LOCAL COURT of NEW SOUTH WALES Coronial Jurisdiction Inquest: Inquest into the death of Heather May SMITH File number: 2009 / 26 Date of birth: 12 November 1930 Date of death: 19 July 2009 Place of death: Caloola Centre for Aged Care, Plumpton Road, Wagga Wagga 2650 Hearing dates: 3 to 5 December 2013 Date of findings: 5 December 2013 Place of findings: Coroner s Court, Wagga Wagga Representation: Mr C McGorey, Counsel Assisting Mr T Hickey, representing Dianne Wood, Susan Young, Sandra Smith and Lynette Layton Mr T Quinlivan, representing Dr Ferdinand Saldevar Mr A Vincent, representing Baptist Community Services Decision maker: Findings: Coroner Megan Greenwood I find that Heather Smith died on 19 July 2009 at Caloola Centre for Aged Care, Plumpton Road, Wagga Wagga 2650. The cause of her death was: Bronchopneumonia head trauma (subdural haemotoma,
subarachnoid haemorrhages and cerebral contusions) from the fall on 16 July 2009 and chest trauma from the fall on 16 July 2009 Antecedent causes of Mrs Smith s death were: a prior stroke in 2002 her frail state following a 2006 fall and Dementia. The manner of Mrs Smith s death was as a result of a fall at the nursing home on 16 July 2009. Recommendations: To Baptist Community Services: That BCS review clinical record keeping and training at Caloola to make sure records can be easily maintained and updated by staff and doctors with a view to ensuring legibility, transparency and accountability. 2
REASONS FOR FINDINGS Heather Smith 1. Heather May Smith, a 78 year old woman, was married to Harold Smith. They had four children, Dianne Wood, Susan Young, Sandra Smith and Lynette Layton. Mr Smith provided a medical certificate stating he was too unwell to attend the inquest. 2. Mrs Smith s four daughters told the court that Mrs Smith was a generous and loving wife, mother and grandmother who loved music, dancing, her dog and home. Most of all she loved her husband and family, with her happiest times being when she was with them. Mrs Smith was deeply loved and is sorely missed by her husband and daughters. Background 3. Mrs Smith lived at the Caloola Centre for Aged Care in Plumpton Road Wagga Wagga (Caloola). Baptist Community Services (BCS) is the parent service provider for Caloola residents. Mrs Smith had been resident at Caloola for 18 months, having suffered a debilitating stroke in 2002. She was immobile, with a history of dementia, osteoporosis, depression and hypertension and a previously broken hip. Dr Ferdinand Saldevar was Mrs Smith s treating doctor. Prior to the fall Mrs Smith s medications included: Cipramil (Citalopram Hydrobromide) used to treat anxiety and depression Kapanol (morphine) Paracetamol and Warfarin, an anti-coagulant. 4. Mrs Smith was described as having a frail and slight build. On the morning of 16 July 2009, a Caloola employee, Grace Wilson, a nursing assistant (AIN), was transferring Mrs Smith from her bed to a chair using a mechanical lifter. During this process Mrs Smith fell to the floor, a distance 3
of 1.2 to 1.5 metres and was injured. An ambulance was immediately called and Mrs Smith was treated at Wagga Wagga Base Hospital for: a laceration to the head a small intra-cerebral contusion and small parafalcine subdural haemorrhage a fractured right elbow and abrasions to her hand and leg. 5. After treatment, Mrs Smith was discharged back to Caloola on the same day. Mrs Smith died on 19 July 2009, three days after the fall. Dr Saldevar certified Mrs Smith s death. Her death became a concern to police when a call was made to Crime Stoppers in the days following, alleging a possible cover up of the circumstances of Mrs Smith s fall. In the following days the coroner assumed jurisdiction and a post mortem was ordered. 6. Dr Peter Smart, forensic pathologist, found no evidence of a recent stroke, but high levels of morphine and citalopram were found in Mrs Smith s body. She also had bronchopneumonia and other serious conditions. Issues 7. The following issues were identified for exploration at inquest: How did Mrs Smith come to fall at the Caloola Centre on 16 July 2009? What was Mrs Smith s prognosis at the Caloola Centre following her return there on 16 July 2009 and was her treatment, including the amount of morphine prescribed, reasonable? What, if any, conclusions can be drawn from the morphine levels noted in the certificate of analysis? What was the cause of Mrs Smith s death? What were the circumstances concerning the issue of the death certificate by Dr Saldevar? 4
How did Mrs Smith come to fall? 8. Caloola s Executive Care Manager, Marjorie Hale, conducted a critical incident investigation concerning the injuries experienced by Mrs Smith. BCS itself, the Department of Health and Ageing and the Workcover Authority also inquired into the fall. 9. Investigations determined that Ms Wilson used the wrong sling for Ms Smith (a general sling, instead of the full body sling required by her care plan) and operated the mechanical lifter in an incorrect manner. She also operated it on her own, not waiting for another carer to assist, as is required by Caloola s work processes. Training records indicated that Ms Wilson had not completed the workbook component of training in manual handling techniques. 10. Samantha Said said that she was helping another patient in the same room when Ms Wilson was helping Mrs Smith. Curtains were drawn around the beds at least to a large extent, and Ms Said said she couldn t see what was happening at Mrs Smith s bed. 11. Ms Said said that Ms Wilson asked her for help with lifting Mrs Smith. Ms Said said she would be a moment. Ms Said said Ms Wilson said it was okay if the second person just watched the lifting. Ms Said said, next thing, she heard Mrs Smith fall to the floor. She said she wasn t near Mrs Smith and didn t see the fall. Initially, in panic, Ms Said lied and said she was there, but she admitted she lied that very same day. 12. Ms Wilson maintained to the court that Ms Said was at the air chair at the end of Mrs Smith s bed when Mrs Smith fell, the curtains being partly open. Ms Wilson did not recall telling Ms Said that it was okay for the second person to observe the lifting only, but agreed she believed this at the time, as long as the lifter was not being used. There was evidence this might have been custom and practice at Caloola at the time. 13. There are difficulties with Ms Wilson s evidence in that she agreed Mrs Smith fell from the sling when she was suspended over the floor, the lifter having been used, and yet by Ms Wilson s own evidence Ms Said appears to have been watching from at least a metre away from Mrs Smith. Further, in her statement on 16 July 2009, the day of the fall, Ms Wilson 5
said we heard a terrible thump, Sam pulled the curtain completely open and we both saw heather (sic) face down on the floor... This suggests that Ms Said was not inside the curtained area at that time. I am satisfied that Ms Said was not immediately present when Mrs Smith fell. 14. Ms Wilson said she had completed TAFE training in aged care and had been trained in the use of different slings. She was aware of the care plan inside the cupboard but didn t know how much notice she had taken of it. 15. The Department of Health and Ageing found there had been noncompliance with Caloola s responsibilities towards Mrs Smith. Investigations revealed a range of systemic issues around the practice, procedure, education and training that directly contributed to the environment in which the incident occurred. For example, while she received some initial training, Ms Wilson does not appear to have completed the workbook assessment for manual handling. Further, she had not been required to undergo an annual manual handling competency assessment. 16. Caloola took remedial actions and the department was satisfied with those actions, including: staff counselling and retraining in manual handling incident reporting training a review of the manual handling framework and processes and a commitment by Caloola to comply with the BCS manual handling policy. 17. Paul English, General Manager Residential at BCS provided a comprehensive report on actions taken since Mrs Smith s death. These include: appointment of an experienced clinician to the role of educator at Caloola, who works specifically in the areas of manual handling and other mandatory reporting needs development of four Care Improvement Manager positions at Caloola whose roles are to coordinate, assess and deliver standardised training 6
outcomes in key areas while working to continuously improve the key components of care delivered at Caloola and a review of, and changes to, the manual handling system at Caloola. 18. Mr English said that Mrs Smith s death has led to improvements in resident care across all BCS facilities with a view to ensuring that a similar incident never occurs again. Mrs Smith s subsequent prognosis and treatment at the Caloola Centre 19. Dr Brian Burns treated Mrs Smith at the hospital. In his discharge letter he noted that Ms Wood and Mr Smith had discussed with him Mrs Smith s prognosis. Dr Burns noted that while her injuries were not life threatening, because of her age and condition prior to the injuries, there was always a risk of deterioration. He considered that, should Mrs Smith s condition deteriorate, she was not an appropriate candidate for neurosurgery given her poor quality of life and the relative lack of benefits that would arise for her. Dr Burns discharge summary recorded Mrs Smith had: a fractured right elbow a small right hemispheric bleed in her brain and a large laceration to her forehead and other abrasions. 20. Mrs Smith was taking prescription Kapanol, a morphine-based narcotic, in tablet form prior to the incident. She had been experiencing difficulty in swallowing and was not given the Kapanol on 17 July 2009. On 17 July Dr Saldevar was contacted by facsimile and he prescribed 10mg/ml morphine sulphate to be administered by injection to Mrs Smith every four hours. The progress notes indicated that Mrs Smith did not always receive the 10mg every four hours. There were larger gaps between injections. 21. Over the following days Mrs Smith s condition gradually deteriorated, with her becoming unresponsive, experiencing minor seizures, having a reduced eye blink time and skin mottling in the lower limbs, suggestive of poor circulation and often seen in the hours leading to death. 22. Relevant Caloola medication records concerning Mrs Smith comprise: the schedule 8 register 7
medication chart and Mrs Smith s progress notes. 23. While there were some discrepancies in dates and some illegible clinical records concerning the medication given to Mrs Smith in her final days, a full investigation has shown that 10mg/ml doses of morphine sulphate were used in injections given to Mrs Smith as follows: 17 July 2009 at 2.30pm by Registered Nurse (RN) Donna Lennon 18 July 2009 at 2.30am by an unknown staff member 18 July 2009 at 12.30pm by RN Julie Marwood 18 July 2013 at 6.00pm by RN Sally Davies 19 July 2009 at 12.20am by the same unknown staff member 19 July 2009 at 9.10am by RN Marwood and 19 July 2009 at 2.10pm by RN Marwood. 24. RN Marwood explained in very great detail her procedures for administering morphine by injection when a butterfly needle is used, which was the case for Mrs Smith. She explained that it is difficult to draw the morphine into a small syringe and she always uses a larger one than is necessary. Further, she draws a larger amount of saline into a separate, larger needle and then uses some of it to flush the line after she has injected the morphine into the butterfly needle canula. This might account for one of Mrs Smith s daughters noting that there seemed a rather large amount of liquid in the last morphine injection given to Mrs Smith. 25. Shirley Crivellaro, a care supervisor, told the court that she supervised Ms Marwood giving Mrs Smith morphine at 2.10pm on 19 July 2009. Ms Crivellaro said she never signs the schedule 8 register unless she has checked patient records to ensure the drug is prescribed and has witnessed the drug being removed from the drug cupboard and administered as prescribed. 8
Morphine levels detected after death 26. Dr Peter Smart, a forensic pathologist, performed a post mortem on Mrs Smith s body. Dr Smart found a morphine level of 0.87mg /L, as well as warfarin, paracetamol and Citalopram in her blood. 27. Dr William Allender, who has degrees in applied science majoring in drug metabolism and analysis provided expert evidence. Dr Allender initially found Mrs Smith s blood contained excessive amounts of Citalopram and morphine. 28. Dr Michael Kennedy, consultant physician and clinical pharmacologist also gave expert evidence. He noted that Mrs Smith had been taking morphine for nearly a year prior to her death. This would have meant that she had developed some tolerance to the drug by the time of her fall. He formed the view that morphine was unlikely to be the cause of her death and the concentration of the drug in her system was likely caused by the redistribution of the drug throughout her body and natural chemical processes occurring after death. 29. Dr Kennedy, Dr Allender and Dr Smart considered these matters in a conclave of experts. Drs Kennedy and Smart agreed that, putting aside any morphine issue, when she returned to Caloola from the hospital on 16 July 2009, Mrs Smith was very ill with a very poor outlook of probably only days to live. 30. Dr Kennedy said that the morphine prescribed in Mrs Smith s final days was a reasonably large dosage. However, he noted the tolerance to morphine she would have developed over the previous year or so, how unwell she was and the pain she would probably have been suffering. He concluded the dosage was not inappropriate. Dr Kennedy noted how very effective morphine is for pain relief and that some very ill patients can properly be prescribed 100mg of morphine a day for pain relief and the research suggests that morphine in these circumstances does not particularly hasten death. 31. Doctors Kennedy & Allender agreed there are difficulties in reading anything into the level of morphine found in Mrs Smith s body at post mortem. The reasons for this are: 9
first, morphine is not a drug that can be counted back. That is, a doctor cannot look at post mortem morphine amounts in the blood and work out how much morphine a patient has been administered. Part of the reason for this is that when a person is administered morphine, the body metabolises free morphine into glucuronides. After death, the body can convert the glucuronides back to free morphine. The body s bacteria play an important role in this process second, the fact that blood had been taken from the stomach area during post mortem and not the leg artery. The blood would have been taken from near the gall bladder and liver, both of which store glucuronides, therefore suggesting a misleadingly high concentration of morphine and third, the five days that passed between death and post mortem and the fact that Mrs Smith s body had not been refrigerated for periods of time before the post mortem was performed, first at Caloola following her death and second, leading up to, during and after the funeral. This would have increased bacteria levels and therefore exacerbated the difficulties in understanding the meaning of any morphine levels found in Mrs Smith s blood. 32. Doctors Kennedy and Smart agreed that nothing should be read into the morphine levels found in Mrs Smith s blood that can assist in determining her cause of death. What was the cause of Mrs Smith s death? 33. Doctors Kennedy and Smart agreed that before the fall Mrs Smith was a very thin, frail, elderly woman suffering a number of serious conditions, including a terminal illness (the dementia), and her health was in general decline. Dr Kennedy said Mrs Smith s death at any time might not have surprised her treating doctor but, until the fall, Mrs Smith was able to converse with Caloola staff and her family, although her daughters noted that she had good and bad days. 10
34. The two doctors agreed that Mrs Smith s frailty and medical conditions meant that her outlook was atrocious following the fall and her life expectancy was in the order of days. They also agreed that her cause of death was due to a number of conditions, including: cerebral haemorrhages bronchopnuemonia narrowing of the coronary arteries bruising near the kidneys and muscle wasting. There was no evidence of a recent stroke at post mortem. 35. There was agreement that while she was in general decline until 16 July 2009, the fall on that date caused Mrs Smith s terminal decline. Dr Saldevar s death certificate 36. Ms Hale said she attended Caloola upon hearing of Mrs Smith s death. A Dr Guirguis pronounced Mrs Smith s death. Dr Guirgis telephoned Dr Saldevar who then attended Caloola. 37. Ms Hale said she met with Dr Saldevar alone (meeting one). She said that Dr Saldevar told her he would be issuing a death certificate with stroke as the cause of death. She pointed out that the matter should be reported to the coroner because of the fall. Ms Hale said that despite their discussion he would not change his mind. During this meeting Ms Hale said Dr Saldevar reviewed Mrs Smith s most recent medical records. 38. They then met with Harold Smith, Ms Wood, Ms Smith and Ms Layton (meeting two). Ms Hale said that Dr Saldevar said Look at it this way. What came first, the chicken or the egg? Did Heather have a fall then a stroke or a stroke then a fall? She may have had a stroke in the lifter. A post mortem could be done but what would that show? 39. Mr Smith then said he did not want a post mortem performed on his wife s body, with Mrs Smith s daughters divided on whether they wanted further investigations into her death. Ms Wood said that for their father s sake, 11
the family didn t want a post mortem and Dr Saldevar offered to record the death as a stroke on the death certificate, saying it would be the easiest way to go. 40. Ms Hale said that she again met with Dr Saldevar (meeting three) where their different positions on the death certificate were again discussed. Ms Hale remained of the view that the matter should be reported and later contacted Police. After the coroner assumed jurisdiction over Mrs Smith s death, Ms Hale said she two further discussions with Dr Saldevar (meetings four and five) where he became upset with her and, in the final meeting, claimed to have been trying to protect her by writing the death certificate. 41. Dr Saldevar agreed that he met with the family with Ms Hale after Mrs Smith s death. Dr Saldevar said he told them that the law required he report her death to the Coroner. He said that Mr Smith became very upset, saying he didn t want Mrs Smith s body cut up. Ms Layton said that Dr Saldevar told them about three times that an autopsy was required to determine Mrs Smith s cause of death. Because of Mr Smith s distress, Dr Saldevar suggested he could record stroke as Mrs Smith s cause of death, thereby avoiding an autopsy. Out of compassion for their father, the daughters in the meeting agreed. 42. Initially, Dr Saldevar denied the first and third meetings with Ms Hale, although he later agreed he could have had a brief discussion with her in the corridor prior to the meeting with the family. It is difficult to accept his evidence that he would have reviewed Mrs Smith s clinical notes while in the room with the family. He also agreed that he and Ms Hale might have had a brief conversation as he was leaving Caloola that evening. 43. As to the fourth and fifth meetings, Dr Saldevar said there was only a very brief discussion where he requested the file (meeting four) and he denied meeting five took place or that he ever said he issued the death certificate to protect Ms Hale. Dr Saldevar s concessions about the first and third meetings and Ms Hale s adamant evidence both suggest that Ms Hale did raise with Dr Saldevar her concerns about reporting the matter to the coroner. As to meetings four and five, Ms Hale made some 12
contemporaneous notes, but not as to the substance of what was discussed. However, this doesn t really matter because the entire responsibility for issuing death certificates always rests with the treating doctor, Dr Saldevar. No other person plays a role. 44. In a letter of 26 February 2010 to the NSW Medical Board, Dr Saldevar agreed that it was ill advised for him to record a stroke on the death certificate given the fall only days earlier. However, he said he did so out of compassion for the family. 45. Dr Saldevar told the court that his real concern was Mr Smith s distress, having come to know him over the period he treated Mrs Smith. Dr Saldevar told the court he knew the law required him to report the death to the coroner, and yet he completed the death certificate, even ticking the box on the form stating that there was no injury involved in Mrs Smith s death. 46. The Medical Board admonished Dr Saldevar, reminding him of his professional obligations concerning the signing of certificates, counselled him, but took no further action. Dr Saldevar told the court that he has learnt from the experience, recognising his issue of the certificate was illadvised. He has vowed never again to allow sentiment or compassion to influence his professional obligations. Conclusions 47. Ms Wilson agreed that when Mrs Smith was lifted up, across and over the floor, Ms Wilson was behind Mrs Smith and there was nothing to prevent her falling forward, which is what happened. As to Ms Said s alleged presence at the air chair, for the reasons I have given I do not believe Ms Wilson on this point and find Ms Said was with another patient at the time Mrs Smith fell. 48. I find that BCS staff did not attempt to cover up Mrs Smith s fall. An ambulance was immediately called, Mrs Smith s family was notified of the circumstances of her injury, the matter was notified to head office and the relevant government authorities and investigations commenced. The 13
evidence before me is that staff fully cooperated in those investigations. Further, Mrs Hale contacted the police to report Mrs Smith s death. 49. BCS went on to accept the findings made by investigators and implement all recommendations in a timely way. The relevant government authorities were satisfied with the steps taken by BCS. 50. Mr Smith and the two daughters present in the hours prior to her death were keen to ensure that Mrs Smith was not in pain. The evidence shows that Mrs Smith s family showed only loving concern for their wife and mother. They did nothing inappropriate at any time and made no inappropriate requests of Caloola staff in the days following the fall. There is absolutely no evidence that there was any request from family members for Mrs Smith to be deliberately administered a morphine overdose to end her life. 51. The evidence was clear that the registered nurses caring for Mrs Smith in her final days were authorised to prescribe up to 60 mg of morphine each day. A total of 70mg of morphine was administered to Mrs Smith between 17 and 19 July 2009 out of a possible 110mg that could have been administered. It is important to remember that Ms Wood and Ms Young were due to arrive in Wagga Wagga in the early evening and the family would have been hoping that Mrs Smith would not die before then. 52. I reject any suggestion that RN Marwood gave Mrs Smith an overdose of morphine on the day of her death. All drugs of addiction procedures were followed and all morphine was accounted for. I am satisfied that Caloola staff members administered all medications in strict accordance with the prescription by Mrs Smith s treating general practitioner in those final days of Mrs Smith s life. 53. Dr Kennedy noted it was difficult to read some of Caloola s medical records. In particular, some names and times were difficult to read and some signatures were missing. These aspects of clinical record keeping at Caloola could be improved. 54. The Coroners Act 1980 was in place at the time of Mrs Smith s death. Section 12B of that Act prohibited a doctor from issuing a death certificate in certain circumstances, including where the person died within a year 14
and a day of any accident to which the cause of his or her death may be attributable. There were exceptions to this rule, but not where the accident occurred in a nursing home. As the fall occurred three days prior and because of the nature of the injuries Mrs Smith received, Dr Saldevar was prohibited from issuing a death certificate, and yet he did so. He certified cause of death as stroke cerebrovascular (2-3 days duration) with dementia a significant condition contributing to, but not causing, death. 55. Dr Saldevar told the court he knew he had to report Mrs Smith s death, but maintained that his only motivation in signing the death certificate was to avoid any further distress for Mr Smith and his family. I am satisfied this was the case. 56. The Coroners Act is a statutory regime put in place to ensure there is independent oversight and investigation of certain deaths. It is extremely important that those entrusted with powers under the Act, such as doctors, exercise those powers in full accordance with the law so that the deaths of vulnerable persons are subject to appropriate scrutiny and community confidence is maintained. Cause and manner of death 57. I find that Heather Smith died on 19 July 2009 at Caloola Centre for Aged Care, Plumpton Road, Wagga Wagga 2650. The cause of her death was: Bronchopneumonia head trauma (subdural haemotoma, subarachnoid haemorrhages and cerebral contusions) from the fall on 16 July 2009 and chest trauma from the fall on 16 July 2009 Antecedent causes of Mrs Smith s death were: a prior stroke in 2002 her frail state following a 2006 fall and Dementia. The manner of Mrs Smith s death was as a result of a fall at the nursing home on 16 July 2009. 15
Recommendations 58. That BCS review clinical record keeping and training at Caloola to make sure records can be easily maintained and updated by staff and doctors with a view to ensuring legibility, transparency and accountability. Conclusion 59. To Mrs Smith s daughters, this must have been a distressing four years for you and your father. I extend to you my deepest sympathies on the loss of your mother and ask that you pass on my sympathies to your father. Megan Greenwood NSW Coroner 16