RECORD OF INVESTIGATION INTO DEATH (WITHOUT PUBLIC INQUEST)
Coroners Act 1995
Coroners Rules 2006
I, Glenn Hay, Coroner, have investigated the death of
RUTH MARINA BATCHELOR
WITHOUT HOLDING AN INQUEST
I have decided not to hold a public inquest hearing into her death because my investigations have sufficiently disclosed the identity of Mrs Batchelor, the time, place, cause of death, relevant circumstances concerning how her death occurred and the particulars needed to register her death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me.
a) Ruth Marina Batchelor (Mrs Batchelor) was born in Nubeena, Tasmania, on 14 June 1927. At the time of her death she was aged 93 years. Mrs Batchelor was a widow, with three adult children (one deceased), and was residing at the Glenview Nursing Home, in Glenorchy.
b) Mrs Batchelor died on 7 March 2011 at Glenview Nursing Home, Glenorchy in Tasmania.
c) Mrs Batchelor died as a result of asphyxia due to choking. Significant contributing factors were severe atherosclerotic coronary vascular disease, valvular heart disease and dementia of the Alzheimer's type.
Mrs Batchelor had been residing at Glenview Nursing Home, Glenorchy, since mid-2010, after being diagnosed with the early stages of dementia. After a few months, Mrs Batchelor's condition began to deteriorate and she was provided with increased assistance and supervision. Her mobility was with the aid of a four-wheeled walking frame. During the early part of 2011, Mrs Batchelor began to have difficulty with mobility in her hands and staff assisted her at meal times by cutting up her food. She then was able to feed herself by using her hands as she could not hold her cutlery. According to Mrs Batchelor's son, Mr Keith Batchelor, his mother would often have a rolled up bandage between her palm and fingers to stop her hand closing into a fist.
Circumstances Surrounding the Death:-
About 5.00pm on 7 March 2011, Mrs Batchelor was having her evening meal in the dining room of the Glenview Nursing Home. A member of staff had cut up her meal, which included a saveloy, into small slices for her but short time later, Mrs Batchelor indicated to the staff member, Ms Hinds, that she could feel something in her throat.
Ms Hinds assisted Mrs Batchelor by rubbing her back a number of times and bringing her a glass of milk to clear her throat. She appeared to be quite calm, not coughing and speaking clearly at this time. She indicated to Ms Hinds the obstruction was in the area of the middle of her throat. Ms Hinds continued to pat Mrs Batchelor on the back and called for assistance from the on duty Registered Nurse, Ms Wilkinson, who arrived within minutes to assist.
Ms Wilkinson and Ms Hinds assisted Mrs Batchelor to her room with the aid of her walking frame where she sat on her bed and drank another glass of milk. Mrs Batchelor had no difficulty drinking however she indicated she could still feel an obstruction in her throat. Ms Wilkinson asked Mrs Batchelor to cough, which she did, but she indicated that it still felt as if there was an obstruction. Ms Wilkinson then checked Mrs Batchelor's mouth and throat and used her finger to feel for an obstruction. Believing she could feel something at the back of Mrs Batchelor's throat she gave three or four sharp pats on her back to dislodge any object. After this Mrs Batchelor indicated she then felt a little better but could still feel something in her throat. Ms Wilkinson physically checked her mouth again but could not feel anything so she used a portable suction machine to try to clear Mrs Batchelor's airway. The device was used on three occasions and removed small pieces of food and a small portion of saveloy from her mouth however Mrs Batchelor said she could feel something still there.
Unfortunately Mrs Batchelor gradually became less responsive and Ms Wilkinson administered oxygen to her. When she became concerned Mrs Batchelor's condition had continued to deteriorate she called for an ambulance and, with Ms Hinds, commenced CPR and continued until the ambulance arrived.
On examination, Mrs Batchelor was determined by paramedics to be in asystole and a check for any obstruction in Mrs Batchelor's throat proved negative. CPR was continued for a number of minutes but with no change in her condition resuscitation was ceased due to a do not resuscitate order in place for her. Mrs Batchelor died just prior to 6.00pm on Monday 7 March 2011 at the Glenview Nursing Home.
A post-mortem examination was conducted by Dr Donald Ritchey who determined Mrs Batchelor died as a result of asphyxia due to choking. He further stated significant contributing factors were severe atherosclerotic coronary vascular disease, valvular heart disease and dementia of the Alzheimer's type. Dr Ritchey further noted that, "although choking was not clearly demonstrated at autopsy and food was not dislodged by ambulance personnel; the clinical history of an apparent choking event is compelling in my opinion. Further, nurses report removing a small amount of food debris from the mouth during resuscitative efforts. Individuals with dementia are at increased risk of choking on food whilst eating."
Findings, Comments and Recommendations:
I am satisfied that a full and detailed police investigation has taken place into this incident and this has indicated that there are no suspicious circumstances surrounding this death.
In closing I wish to convey my sincere condolences to Mrs Batchelor's family.
DATED:- 30 March 2012 at Hobart in the State of Tasmania.