Coronial
TAShospital

Coroner's Finding: Tedmanson, Wayne Douglas

Deceased

Wayne Douglas Tedmanson

Demographics

76y, male

Date of death

2020-11-06

Finding date

2022-08-09

Cause of death

ischaemic heart disease following hyperglycaemic hyperosmolar syndrome (HHS) due to type 2 diabetes mellitus

AI-generated summary

Wayne Douglas Tedmanson, aged 76, died from ischaemic heart disease following hyperglycaemic hyperosmolar syndrome (HHS), a complication of type 2 diabetes mellitus. Clinical lessons include recognising HHS presentations: polydipsia, polyuria, confusion, and disorientation warrant urgent hospitalisation. Mr Tedmanson's initial reluctance to seek care, coupled with delayed recognition of diabetic emergency, likely contributed to his deterioration. Early intervention when symptoms began on 31 October would have enabled timely treatment. The case underscores importance of patient education regarding diabetes warning signs and physician responsiveness to family concerns about acute metabolic derangement. Post-mortem examination confirmed natural causes; an unsubstantiated allegation of homicide was thoroughly investigated and dismissed.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinegeneral medicinecardiologyendocrinologypathology

Error types

delay

Contributing factors

  • delayed presentation to hospital
  • patient refusal of medical care despite worsening symptoms
  • HHS-induced severe dehydration and electrolyte disturbance
  • acute kidney injury
  • pre-existing ischaemic heart disease
  • renal calculi and possible renal infection
Full text

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 Wayne Douglas Tedmanson Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Wayne Douglas Tedmanson (Mr Tedmanson); b) Mr Tedmanson died in the circumstances set out below; c) Mr Tedmanson’s cause of death was ischaemic heart disease following hyperglycaemic hyperosmolar syndrome (HHS) which is a complication of diabetes mellitus; and d) MrTedmanson died on 6 November 2020 at Hobart, Tasmania.

Introduction In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Tedmanson’s death which includes:  the Police Report of Death for the Coroner;  affidavits of identity and life extinct;  Tasmanian Health Service (THS) medical certificate of cause of death;  affidavit of Dr Christopher Lawrence, forensic pathologist;  affidavit of the forensic scientist, Mr Neil McLachlan Troup, from Forensic Science Service Tasmania;

 affidavit of Mrs Jennifer Tedmanson-Welsh (Mrs Tedmanson);  affidavit of Ms Julie Tedmanson; and  emails and forensic evidence.

The THS medical certificate referred to above certifies Mr Tedmanson died of natural causes namely HHS on a background of type II diabetes mellitus. Mr Tedmanson also had ischaemic heart disease, an acute kidney injury and heart failure. Mr Tedmanson’s death was however investigated because his daughter, Ms Tedmanson, alleged her father had died as a result of him being smothered with a pillow by his wife.

Background Mr Tedmanson was born on 24 February 1944. He grew up in Adelaide and he met Mrs Tedmanson when she was 16 in about 1970. She was working in a factory near to Mr Tedmanson’s workplace. They formed a relationship, subsequently lived together and married in South Australia on 1 March 1975. Mr and Mrs Tedmanson had no children. Mr and Mrs Tedmanson were subsequently advised, for financial reasons, to divorce which they did in September 1981. Despite being legally divorced they lived as husband and wife until Mr Tedmanson’s death.

Mr Tedmanson had been previously married and had 3 biological children from that marriage. The only child he had any lasting relationship with was Ms Tedmanson.

Mr and Mrs Tedmanson sold their property in Murray Bridge and moved to Tasmania in 1990 after holidaying in this State for a period of approximately 6 weeks. They bought and sold properties and initially lived on Bruny Island where Mr Tedmanson obtained work. They moved from Bruny Island to Hobart where they both worked long hours in the security industry. They both retired in 2015 and moved to Pontville.

Mr Tedmanson suffered from shortness of breath from 2013 – 2014 and received some treatment at that time but his condition worsened and in or about 2016 he had treatment for a blockage in one of the arteries of his heart. He also suffered from a bloating stomach.

He was diagnosed with type 2 diabetes a short time prior to his death. Because of his poor health Mrs Tedmanson became her husband’s full-time carer from in or about mid 2019. He was prescribed medication for his ailments. Mrs Tedmanson says at the beginning of 2020 her husband started urinating a black coloured urine. This condition subsequently resolved.

He also suffered from kidney stones. He sought treatment from a urologist.

Circumstances Leading to Mr Tedmanson’s Death On Saturday 31 October 2020 Mr Tedmanson was off colour and unwell. He was a little worse the next day and he would not accept his wife’s advice to go to hospital. On the Monday he complained of a bad stomach ache and she describes him as being on the floor in agony. He refused to go to hospital and she gave him some medication which reduced the pain. He then started drinking any fluids he could find which included milk, water, Coke, coffee and the like. Mrs Tedmanson describes her husband’s thirst as uncontrollable and he was “always going to the toilet.” On the Tuesday he was confused and started calling his wife by his sister’s name or by identifying her as his mother. The next day he was disorientated and was unable to speak. An ambulance was called and when paramedics arrived they determined Mr Tedmanson’s sugar count was “through the roof” and that he required immediate hospitalisation. He was therefore taken to hospital but Mrs Tedmanson was not allowed to follow due to Covid 19 restrictions. Very early on the Thursday morning Mrs Tedmanson was contacted and she went into the hospital at which time she was advised of her husband’s condition. Because of his very poor prognosis he was provided with palliative care.

Mrs Tedmanson then advised Mr Tedmanson’s sister and Ms Tedmanson of her husband’s very poor health and his impending death. It seems it is common ground between Mrs Tedmanson and Ms Tedmanson that the latter had not spoken to her father for about 12 months before his admission to hospital apart from a conversation a few days before. After being contacted by Mrs Tedmanson Ms Tedmanson came to the hospital to see her father and a bed was made up for both of them so that they could remain with him overnight. Ms Tedmanson went to sleep while Mrs Tedmanson comforted her husband until he passed away.

Investigation My office received the medical certificate of cause death from THS which is dated 6 November 2020. On 10 November 2020 my associate Senior Constable Alisha Barnes received a telephone call from Ms Tedmanson in which she said she believed her stepmother had smothered her father with a pillow. When asked why she believed this Ms Tedmanson advised Senior Constable Barnes her father went downhill quickly and her stepmother made a comment in front of her in the absence of any other witnesses that you could put a pillow over him and finish him now. Given this allegation a statement was taken from Ms Tedmanson in which the following is said:

“At some stage during the conversation Jennifer said to me that it would be better to put a pillow over dad’s face. At no stage did I see Jennifer put a pillow over dad’s face. There was no one else in the room at the time when Jennifer said this. I told Jennifer that she could not do that as dad would know what was going on…. I think I slept for ninety minutes to two hours before Jennifer woke me and said that dad had passed away. Jennifer told me that she had been trying to wake me. I don’t know if Jennifer has done something to dad after her comment or if dad has passed away from natural causes or if something has happened to him… I think Jennifer might have done something because she had to get the house ready for Robin and Paul who are her brother and sister… I don’t know exactly what happened to dad if it was natural causes or if Jennifer has done something to him, if Jennifer has done something to dad, I don’t know why she didn’t just wait for the drugs to take dad.” I note there is common ground between Mrs Tedmanson and Ms Tedmanson that there was a dispute over his assets and the nature of his funeral service. Ms Tedmanson concedes in her affidavit that she does not “get along all that well with Jennifer”.

Mrs Tedmanson denies the allegations made against her by her husband’s daughter. When she was advised of the allegation by Senior Constable Barnes and that there would need to be a full autopsy and an investigation Mrs Tedmanson told Senior Constable Barnes “to do anything that needed to be done.” She has also advised that when she got home, after her husband had passed away, Ms Tedmanson came to her home with a man who demanded to see her husband’s will which she refused. She was intimidated and frightened by this event.

In his affidavit the forensic pathologist, Dr Christopher Lawrence, notes the history as set out above and Ms Tedmanson’s allegation that her father may have been smothered. After conducting an external examination, an internal examination and after considering the histology and toxicological results Dr Lawrence concluded Mr Tedmanson died of natural causes namely ischaemic heart disease following HHS which was due to diabetes mellitus.

HHS is a complication of diabetes mellitus where the patient’s blood sugar level is very high for a long period of time. This can lead to severe dehydration and confusion. It can lead to death if not treated promptly. The dehydration occurs as a result of the patient urinating to excess in order to rid the body of excess blood sugar. Mr Tedmanson also had renal stones in both kidneys, a possible infection and renal failure. In so far Ms Tedmanson’s allegation is concerned Dr Lawrence found no supporting evidence whatsoever. In particular he found no evidence of petechiae or airway compression.

I therefore conclude there is no substance in Ms Tedmanson’s allegation. The reasons for this conclusion are:

 Dr Lawrence has determined, as a result of conducting a full post mortem, that Mr Tedmanson died of natural causes and he has specifically ruled out that Mr Tedmanson died from being smothered;  the THS medical certificate says the cause of death is natural causes;  Ms Tedmanson, when she contacted Senior Constable Barnes, alleged her father had been smothered. She was not so adamant when she swore her affidavit in that she says she does not know whether he died of natural causes or was smothered and  it appears from the evidence Ms Tedmanson has a clear motive to make the allegation she made.

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

It is regrettable scarce resources had to be diverted in this case in order to discount what can only be described as a scurrilous allegation.

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

Dated: 9 August 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner

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