Inquest into the Death of Marjorie Mary DONE

Coroners Act 1996 [Section 26(1)] Western Australia

RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref: 17/14 I, Barry Paul King, Coroner, having investigated the death of Marjorie Mary Done with an inquest held at the Perth Coroner’s Court, Court 51, CLC Building, 501 Hay Street, Perth, on 13 May 2014, find that the identity of the deceased person was Marjorie Mary Done and that death occurred on 3 December 2010 at Mercy Hospital from an unascertained cause in the following circumstances: Counsel Appearing: Sergeant Lyle Housiaux assisting the Coroner Mr M Williams (DLA Piper) appearing on behalf of Mercy Hospital Mr J Winton (State Solicitor’s Office) appearing on behalf of the Health Department of Western Australia TTaabbllee ooff CCoonntteennttss Quality of the supervision, treatment and care of the Inquest into the death of Marjorie Mary DONE

INTRODUCTION

1. Marjorie Mary Done (the deceased) died in the evening of 3 December 2010 while she was a patient at the Ursula Frayne Unit (UFU) of the Mercy Hospital in Mount Lawley.

2. As the deceased was an involuntary patient under the Mental Health Act 1996 at the time of his death, she was a ‘person held in care’ under section 3 of the Coroners Act 1996.

3. Section 22 (1)(a) of the Coroners Act 1996 provides that a coroner who has jurisdiction to investigate a death must hold an inquest if the death appears to be a Western Australian death and the deceased was immediately before death a person held in care.

4. An inquest to inquire into the death of the deceased was therefore mandatory. An inquest was held on 13 May 2014 at which the investigating police officer, Senior Constable R M Russell of the Coronial Investigation Unit, and the deceased’s psychiatrist, Dr Amatul Uzma, gave oral evidence. Documentary evidence comprised a report by Senior Constable Russell together with copies of relevant documents he had obtained.1

5. Under s25(3) of the Coroners Act 1996, where a death investigated by a coroner is of a person held in care, the coroner must comment on the quality of the supervision, treatment and care of the person while in that care.

I have found that the relevant supervision, treatment and care provided to the deceased was reasonable and appropriate.

TTHHEE DDEECCEEAASSEEDD

6. The deceased was born Marjorie Mary Chapman on 9 October 1926 in Vancouver, British Columbia, Canada.2 She immigrated to Australia with her family 1 Exhibit 1 2 Exhibit 1, Tab 17 Inquest into the death of Marjorie Mary DONE

when she was seven years old and grew up in suburban Sydney.3

7. In 1944 when the deceased was 18 years old she enlisted in the Australian Military Forces after working as a clerk in a department store in Sydney. In June 1947 she was discharged due to demobilisation and found work as a bookkeeper in another department store.4

8. In 1948 the deceased studied art and then married another student and artist, Allan George Waite, in November 1948 in Melbourne.5 The deceased and her husband had one child, Cynthia.6

9. The deceased and her husband separated when Cynthia was about six years old. The deceased raised her daughter on her own in Mona Vale to the north of Sydney.7

10. The deceased’s divorce with her husband was finalised in November 1965.8

11. As a young adult the deceased suffered from mental health problems, resulting in psychiatric treatment which included electroconvulsive therapy.9

12. In 1972 the deceased married James Done, a widower with three children who was a senior lecturer in biochemistry at Sydney University. At the time, the deceased was taking anti-psychotic medication and shortly after the marriage the deceased was admitted to hospital for psychiatric care.10

13. From 1972 to 1974 the deceased and her husband James Done lived in Beecroft New South Wales. In 1974 they 3 Exhibit 1, Tab 15 4 Exhibit 1, Tab 17 5 Exhibit 1, Tab 17 6 Exhibit 1, Tab 15 7 Exhibit 1, Tab 15 8 Exhibit 1, Tab 15 9 Exhibit 1, Tab 15 10 Exhibit 1, Tab 15 Inquest into the death of Marjorie Mary DONE

moved to Croydon Park in New South Wales to be closer to the university at which James Done taught.11

14. Over the next decade the deceased had several psychotic episodes requiring hospital care. During periods when she was not psychotic, the deceased had some insight into her mental health problems.12

15. In 1986 James Done retired from the University of Sydney and they moved to Western Australia where they lived in Mount Lawley and then Menora. They stayed in Menora, with James Done acting as the deceased’s carer for much of the time, until 2001 or 2002 when James Done died from prostate cancer.13

16. During that time, the deceased’s psychiatric problems increased as she got older. She received psychiatric treatment from Dr John Booth for 10 years and then began admissions to Swan Lodge where she was treated by Dr Jonathan Spear from December 1997. She started seeing Dr Boon Loke in 1998 after she had been referred to him by Dr Spear. She saw Dr Loke until May 2007.14

17. In 2002, the deceased moved into Riverslea Lodge, an aged care facility in Mount Lawley where, as I understand the evidence, she remained until August 2010 apart from brief admissions to Mercy Hospital and Royal Perth Hospital.15 By October 2005 at the latest, the deceased began to suffer from recurrent falls16

18. In August 2010 the deceased was admitted to Royal Perth Hospital after a fall in which she fractured her hip. She underwent a hemi-arthroplasty and was transferred to the rehabilitation site at Shenton Park.17 While there she was reviewed by a psycho-geriatrician, Dr Stephen Fenner, who referred her to the UFU for further 11 Exhibit 1, Tab 15 12 Exhibit 1, Tab 15 13 Exhibit 1, Tab 9 and Tab 15 14 Exhibit 1, Tab 9 15 Exhibit 1, Tab 8 16 Exhibit 1, Tab 9 17 Exhibit 1, Tab 7 Inquest into the death of Marjorie Mary DONE

assessment and management of her psychiatric symptoms.18

19. The deceased was admitted into the UFU on 6 September 2010 and was given involuntary status under the Mental Health Act 1996 on 16 October 2010. She was under the care of consultant psychiatrist Dr Amatul Uzma.19

20. Dr Uzma noted that the deceased had a history of over 50 years of serious mental illness with numerous psychiatric admissions and self-harm attempts, but that she had had no psychiatric admissions for 10 years and no self-harm attempts for 12 years.20

21. At the UFU the deceased was treated with anti-psychotic and anti-depressant medication, but her medication intake was intermittent because she would sometimes refuse food and medication. Her general health was frail.21

TTHHEE DDAAYY TTHHEE DDEECCEEAASSEEDD DDIIEEDD

22. On 3 December 2010 between 4.50pm and 5.30pm the deceased was supervised by nursing staff while she had her evening meal sitting down at a dinner table with other residents of the UFU. As was not unusual, the deceased ate very little, only a couple mouthfuls of soup and some water.22

23. After the meal, the deceased regurgitated a small amount of food and medication into her glass. She then got up to go to the toilet, but staff re-directed her to the TV lounge because they wanted to stop her from throwing up her meal in the toilet as was customary for her.23 18 Exhibit 1, Tab 8 19 Exhibit 1, Tab 8 20 Exhibit 1, Tab 8 21 Exhibit 1, Tab 8 22 Exhibit 1, Tab 6 23 Exhibit 1, Tab 6 Inquest into the death of Marjorie Mary DONE

24. At about 6.15pm the deceased was sitting in a chair in the TV room staring into space as she often did. Between 6.15pm and 6.25pm she was chatting to another resident, Frank, about cricket. At about 6.30pm, unit staff began providing residents with cups of tea.24

25. At about 6.40pm, clinical nurse Mark Manton noticed that the deceased was pale and very yellow and was staring into the distance. He checked her and found no signs of life.25

CCAAUUSSEE AANNDD MMAANNNNEERR OOFF DDEEAATTHH

26. Forensic pathologist Dr J White conducted an external examination of the deceased on 7 December 2010 and found no physical explanation for the death. A toxicology analysis showed a number of prescription-type medications, many of which had a sedating side-effect.26

27. Dr White formed the opinion that the cause of death was unascertainable from an external examination. Dr White suggested that, given the deceased’s age and medical history, the possible causes of death may have included cardiac arrhythmia, myocardial infarction, stroke or pulmonary thromboembolism.27

28. In these circumstances, I find that the cause of death was unascertained.

29. However, I am satisfied that the death occurred by way of natural causes.

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30. The evidence available to me indicates that the supervision, treatment and care of the deceased was of a 24 Exhibit 1, Tab 6 25 Exhibit 1, Tab 6 26 Exhibit 1, Tab 11 27 Exhibit 1, Tab 11 Inquest into the death of Marjorie Mary DONE

reasonable quality. The deceased’s daughter Cynthia apparently considered that the staff and amenities at the UFU were wonderful.28

CCOONNCCLLUUSSIIOONN

31. The deceased died peacefully after a lifetime that included a considerable amount of institutional care, much of which for her psychiatric illness.

32. The evidence before me, though somewhat superficial, indicates that there were no issues requiring comment or recommendation. I am confident that, had the deceased not been an involuntary patient under the Mental Health Act 1996 at the time of her death, an inquest would not have been held into her death.

Barry King Coroner 26 May 2014 28 Exhibit 1, Tab 15 Inquest into the death of Marjorie Mary DONE