Finding into death of Margaret Jane Gardiner

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2014 4303

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2)

Section 67 of the Coroners Act 2008

I, AUDREY JAMIESON, Coroner having investigated the death of MARGARET JANE

GARDINER

without holding an inquest: find that the identity of the deceased was MARGARET JANE GARDINER born 14 February 1944 and the death occurred on 24 August 2014 at Marjorie Phillips Aged Psychiatry Unit, Bendigo Health, Barnard Street, Bendigo Victoria 3550 from: 1(a) BRONCHOPNEUMONIA

Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1, Margaret Jane Gardiner was 70 years of age at the time of her death. She ordinarily resided in Rochester. Ms Gardiner had two children, from whom she was estranged. She had a medical history including depression, anxiety, cholecystectomy, arthritis and chronic insomnia. Ms Gardiner also had a history of alcoholism, but had ceased drinking approximately two years prior to her death. She was a heavy smoker and her physical and mental health had steeply

declined in the last months of her life.

2. On 18 June 2014, Ms Gardiner was admitted to Bendigo Health’s Marjorie Phillips Aged Psychiatric Unit (“Marjorie Phillips Unit’), following treatment in a medical/rehabilitation part

of the hospital since 30 May 2014. She was assessed as having ongoing severe anxiety and an

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eating disorder. Ms Gardiner’s behaviour was characterised by poor cooperation, medication refusal, as well as verbal and physical aggression towards staff. She was placed on an Assessment Order and then a Temporary Treatment Order to facilitate her care. Ms Gardiner’s diagnosis was revised on 11 July 2014 to possible psychotic depression with somatic features,

along with an eating disorder and ‘Cluster B’ personality traits.

3, A Mental Health Tribunal hearing was held on 5 August 2014, and an Inpatient Treatment Order was made for a duration of 26 weeks. On 10 August 2014, Ms Gardiner was pushed by another patient and sustained a bruise to her right hip. On 12 August 2014 a chest x-ray confirmed that Ms Gardiner had pneumonia and antibiotics were commenced. She was referred to the medical unit for consideration of intravenous antibiotics. Various management

interventions were contemplated.

4. On 22 August 2014, Ms Gardiner remained behaviourally disturbed and agitated towards medical staff. In view of Ms Gardiner’s fragile physical state and very poor prognosis, a multidisciplinary case conference occurred on 22 August 2014, palliation was discussed with Ms

Gardiner’s family and she was referred to palliative care.

5. At 12.30am on 24 August 2014, Ms Gardiner woke and became behaviourally disturbed. She was moved to a ‘quiet room’ and nursed in a Henderson chair, with a table that locks into the arms of the chair, to restrict her movements. An Enrolled Nurse checked on Ms Gardiner at 4.00am and observed that she was breathing. At approximately 4.15am on 24 August 2014, while Ms Gardiner was still awaiting review by the palliative care team and remained under the Inpatient Treatment Order, she was found deceased. Ms Gardiner was taken to her room, an electrocardiogram was performed and a doctor was notified. No attempt at resuscitation was

made due to her deteriorating physical state and referral for palliation.

INVESTIGATIONS Forensic pathology investigation

6. Dr Michael Burke, Senior Forensic Pathologist at the Victorian Institute of Forensic Medicine performed a full post mortem examination upon the body of Ms Gardiner and referred to the Victoria Police Report of Death, Form 83. At autopsy, Dr Burke did not identify evidence of any injury that would have contributed to or led to Ms Gardiner’s death. However, he found

bronchopneumonia, focal coronary artery atherosclerosis and mild myocardial fibrosis.

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Toxicological analysis of post mortem blood detected sertraline,! olanzapine? and diazepam.> Dr Burke opined that there was no evidence to suggest Ms Gardiner’s death was due to anything

other than natural causes, and he ascribed the cause of her death to bronchopneumonia.

Police investigation

The circumstances of Ms Gardiner’s death have been the subject of investigation by Victoria Police on my behalf. Police obtained statements from Ms Gardiner’s sister-in-law Faye Kellett, General Practitioner at Rochester Medical Clinic Dr Nigel Fang, Bendigo Health Consultant Psychiatrist Dr John Cooper, and Marjorie Phillips Unit staff: Enrolled Nurse Rikki Petri and

Registered Nurse Ian Thurrowgood.

General Practitioner Dr Fang stated that Ms Gardiner was treated at the practice from 2002 to

2014. In 2002, Ms Gardiner was referred to Echuca Mental Health and she had since been taking various anti-anxiety and anti-depressant medications, including sertraline, alprazolam

and citalopram. Dr Fang noted that Ms Gardiner had a number of falls over 2012 and 2013.

In the course of their investigation, police learned that Ms Gardiner’s mental state had deteriorated significantly in recent months. Ms Gardiner’s sister-in-law Mrs Kellett stated that an ambulance was called to her house on several occasions because she was having a panic attack, and the majority of times she did not require hospitalisation. In addition, her personal

hygiene had begun to deteriorate.

. Dr Fang stated that in April 2014, Ms Gardiner presented as tearful, with panic attacks at night

and insomnia, but refused to see a psychiatrist and was ambivalent about seeing a psychologist.

Following extensive discussions with regional mental health services, Ms Gardiner was admitted to the Marjorie Phillips Unit on 1 May 2014. Consultant Psychiatrist Dr Cooper stated that Ms Gardiner was diagnosed with generalised anxiety disorder and presenting problems included worsening anxiety, various physical complaints, poor appetite and weight loss. On 23 May 2014, the general medical unit provided an assessment to assist with discharge planning.

They identified problems including low weight, pressure wounds, low blood pressure and

Sertraline is an anti-depressant drug for use in cases of major depression.

? Olanzapine is indicated for the treatment of schizophrenia and related psychoses. It can also be used for mood stabilisation and as an anti-manic drug.

• The metabolite of diazepam, nordiazepam, was also detected. Diazepam is a sedative/hypnotic drug of the benzodiazepines class.

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anaemia. On 30 May 2014, Ms Gardiner was transferred to a medical/rehabilitation part of

Bendigo Health due to her severe weight loss.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected with

the death:

1. Ms Gardiner’s death was reportable pursuant to section 4 of the Coroners Act 2008 (Vic) (‘the Act’) because she was immediately before death a person placed in care, as defined by section 3 of the Act. Section 52 of the Act mandates the holding of an Inquest, save for circumstances where the person is deemed to have died from natural causes, pursuant to section 52(3A). In Ms Gardiner’s circumstances, it is therefore appropriate to conclude the investigation by an in-

chambers Finding.

FINDINGS Ms Gardiner had a significant history of both physical and mental health issues. On the evidence available to me, I find that the provision of care to Ms Gardiner while she was an involuntary

inpatient at Bendigo Health’s Marjorie Phillips Aged Psychiatry Unit appears to have been

appropriately holistic given the complexity of her presentation.

I accept and adopt the medical cause of death as identified by Dr Michael Burke and find that

Margaret Jane Gardiner died from natural causes in the form of bronchopneumonia.

Pursuant to section 73(1B) of the Coroners Act 2008, I order that this Finding be published on the internet.

I direct that a copy of this finding be provided to the following:

Ms Fay Kellet

Dr Nigel Fang, Rochester Medical Clinic

Associate Professor Philip Tune, Psychiatric Services, Bendigo Health

Ms Megan Kairns, Bendigo Health

Ms Kym Peake, Secretary of the Department of Health and Human Services

Office of the Chief Psychiatrist

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Signature:

(

AUDREY JAMIESON-~— CORONER

Date: 7 June 2016

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