplasty on 17 February 2020.

Post operatively Ms Procter declined multiple routine medical therapies including prophylactic anticoagulation which is provided to prevent deep vein thrombosis and pulmonary embolism, nasal prong oxygen for transient hypoxia as well as paracetamol and aperients to treat pain and prevent constipation. It was believed Ms Procter’s refusal was based on fixed beliefs about the nature of these medications.

The high risk of venous thrombosis, pulmonary embolism and death were discussed on multiple occasions by the treating medical staff and second and third opinions were obtained from a consultant liaison psychiatrist and a psychologist and then the situation was discussed with a second geriatrician prior to Ms Procter’s transfer, which she consented to, to the Old Persons

Unit. The notes reflect at 10 AM on 19 February 2020 and at 10:50 AM on 20 February 2020 the risk including death by blood clot of not taking clexane2 was discussed with Ms Procter. It was considered by the medical staff who spoke to her that she had the capacity to refuse this treatment.

Ms Procter still had prophylactic anticoagulation chartered which was offered daily however she continued to refuse this treatment. Ms Procter was encouraged to sit out of bed daily and mobilise and maintain her fluid intake to reduce the risk of thrombosis. She declined physiotherapy on some days and elected to remain in bed rather than in her chair despite encouragement from staff.

On 26 February 2020 15 minutes prior to a code blue being called she was seen during the consultant ward round where she was seen to be well, alert and breathing comfortably with some mild oedema on the side of her fractured neck of femur without tenderness which was thought to be secondary to her fracture and repair. She was encouraged to sit out of bed and mobilise and she was assisted out of bed by the medical team at which time she walked to the toilet largely unaided and without concern. She was subsequently found by nursing staff to be unresponsive and without a pulse and only intermittently breathing. CPR was initiated and a code blue was called. She received IV adrenaline and was intubated with ongoing CPR in keeping with the Advanced Life Support Protocol for Pulseless Electrical Activity which was thought to be due clinically to a massive pulmonary embolism. During resuscitation Dr Beaumont was contacted to discuss the goals of care given Ms Procter’s refusal of less invasive measures and despite this conversation Dr Beaumont confirmed Ms Procter had consented to CPR when she was specifically asked. Accordingly CPR was continued. At 30 minutes resuscitation the ICU consultant attended the resuscitation and thrombolysis3, on the presumed diagnosis of pulmonary embolus, was discussed but ultimately not given due to clinical signs and an expected very poor neurological and functional outcome. This discussion took place in consultation with Ms Procter’s treating geriatrician and the attending anaesthetist.

Ms Procter was subsequently declared deceased.

2 Clexane is an anticoagulant that belongs to a group of medicines called Low Molecular Weight Heparin (LMWH). These medicines help to prevent clots from getting bigger and they prevent new clots from forming.

3 Thrombolysis uses medications or a minimally invasive procedure to break up and dissolve blood clots and prevent new clots from forming.

Post-Mortem Examination The post-mortem examination was carried out by Dr Ritchey on 28 February 2020. As a result of his examination he determined Ms Procter’s cause of death to be pulmonary thromboembolus4. This had occurred subsequent to a fall in which she had fractured her right neck of femur which required surgical repair by way of a right hip hemiarthroplasty.

Comments and Recommendations Tragically Ms Procter passed away from a condition, the risk of which would have been reduced very significantly if she had accepted the medical treatment which was recommended to her. I am, given my consideration of the file and all medical records, satisfied Ms Procter had the capacity to consent or refuse this treatment. In my view the treatment provided by the THS was of a good standard.

The circumstances of Ms Procter’s 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 Ms Procter.

Dated: 21 December 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner 4 Pulmonary thromboembolism is a blockage of an artery in the lungs by a bloodcot that has moved from elsewhere in the body, usually the leg, through the bloodstream. The risk of such a condition is increased, amongst other things, by prolonged bed rest and after some types of surgery.