Finding into death of Heather Jane Kinder

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2011 000270

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of: HEATHER JANE KINDER

Delivered On: 21 June 2013

Delivered At: Coroners Court of Victoria Level 11, 222 Exhibition Street

Melbourne Victoria

Hearing Date: 4 June 2013 Findings of: CORONER K. M. W. PARKINSON Representation: Mr W O’Shea, General Counsel, Alfred Health

Police Coronial Support Unit Leading Senior Constable King Taylor Assisting the Coroner

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I, K. M. W. PARKINSON, Coroner having investigated the death of HEATHER JANE KINDER AND having held an inquest in relation to this death on 4 June 2013

AT MELBOURNE

find that the identity of the deceased was HEATHER JANE KINDER

born on 16 April 1951

and that the death occurred on 21 January 2011

at Novotel Hotei, Alfred Place, St Kilda

from:

1 (a) Toxicity to quetiapine

in the following circumstances:

I.

An inquest was held into the death of Ms Heather Kinder on 4 June 2013. After hearing a summary read, the following witnesses gave evidence at the inquest: Ms Kinder’s treating psychiatrist, Dr Jianyi Zhang, and Mr R Dube, Registered Psychiatric Nurse and Manager Ground Floor Psychiatry, both employed by Alfred Health.

BACKGROUND AND CIRCUMSTANCES

Ms Heather Kinder was a 59 year old woman who lived with her husband David. She is survived by her husband and adult daughter. Ms Kinder had a past history of mental illness, having been diagnosed with a dependent personality disorder, anxiety and depression. Her first admission to a psychiatric hospital was in 1982, since then she had had numerous

admissions, mostly to private hospitals.

Ms Kinder had engaged in therapy and had been prescribed a variety of antidepressants and other medications, none of which had achieved lasting relief from the significant symptoms that she suffered, primarily a preoccupation with somatic symptoms involving loud noises in her head and ears, pain, headaches and nausea. Her condition worsened after the death of her

brother in 2006.

Ms Kinder was described as having a debilitating psychiatric illness and chronic suicidal ideation, and had previously tried to overdose on medication. The most effective treatment

regime to date appeared to have been Electro-Convulsive Therapy (ECT). Ms Kinder’s

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treatment had been managed by Associate Professor Peter Doherty from the Melbourne Clinic from 2008.

In the lead up to her admission to the Alfred Hospital, Ms Kinder was admitted to the Melbourne Clinic on 9 December 2010, where she refused to continue with ECT after six

treatments and was discharged on 8 January 2011.

On 10 January 2011, Ms Kinder’s husband contacted the Crisis Assessment and Treatment Team at the Alfred Hospital as Ms Kinder was preoccupied with somatic complaints and voicing suicidal intention. She was admitted to the Alfred Hospital Psychiatric Ward as a voluntary patient. On 11 January 2011 her status as a voluntary patient was changed to involuntary as a result of an assessment that she was unable to provide instructions regarding

her treatment and due to suicidal ideation.

On 11 January 2011, she was reviewed by consultant psychiatrist, Dr Zhang, whose evidence detailed the reviews and treatment she received during the course of the admission. A decision was made to provide ECT treatment and Dr Zhang sought a review and second opinion of this treatment option from Dr Mark Jeanes. As a result of the review on 14 January 2011 it was decided to withhold the ECT treatment as her condition appeared to be improving. A review on 17 January 2011 however noted a further deterioration in her condition, evidence of

paranoia, agitation and distress, and Ms Kinder requested ECT.

At a further review on 18 January 2011, Ms Kinder reported feeling suicidal, however had no plans or intention. Ms Kinder had her first ECT treatment on 19 January 2011. Registrar Dr L Forrester reviewed her on 20 January 2011 when she complained of worsening physical symptoms which she attributed to the ECT treatment the day before. She had made similar

complaints after previous ECT treatments.

According to Dr Zhang, Ms Kinder had never expressed any intention to leave the hospital and there was no evidence to suggest that she would abscond from the ward, which was open (untocked) at all times. Ms Kinder spent most of her time in her bedroom or in the common atea on the first floor, watching TV and was not observed for any lengthy period near the

external door.

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Ms Kinder was subject to 15 minute observations and was sighted in the common area at 14.30 pm on 20 January 2011. She was found to be missing at the next 15 minute observation, It appears that Ms Kinder left the unit through the general entrance door to the unit. Mr Kinder was contacted and he reported that Ms Kinder had returned home, and that he would bring her back to the hospital shortly. Some minutes later, he advised that Ms Kinder had left the home and could not be located. The hospital notified the police accordingly.

Initially, a family and police search failed to locate Ms Kinder. A subsequent police search

with the assistance of mobile telephone triangulation located her at the Novotel Hotel St

Kilda, where she had checked in under a different name.

Ms Kinder was located by police at approximately midday on 21 January 2011 in the ensuite of her hotel room. Ms Kinder was deceased and she appeared to have been dead for some time. There was no sign of forced entry or evidence to suggest anyone else had been involved in her death. A number of packets of the prescription medications Seroquel and Imovane,

including empty packets, were found in her handbag and the bathroom.

FORENSIC PATHOLOGIST EXAMINATION AND EVIDENCE

An examination was undertaken by Dr M Burke, a Forensic Pathologist with Victorian Institute of Forensic Medicine, who provided a report to the Coroner. Dr Burke noted that the examination was largely unremarkable and that a smali cut to her face did not appear to be

suspicious.

A Toxicology report noted the presence of a number of drugs in her system, all prescription medications. These included Quetiapine (Seroquel), Zopiclone (Imovane), Mirtazapine, Olanzapine (ali antidepressant or antipsychotic medications), and Propofol (an anaesthetic, probably used during ECT). Quetiapine and Zopiclone were detected in high and potentially

fatal concentrations. The remaining medications were within therapeutic range.

A post mortem CT scan showed radio-opaque material within the stomach, and the toxicology analysis showed a raised level of Quetiapine. Dr Burke reported that a reasonable cause of

death was: 1(a) Toxicity to Quetiapine.

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EVIDENCE AS TO INPATIENT MANAGEMENT

I was assisted by the evidence of witnesses as to the management of voluntary and involuntary patients within the low dependency unit (LDU) as to unlocked or locked door access to the ward, the process of risk assessment of patients with suicide and self harm concerns, policies concerning routine nursing observation of patients, and changes to policies and procedures as

a result of the death of Ms Kinder.

Dr Zhang explained the inherent difficulties for consultants and clinical staff in balancing the security and safety needs of individual patients with high risks against the rights of the remaining patients, as required by the Mental Health Act 1986 under the rubric of the least

restrictive environment.

His evidence was that since the death of Ms Kinder in January 2011, the policy position had changed and that the ward entrance doors were locked for the majority of shifts, requiring individual voluntary patients to request the right to leave the ward as and when needed. At the

time of Ms Kinder’s death this was not the case.

Mr Dube provided an overview of the general management of patients in the LDU and the risk assessment processes by which vulnerable and suicidal patients might be considered for treatment in the high dependency unit (HDU). His evidence was that such decisions are, in themselves, difficult because of the nature of the patient group in the HDU whose level and

nature of symptoms make the environment far less secure for patients such as Ms Kinder.

Mr O'Shea, on behalf of Alfred Health, tendered a number of policy and procedure documents that have been updated since the death of Ms Kinder. He highlighted that the standard periods of observation of patients has changed, and is now more flexible and based on the individual

risk assessment and needs of each patient.

FACTORS CAUSING AND CONTRIBUTING TO DEATH

I am satisfied having regard to Ms Kinder’s prior psychiatric history, including a long-

standing history of suicidal ideation, the circumstances in which she left the in patient facility,

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and the obtaining of a significant quantity of prescription medication, that Ms Kinder

intentionally took her own life.

I am satisfied that there was no clinical indication that Ms Kinder was likely to have absconded and that her leaving the premises on 11 January 2011 was likely unplanned and opportunistic absconding which was not reasonably to have been anticipated in the clinical

circumstances and having regard to Ms Kinder’s history.

23. Having heard the evidence of Dr Zhang and Mr Dube and the statement of Dr Stafirace as to the course of treatment and management, I am satisfied that the treatment Ms Kinder received as a patient in the psychiatry ward at the Alfred Hospital was reasonable and appropriate.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the death:

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The circumstances of the tragic death of Ms Kinder reinforces the difficult balance that is required to be struck by staff in psychiatric inpatient units in applying policies concerning clinical risk assessment, nursing observation of high-risk patients and ward management in

relation to unlocked or locked access to low dependency unit wards. The evidence of the

• Alfred staff was compelling in this regard, and I note that following the death of Ms Kinder a

number of policy and practice changes have been implemented by Alfred Psychiatry.

The evidence is that the aim of these changes has been to balance the obligation to ensure the safety of individual patients with high absconding and suicidal risks against the impact that increased security measures may have on patients without such a high level of need. It was apparent that the staff were conscious of the requirements of the Mental Health Act 1986 and the imperative in s4(2)(a) of that Act that care and treatment appropriate to a persons be provided in the least possible restrictive environment and least possible intrusive manner and that restriction upon liberty of patients with a mental disorder be kept to the minimum

necessary in the circumstances.

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However, as Ms Kinder’s case highlights, staff of psychiatric services make difficult clinical and management decisions in the context of the need to protect unwell psychiatric patients from the potential risk of accidental or deliberate self-harm or suicide, especially when they

have a documented history or propensity.

It is relevant to note that the opportunity to leave the in-patient psychiatric facility despite being an involuntary patient arose as the LDU was an unlocked ward with no security code or

other mechanism required.

A review of policies and procedures, including access arrangements into and out of the LDU, followed the death of Ms Kinder and the current policies and procedures are such that the circumstances which led to Ms Kinder absconding from the ward are less likely to occur in the

future.

In view of the alterations to the LDU access arrangements into and out of the LDU and exiting arrangements designed to protect patients against absconding ftom treatment, there are no

recommendations which might usefully be made in this case.

I direct that a copy of this finding be provided to the following: The family of Ms Kinder;

The interested parties;

Dr S Stafrace, Director of Alfred Psychiatry

The Investigating Member

Signature:

ib —__

CORONER K. M. W. PARKINSON Date: 21 June 2013

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