TITLE OF COURT: Coroner's Court
JURISDICTION: Darwin
FILE NO(s): D0133/2002
DELIVERED ON: 21 January 2004
DELIVERED AT: Darwin
HEARING DATE(s): 1- 5 September 2003
FINDING OF: Ms ELIZABETH MORRIS
DEPUTY CORONER
CATCHWORDS:
CORONERS: Inquest, Hospital Procedures, Adult Guardianship Board, Police Communications
REPRESENTATION:
Counsel:
Assisting: Ms Lyn McDade
Department of Health Ms Judith Kelly
and Community Services
Solicitors:
Department of Health and
Community Services Mr Chris Rowe, NT Attorney Generals Department
Judgment category classification: B
Judgement ID number: NTMC [2004] 004
Number of paragraphs: 68
Number of pages: 20
IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN
TERRITORY OF AUSTRALIA
No. D0133/2002
In the matter of an Inquest into the death of
RITA ANDERSON
ON 16 MAY 2002
AT BUSHLAND ADJACENT TO ROYAL DARWIN HOSPITAL, NORTHERN TERRITORY
FINDINGS
(Delivered 21 January 2004)
Ms Elizabeth Morris, Deputy Coroner:
THE NATURE AND SCOPE OF THE INQUEST
1. Rita Anderson ("the deceased") was an approximately 43 year old
Aboriginal female whose remains were found in bushland adjacent to Royal Darwin
Hospital on the 16th of August 2002.
2. The death is a "reportable death" pursuant to section 12 of the
Coroners Act ("the Act") as her death was unexpected. A public Inquest
was held pursuant to section 15(2) of the Act. The holding of the Inquest (and
commencement date) was advertised in the local press on 5 May 2003.
3. Section 34(1) of the Act details the matters that a Coroner is required to
find during the course of an inquest into a death. That section provides:
(1) A coroner investigating -
(a) a death shall, if possible, find -
(i) the identity of the deceased person;
(ii) the time and place of death;
(iii) the cause of death;
(iv) the particulars needed to register the death under the Births, Deaths and
Marriages Registration Act;
(v) any relevant circumstances concerning the death."
4. Section 34(2) of the Act operates to extend the Coroner's function as follows:
"A coroner may comment on a matter, including public health or safety or
the administration of justice, connected with the death or disaster being investigated."
5. A public inquest commenced at the Darwin Magistrates Court on 1 September
2003. Counsel assisting me was Ms Lyn McDade. Ms Judith Kelly sought leave to
appear on behalf of the Northern Territory Government, specifically the Department
of Health and Community Services and the Northern Territory Police. I granted
leave to her pursuant to section 40(3) of the Act.
6. Oral evidence was taken, in person and via video teleconference facilities,
over five days from 1 to 5 September 2003 inclusive. On the first sitting day
the witnesses were Sweeny Anderson, a son of the deceased, Senior Sergeant Vincent
Michael Kelly, the officer in charge of the investigation into the death of
the deceased; Doctor Terence John Sinton, Forensic Pathologist who performed
a post mortem examination of the deceased, and Professor Andrew Dawson, the
Professor of Clinical Pharmacology at the University of Newcastle, who provided
an expert report into the drug regime of the deceased.
7. On the second sitting day the witnesses comprised Sonia Lee Fagg, Aboriginal
Liaison Officer at Royal Darwin Hospital (RDH), Denby Kitchener, Acting Executive
Director of Nursing and the Nursing Director for the Medical Division at RDH,
Steve Hugh Gelding, Senior Human Resources Officer of the Department of Health
and Community Services, Susan Jane Paltridge, Manager, Legal Support Services,
Department of Health and Community Services and Anne Cunningham, former Executive
Officer of the Adult Guardianship Board.
8. On the third sitting day evidence was given by Doctor Robert Michaelis Parker,
Acting Director of Psychiatry for the Top End Mental Health Service, Sarah Margaret
McHugh, Clinical Nurse Manager of Ward 4B at RDH, Gary Keith Markell, security
officer at RDH, Christine Naylor, Patient Care Assistant at RDH, Ferdinand Orion,
Patient Care Assistant at RDH, and Susan Mary Rohrig, Registered Nurse at RDH.
9. On the fourth day of sitting the witnesses were Mr Paul Damien Lawton, Consultant
Physician at RDH, Doctor Leonard George Notaras, Medical Superintendent at RDH,
Doctor Vinothini Inpamathy Evangeline Saphianathan (Doctor Vino) Deputy Medical
Superintendent at RDH, and Doctor Anna Ralph, Registrar at RDH.
10. On the fifth day of sitting the witnesses comprised Sergeant Shaun Rodney
Furniss, of the police communication centre, and Judith Dikstein, Legal Officer
with the Adult Guardianship Board.
11. In addition to those witnesses a number of documents were tendered including
an investigation file compiled by Senior Sergeant Kelly and various other reports
and statements tendered by Counsel Assisting and Ms Kelly, Counsel for the Department
of Health and Community Services.
FORMAL FINDINGS
12. Pursuant to Section 34 of the Act, I find, as a result of the evidence adduced
at the Inquest the following:
1. The identity of the deceased was Rita Anderson, also known as Rita Rory Anderson,
who was recorded as being born at Calvert Hills, Northern Territory on 28 May
1958.
2. The time and place of death are at sometime after 16:00 hours on 16 May 2002
in bushland adjacent to Royal Darwin Hospital in the Northern Territory.
3. The cause of death is unknown.
4. Particulars required to register the death are:
(a) The deceased was a female.
(b) The deceased was Rita Anderson.
(c) The deceased was an Australian resident of Aboriginal origin.
(d) The death was reported to the Coroner.
(e) The cause of death is unknown. The cause of death was confirmed by a post-mortem
examination.
(f) A pathologist viewed the body after death.
(g) The pathologist was Doctor Terence John Sinton, Forensic Pathologist of
Royal Darwin Hospital
(h) The deceased's mother is Mary Aga-Jibinna.
(i) The deceased's father is Dick Gardalagi.
(j) The deceased resided in and around the Darwin region and at the Royal Darwin
Hospital.
(k) The deceased was a pensioner.
(l) The deceased had been married, and had five children.
(m) The deceased was about 43 years old having been born in 1958.
RELEVANT CIRCUMSTANCES SURROUNDING THE DEATH
The deceased's background
13. The deceased was born at Calvert Hills, a small community near the Calvert
River on the Gulf of Carpentaria on 28 May 1958. Her mother was Mary Aga-Jibinna
and her father Dick Gardalagi. Her family were from the Robinson River area.
She had five sons: Sweeny, Barry, David, Percy and Romany Anderson, Sweeny being
the eldest, born 9 March 1973 when the deceased was 15. Their father is Gordon
Jiminminya Anderson a station hand from Brunette Downs. Sweeny and his brothers
were raised by their Aunty and Uncle when the deceased left the family whilst
they were still young.
The deceased's medical history
14. Mrs Anderson had been an inpatient of the Royal Darwin Hospital on an almost
continuous basis since March 2002. She had many admissions throughout her lifetime,
and particularly since 1996. Her medical history from 1970 comprises some six
medical volumes. The majority of her admissions were for treatment relating
to alcoholic seizures and trauma.
15. The records show that during 1986 the deceased was treated twice for injuries
resulting from assaults and once for post-seizure care. On each admission she
was intoxicated. By December 1986 she reported drinking a flagon of wine a day.
At that time she was 28 years of age, had no fixed address, and had several
miscarriages.
16. Between February 1987 and January 2002 police and ambulance brought the
deceased to hospital some 47 times as a result of suffering a seizure. On each
admission she was intoxicated. She was also brought in by police or ambulance
21 times for treatment for injuries sustained in accidents or assaults whilst
intoxicated. She frequently left the hospital prior to treatment being completed.
She required two admissions to intensive care for intubation and ventilation.
17. The deceased had organic brain damage, as well as chronic liver disease
due to alcohol, cerebella ataxia and thrombocytopenia. It would appear from
her medical files that from as early as 25, she had already reached the stage
of organic brain syndrome from alcohol abuse.
18. These conditions resulted in Mrs Anderson suffering from poor judgment and
impulsiveness. She displayed intermittent aggression, which could be diminished,
but not completely controlled by, medication.
19. I quote from and adopt Ms Judith Kelly's submissions
"Such a history as can be gained of the life of the deceased illustrates
the desperate circumstances which befell her from her earliest years. She became
a mother when still a child herself, yet lost the opportunity to raise her own
children. She fell out of her own community and into an itinerant lifestyle
in the suburbs of Darwin, where she appears to have been the victim of repeated
abuse at the hands of others and herself succumbed to chronic alcohol abuse.
This lifestyle caused the cognitive deterioration which resulted in the impulsive
and aggressive behaviour which came to characterise her and the total lack of
insight into her own medical condition at the time of her final admission in
March 2002".
Care and Treatment at Royal Darwin Hospital
20. In March 2002 one of the deceased's sons, Barry Anderson, attempted to look
after his mother at his home in Bachelor. Mr Anderson is a married man with
four children. He found, because of her irrational and threatening behaviour,
he was unable to care for her as he wished.
21. Thus the deceased was returned to hospital and admitted to Ward 4B. The
admission occurred with the intention of assessing and hopefully stabilising
her condition, and to give the opportunity to health workers, social workers
and medical professionals to find appropriate medications and placements for
her. Ward 4B is a ward for acute care medical patients. Her condition was chronic
and not acute. There was no other place for her to be placed pending treatment.
22. Her behaviour from the time of this admission (and indeed before) was impulsive,
random and unpredictable. There was a general view that she was a danger to
herself and others. This view is supported by the evidence produced at the Inquest.
On occasion the deceased would harass, intimidate and assault other patients
and staff members. She was a tall strong woman, despite her physical ailments.
23. From the evidence it is clear that the deceased was unable to care for herself
without direction. She was unable to conduct ordinary daily routine matters
to such an extent that she could live independently in the community or indeed,
live in the community with support services that are available throughout the
community to assist people in her condition.
24. There was a belief held by Hospital staff, due to the deceased's inability
to look after herself, that it was the Hospital's obligation, because of where
she was, to care for her, to look after her and to ensure that she was safe.
By keeping Rita Anderson in the hospital and denying her access to alcohol,
they were providing her with an environment in which she could safely go about
her life and avoid experiencing the seizures that had beset her. There was a
real desire to keep the deceased from danger. I find that this desire was motivated
by the best of intention, that is, the safety and well being of the deceased.
The deceased, however, did not wish to remain at all times in the hospital.
She wished to go about her business as she saw fit, and was frustrated by restraints
placed upon her whilst she was in the hospital. This frustration was vented
in her unpredictable and sometimes violent behaviour.
25. In order to manage her behaviour, from 21 March until her death, the deceased
was provided with a full time 24 hour per day patient care assistant (PCA).
26. Two of these assistants gave evidence. They saw their role as, among other
things, to persuade Rita to remain in hospital, and when she wandered, to convince
her to come back. Christine Naylor spent a great deal of time with the deceased,
and eventually developed a rapport with her, such that the deceased referred
to Ms Naylor as "her friend".
27. Dr Lawton, a consultant physician at RDH, who gave evidence at the Inquest,
directed that the deceased be physically restrained if required, to keep her
on the ward. He considered that given the deceased's mental impairment, and
that having regard to an adult guardianship order being pending, the hospital
owed a duty of care to the deceased to prevent her from causing injury to herself.
In Dr Lawton's opinion a guardianship order would have been a "formality",
considering the evidence he was aware of in relation to the deceased.
28. She was also on a medical drug regime. There is no evidence that this was
not an appropriate treatment course for the deceased. Indeed an independent
expert, Professor Dawson, confirmed that the prescribed drugs were appropriate
for the deceased's condition.
29. Decision making regarding the management of the deceased was done by a series
of team meetings, involving members of the medical, nursing, and social work
hierarchies. Over time members of this team began to have concerns about the
legitimacy of the care and containment of Ms Anderson. Legal advice was obtained,
and an application for Adult Guardianship sought in attempts to define the legally
appropriate course.
Application for Adult Guardianship
30. The Adult Guardianship Act (AG Act) makes provision for a scheme of guardianship
for certain adults under an intellectual disability. Around the time of her
death the deceased clearly fell within the ambit of this legislation, evidenced
by the fact of an order granting guardianship being issued on 25 May 2002.
31. Evidence was given as to the practice and procedure of applications under
the AG Act by Ms Anne Cunningham, the Executive Officer for the Adult Guardianship
Board at the relevant time, and Ms Judith Dikstein, the present incumbent. Two
issues arose during the Inquest, the length of time taken for such an application
and whether or not a guardian would be able to consent to the deceased being
restrained in the hospital in any event.
32. An application for adult guardianship was made initially in January 2002.
The application originated from a social worker at RDH and was requested urgently.
The application was returned, as the Officer receiving the request preferred
that a family member make the application. Another application was made in February,
the hospital having contacted and assisted Barry Anderson in making the application.
No grant regarding guardianship was made until 23 May, a date probably after
Ms Anderson had died, when a temporary guardianship order was granted. The Public
Guardian was appointed as the Guardian of the deceased. The application was
not deemed to be urgent originally, however on 16 May it was deemed to be "urgent"
and an order was made within a week.
33. There was some evidence presented as to what the criteria for an "urgent
application" were. The criteria were not legislative, but adopted by whichever
officer was dealing with the matter at the time. It appears that the deceased
did not meet the criteria, as she was not scheduled to undergo a medical procedure
to which her consent was required and was not seen (by the assessing officer)
to be at immediate risk to herself without the appointment of a guardian, because
she was a patient at the hospital. However Ms Cunningham was also of the view
that a guardian would not alleviate the risk of the deceased leaving the hospital,
as they would be unable to authorise her detention in hospital against her will.
"Up until that time, you didn't consider the application on Rita's behalf
to be urgent, did you?---Well, I didn't consider it to be any more urgent than
the other ten or 15 that I had on my desk classified as urgent because I didn't
see that appointing a guardian was going to improve her circumstances even in
the short term.
Can you explain to me why you were of that view, having regards to the provisions
of the Adult Guardianship Act?---All right, the - ever since she appear to be
- or as I was told that Rita was violent and she needed to have some sort of
restraints put on whether it was difficult or otherwise, and guardianship provisions
don't allow for any formal constraints or restraints so, therefore, appointing
a guardian, even if I had appointed a guardian or tried to appoint within a
week of receiving the application in February, what would her guardian have
done when all we are supposed to do under the Act is make decisions in place
of that person who had lost their decision making ability, so you know, the
decision that could be made on her behalf was, was she to be sedated in any
way, or was she to be released from hospital and even if a guardian had made
those decisions, she can refuse and just walk away, no-one can tie her down
or hold her back." (Transcript p93).
34. Dr Lawton told the court in his evidence
"However, we had taken all possible steps to actually get a guardianship
order and I would contend that the problem is the long delay to actually getting
- to actually getting the guardianship order. This is my experience in other
cases also in the Territory that there is an inordinate delay in actually processing
applications to go before the courts for a guardianship. This case was relatively
quick in the scheme of things but not quick enough for Rita it seems….and
this is a big problem for the Territory - and a big problem for clinicians."
(Transcript p211)
35. Counsel for the Northern Territory concedes that provisions for expedited
procedures under the AG Act is an issue for consideration in a review of the
law relating to substituted decision making. It is clear from this case that
the practice and procedure of the Adult Guardianship office at the time of the
deceased's death did not lead to expeditious dealing with applications. For
someone to reach the stage of having a request for an application to be made,
they must almost certainly have met the criteria for some time, then to have
to wait several months or years for the application to come to fruition puts
an incredibly difficult load on those tasked to care for them.
36. For the Officer to also hold that the deceased did not meet the "urgent"
order criteria in that she was safe where she was, was of little assistance
to the Hospital staff, who were attempting to keep her there against her expressed
wishes.
37. It is also the case that there was not a clear understanding by health professionals
in the position of care providers, of the powers and role of a guardian and
any orders made.
38. Evidence was given that full guardianship orders are rarely if ever made.
Rather, conditional orders are made under section 18 of that Act.
39. One of the conditional orders eventually made in relation to the deceased,
was that the guardian may make decisions concerning the health care of the person
and consent to health care in her best interests (subject to section 21 of the
Act, pursuant to which major medical treatment requires an order of the Court).
Would this have encompassed the authority to consent to physical restraint of
the deceased to prevent her leaving hospital? The view of the Executive Officer,
who viewed these powers in the light of section 4 of the Act, was that they
would not.
40. Section four of the AG Act is as follows:
4. Best interests of represented person to be promoted
Every function, power, authority, discretion, jurisdiction and duty conferred
or imposed by this Act is to be exercised or performed so that -
(a) those means which are the least restrictive of a represented person's freedom
of decision and action as is possible in the circumstances are adopted;
(b) the best interests of a represented person are promoted; and
(c) the wishes of a represented person are, wherever possible, given effect
to.
41. That view was also supported by the legal advice taken by the Department
and provided by Mr Farqhuar of Cridlands.
42. The conundrum of course, is where the wishes of a person and the means which
are the least restrictive of their freedom, conflict with their best interests,
which include their safety, health and security.
43. Counsel for the Northern Territory submitted that
"Whether, even if a guardianship order had then been in place, a decision
to further restrain the deceased on, say, 16 May 2002, would have been in her
best interests is a very difficult judgment to have been called upon to make.
It would certainly not have given effect to her express wishes. The deceased
was clearly unhappy and unsuited to the environment of an acute hospital ward
and had clearly expressed her desire to leave. She was being medicated to modify
her behaviour but was not otherwise undergoing a specific medical treatment
or procedure. In those circumstances a decision by a guardian to authorise her
restraint would arguably have been taken without proper regard to the intention
of the Adult Guardianship Act, as expressed in section 4 of that Act…"
44. In examining both these issues, any finding must be "connected with
the death or disaster being investigated." Any comment or recommendation
I make is not limited to matters having a direct causal nexus with the death.
The expediency or otherwise of dealing with an application for adult guardianship
is connected with the death of the deceased in this case. At the very least
had such a guardian been appointed earlier, there should have been someone in
a position to agitate for the deceased being a missing person, and for a search
to be conducted at an earlier stage.
45. Whether or not that guardian could have authorised the deceased's restraint
is a legal question which I do not have to determine. The fact I find is that
an order was not made prior to the deceased's death. What this death does highlight
is the lack of clarity in relation to the extent of powers and orders made under
the Adult Guardianship Act, and the need for those powers to be clarified.
Application of the Mental Health Review Act
46. At various stages the deceased was assessed by a psychiatrist with a view
to detaining her under the Mental Health Review Act (the MHRS Act). This is
an Act that was implemented with a view to treating short term transitory illness
that could be rectified and treated by therapeutic intervention. Chronic organic
brain disease appears not to fall within the definition of "mental illness"
in the MHRS Act.
47. The deceased was assessed by Dr San Pedro on the 23 March 2002 and again
assessed by Dr Cynthia Parker on 14 May 2002. She was found not to be suffering
from a "mental illness" as the defined by the MHRS Act, nor a "mental
disturbance" at the time of examination.
48. However, whilst there is evidence that at times Ms Anderson suffered such
a transitory illness or disturbance, including hallucinations, she was not assessed
at the moment of its appearance. I agree with Counsel assisting that it would
be inappropriate to have her under a form of continuous assessment merely in
order to "catch" one of the symptoms of such a disorder.
49. Whilst the MHRS Act contains powers for health professionals to treat non-compliant
patients, I find that from the evidence presented the deceased did not fit the
criteria for her particular situation to be addressed.
Appropriateness of discharge
50. The deceased did not want to remain in hospital. She frequently expressed
a desire to leave (although also at times seemed comfortable in remaining).
On 14 and 16 May 2002, Ms Anderson became increasingly agitated and aggressive.
She wanted to see her sons and wanted to leave in order to do so. Legal advice
was again sought on 16 May as to whether the hospital could hold the deceased.
The forthcoming advice resulted in the release of the deceased at around 16:00hrs
on 16 May. Prior to her release on that day the deceased was physically contained
in her room, with the Patient Care Assistant's (Christine Naylor and Ferdinand
Orion) holding shut the door, in order to prevent her from leaving the hospital.
51. However on that day the deceased had received several doses of medication,
including two doses of droperidol at 13:30 and 14:10hrs. She was also given
diazepam at 08:30, 09:00 and 12:00hrs and Haloperidol at 08:30hrs.
52. Evidence was called from Professor Dawson, the Professor of Clinical Pharmacology
at the University of Newcastle and senior staff specialist in the Hunter area
toxicology unit.
53. He confirmed that the dosages Ms Anderson received were well within the
therapeutic guidelines and were an appropriate course for her condition. In
his opinion the effect of the drugs would have at least "plateaued"
by the time she left the hospital. He did opine that her judgment would have
been impaired. He states that "it would be very unusual to discharge the
patient without observation taking place. They would normally remain in care."
(Transcript p40)
54. Ferdinand Orion and Chris Naylor escorted the deceased from the hospital
building. She was seen walking into bushland adjacent to the hospital, and was
not seen alive again.
55. I find that the decision to allow the deceased to act on her desire to leave,
was the only one that hospital staff could have made in the circumstances they
found themselves in. All other options had been explored, legal advice had been
obtained, there was no power to detain the deceased. Whilst the deceased had
been medicated, the effects of this medication had plateaued. It would not be
expected that the deceased would become more sedated as time passed.
The police response and the search for the deceased
56. Police were notified that the deceased had left the hospital at about 16:00hrs
on 16 May 2002. The hospital notes also indicate that the Northern Australian
Aboriginal Legal Aid Service (NAALAS) and the deceased's family were also contacted
at a later time.
57. During the initial conversation between Sarah McHugh and police communications,
they were informed that she was not sectioned, and that she had self-discharged.
She's just left. She's not under a Section, however she is a very aggressive
patient and we've been through all the legal ramifications. She's been given
a lot of sedation, but she'd been very physically aggressive and verbally aggressive
towards staff and we've been advised that we cannot keep her against her will.
So we were just contacting you just to let you know and she'll, she could be
very drow, I mean she, yep was getting very drowsy but we couldn't keep her
here.
…
Mmm alright. Okay, so if we actually come across her then, where do you reckon….
Just to suggest if she gets in, if she does like you know, willingly, we would
like her brought back…
Yep
Because she's at risk to herself and to others in the Community. But we can't
forcibly bring her back. The thing is that I'm expecting that the sedation will
settle, um set in, and like often she's very placid and she'd quite fine and
she may you know, settle down, and I mean she'd absconded twice this week already.
So yeah. We'll just wait and see.
58. The Communications call taker did not follow exactly the standard operating
procedure reference for an absconder from the hospital, in that they did not
ask whether the informant held "grave concerns for the person's welfare".
An affirmative answer would have led to police officers being tasked to take
some further immediate action.
59. Standard operating procedures are not necessarily a script to be followed,
given that each instance has its own characteristics and good communication
operators need to be able to glean sufficient information to assess the situation.
However certain key questions, especially those that determine the response
by police, must be asked and should have been asked in this instance.
60. As a consequence of the call a "be on the lookout for" was issued,
but a vehicle was not dispatched. In hindsight, given where the deceased was
eventually located, such dispatch may well have found the deceased. Hindsight
however, is the benefit of a coronial proceeding. The deceased had returned
of her own volition on previous occasions in the three days prior to her disappearance.
Given the history of her leaving the hospital, and subsequently returning on
many occasions, to proceed in that manner was not unreasonable. However it is
important that each occurrence should be looked at individually, rather than
merely in the context of a 'habitual absconder' because of the nature of a patient's
condition and medication.
61. On 8 August 2002 police were notified by the Public Guardian that the deceased
had not been seen since 16 May. There was an assumption by the Office of the
Public Guardian that the deceased had been listed as a "missing person"
since she absconded from the hospital. This is evidenced by correspondence on
the Public Guardian's file dated 15 July 2002. It was not until a telephone
call between the Public Guardian and police on 8 August 2002, that it was realised
by the Guardian that the deceased had not been reported as missing. It was only
then that she was officially listed as a "missing person". Various
enquiries were then undertaken by police to ascertain her whereabouts. On 16
August 2002 a search was conducted in the area where the deceased was last seen.
The search commenced at 08:10hrs and the deceased was located at 13:36hrs on
that day in an area some 600 metres north of the rear car park of the hospital.
62. Considering that the deceased had not been since 16 May in and around that
area, and also considering her disabilities and condition, I find that it is
probable that she died in the area where her remains were located, and not long
after she left the hospital. It is improbable for her to have left then returned
to that area, given that there was no food or water, or regular camp at that
place. No access was made to her bank account or Centrelink payments after the
deceased left hospital.
63. It is unfortunate that there was a misunderstanding between Health workers
from various agencies as to the difference between a hospital "absconder"
and a "missing person". It was this misunderstanding that meant that
no concerted action was taken by any party to find the deceased. Indeed once
those experienced at finding people, ie., the police, commenced their investigation,
the deceased's remains were relatively quickly found.
64. There are copies on the deceased's file of acrimonious correspondence between
the Adult Guardianship Board Executive Officer and the Public Guardian as to
division of responsibilities between the two offices. This appears to stem from
a lack of clarity in relation to the roles and responsibilities of those tasked
to administer a system of guardianship. A panel member was instructed at one
stage to "stop looking" for the deceased as that was not the role
of the Adult Guardianship Board. Information about the deceased was not passing
freely between the two agencies.
Conclusion
65. Since the deceased's death, RDH has offered aggression management training
on a monthly basis. From June 2003 the RDH aggression policy is outlined at
staff orientation programs, and an absconding policy is referred to. RDH has
also revised its aggression and absconding patients policies, which seek to
clarify the use of restraint upon aggressive or absconding patients. The absconding
patients policy sets out guidelines for notification to Police in the case of
patients who leave the hospital against medical advice and for appropriate follow-up
to that notification. A corresponding revision of the Police General Orders
has also taken place (H4). Given that revision, there is no need for any recommendation
along those lines.
66. I agree with Counsel for the Northern Territory, who submitted "the
present inquest has identified a legal dilemma for medical professionals concerned
for the welfare of patients who lack capacity to make informed decision concerning
their own health care and are placing themselves at significant risk by refusing
that care. However, any authority to restrain a person in such circumstances
must be tempered by the law's respect for the rights of the individual, specifically
the autonomy of persons suffering an intellectual disability."
67. This case is different from some others in that there is no evidence that
the deceased had a wish or desire to die. It appears she merely wanted to live
free of the restraint that was keeping her safe. Sadly the physical cause of
her death can now not be known.
RECOMMENDATIONS
68. I recommend that the Adult Guardianship Board's practice and procedures
be reviewed with a view to better managing and expediting application. I also
recommend that relevant medical staff receive information about the operation
of the Board and the extent of powers given under the Adult Guardianship Act,
and that such powers be clarified to ensure certainty for those entrusted with
them, and operating under them on a daily basis.
Dated this 21st day of January 2004
_________________________
ELIZABETH MORRIS
DEPUTY CORONER