Coroner's Finding: Shields, Sandra Mary

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

SANDRA MARY SHIELDS

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 Sandra Mary Shields 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 Sandra Mary Shields; b) Ms Shields died in the circumstances set out in this finding; c) The cause of Ms Shields’ death was sepsis and pneumonia due to a sacral ulcer in the setting of catatonic schizophrenia; and d) Ms Shields died on 25 March 2019.

Evidence in the investigation

1. In making the above findings, I have had regard to the evidence gained in the comprehensive investigation into Ms Shields’ death. The documentary evidence tendered at inquest comprised the following exhibits:  Police report of death;  Affidavit of life extinct;  Post-mortem report of Dr Christopher Lawrence, forensic pathologist;  Toxicology report of Mr Neil McLachlan-Troup, forensic scientist;  Medical records – Tasmania Health Service;

 Affidavit of Ms Abbey Eldridge, registered nurse who cared for Ms Shields at the Launceston General Hospital;  Correspondence of Mr Paul Shields, brother of Ms Shields;  Mental health treatment order – Mental Health Services;  Guardianship order – Guardianship and Administration Board; and  Medical report of Dr Anthony J Bell, coronial medical consultant.

Background

2. Sandra Mary Shields was born on 11 November 1955 and aged 63 at the date of her death. She was born to John and Ethenee Shields. She is survived by her brother, Paul.

She never married and had no children. Ms Shields was reported to have been a healthy child, but started experiencing symptoms of schizophrenia at around 13 years of age. It appears that she was formally diagnosed with schizophrenia at about the age of 18 years.

Unfortunately, for the duration of her life, Ms Shields experienced chronic and debilitating schizophrenia for which she was medicated. At the time of her death she was an inpatient at the Launceston General Hospital (LGH) but she lived permanently at Southern Cross Care Glenara Lakes residential aged care facility.

3. At the time of her death, Ms Shields 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. In the weeks prior to her death, Ms Shields’ physical and mental health had deteriorated and she had become non-communicative. On 2 February 2019, Ms Shields was transported by ambulance to the Launceston General Hospital (LGH) as she had become febrile (with a temperature of 38.8 degrees). In the emergency department, Ms Shields was assessed as being in a catatonic state. Such a state typically involves stillness of movement, fast or strange movements, lack of speech, and other unusual behaviour.

Clinical examination revealed a chronic sacral pressure ulcer as the possible source of infection and she was admitted to the LGH as an inpatient.

5. On 3 February 2019, there was a plan to insert a nasogastric tube to ensure that she received her clozapine with which she had showed recent non-compliance. At that time she was also refusing to take oral fluids. She was commenced upon intramuscular injection of risperidone, and then clozapine re-commenced on 4 February. On 6 February a pressure area swab showed staphylococcus aureus infection and antibiotics were commenced.

6. On 8 February, a nasogastric tube was inserted and feeding commenced by this method.

However, the tube was removed by Ms Shields soon after its placement. Clozapine was therefore ceased and she was commenced on olanzapine by injection.

7. On 19 February, Ms Shields remained catatonic and on treatment with olanzapine and sodium valproate. A trial of lorazepam was considered and implemented. She did not tolerate pureed foods or fluid. On 20 February, Ms Shields seemed to improve, being able to verbalise and smile, with more movement. Lorazepam was withheld due to drowsiness. However, the next day, Ms Shields was again catatonic, refusing medication and food.

8. On 4 March, Ms Shields’ treating doctor applied for a treatment order under the Mental Health Act 2013 due to the serious risks to her health and her incapacity to make decisions regarding her treatment. An interim treatment order was made by the Mental Health Tribunal on 5 March, with a treatment order made on 7 March and varied on 14 March. Broadly, the orders required Ms Shields to be treated with medication as specified, to undergo nasogastric feeding and medical examinations, and to undergo ECT treatment sessions as directed by the treating psychiatrist. The treatment order as varied expired on 6 September 2019 and authorised Ms Shields to be detained, if necessary, in an approved facility for the purposes of receiving treatment.

9. On 6 March 2019, Ms Shields was administered electroconvulsive therapy (ECT) which was commenced for drug-resistant catatonia. Her care continued with a regime of medication and ECT. However, Ms Shields’ condition proved resistant to treatment.

Significant issues associated with her care included her non-verbal state, refusal to allow the taking of observations, actively resisting feeding, and her pressure wound failing to heal.

10. By 14 March 2019, Ms Shields had become unresponsive. The consultant physician, Dr Andrew Maclaine-Cross, was consulted and a plan was made with family consultation to cease active treatment and commence palliative care. Ms Shields’ subsequently received palliative treatment and died on 25 March 2019.

Medical evidence

11. Dr Christopher Lawrence, forensic pathologist, determined that Ms Shields’ cause of death was sepsis and pneumonia due to immobility with sacral ulcer resulting from her schizophrenia. I accept his opinion.

12. Dr Anthony Bell, coronial medical consultant, reviewed the medical treatment received by Ms Shields. In addition to his report, he provided helpful oral evidence at inquest. Dr Bell was of the view that the medical treatment by the LGH was appropriate and of a good standard. Dr Bell explained in his report that catatonia is a behavioural syndrome marked by an inability to move normally, which can occur in the context of many psychiatric and general medical disorders. Typically, prompt treatment of catatonia with benzodiazepines and electroconvulsive therapy (ECT), as well as treatment of the underlying cause, leads to remission of catatonia. However, patients with schizophrenia may not respond to treatment as favourably as other patients with psychiatric conditions. He reported that catatonia may persist for many years, especially in patients with schizophrenia.

13. Ms Shields was treated by way of administration of anti-psychotic medications, benzodiazepines and ECT. However, despite this treatment, she remained catatonic and continued to decline. The evidence, including that of Dr Bell, persuades me that no other treatment options could have relieved her condition.

Care, supervision and treatment of Ms Shields

14. I find that Ms Shields suffered a natural decline in her condition before her death.

Unfortunately, such a decline is not unexpected in the context of chronic schizophrenia.

I am satisfied that her medical management, treatment and care while she was a patient at the LGH, including the period during which she was subject to the treatment order, was of a good standard.

15. The brother of Ms Shields, Mr Paul Shields, gave evidence at inquest about his concerns that there were problematic changes to Ms Shields’ medication regime when she was both living at Glenara Lakes and when she was a patient at the LGH before her death.

He was also concerned that he was not consulted about such changes. I observe that the inquest did not, and was not required to, focus on Ms Shields’ medical care before her last admission to the LGH. However, Dr Bell gave helpful general evidence concerning valid reasons for changes in antipsychotic medications and expressed the opinion that Ms Shields’ decline and death was not connected to inappropriate changes of medication either in the residential or hospital setting.

16. The circumstances of Ms Shields’ 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 Ms Shields.

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