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CORONERS COURT OF QUEENSLANDFINDINGS OF INQUEST CITATION:Inquest into the death of John EdwardDrane TITLE OF COURT: Coroners CourtJURISDICTION: BrisbaneFILE NO(s): 2014/148DELIVERED ON: 15 June 2016DELIVERED AT: BrisbaneHEARING DATE(s): 15 April 2016, 23-25 May 2016FINDINGS OF: John Lock, Deputy State CoronerCATCHWORDS: Coroners: inquest, nursing home resident,immolation, burns, whether accidental or self-harm,risk assessments for smoking and/or self-harm,physical diseases as predictors of suicide in olderadults, communication in concurrent investigationsREPRESENTATION:Counsel Assisting: Ms M JarvisCounsel for Masonic Care Queensland:Mr A Herbert i/b McCulloughRobertson Counsel for Metro North Hospital &Health Service (MNHHS): Mr A Suthers i/b MNHHSContentsIntroduction …………………………………………………………………………………………1Background…………………………………………………………………………………………2Autopsy results ……………………………………………………………………………………4Concerns of family ……………………………………………………………………………….4The investigations………………………………………………………………………………..5Queensland Police investigation………………………………………………………5Queensland Fire and Emergency Service investigation ………………………8Office of Fair and Safe Work Queensland ……………………………………….11Review of Masonic Care Queensland records………………………………………..12Report by Pam Bridges……………………………………………………………………….14Conclusions on the issues …………………………………………………………………..17Mental Health and Suicide Risk Assessment………………………………………….21Findings required by s. 45……………………………………………………………………22Identity of the deceased………………………………………………………………..22How he died………………………………………………………………………………..22Place of death……………………………………………………………………………..22Date of death ………………………………………………………………………………22Cause of death ……………………………………………………………………………22Comments and recommendations ………………………………………………………..22Attachment A …………………………………………………………………………………….24Findings of the inquest into the death of John Edward Drane 1Introduction1. John Edward Drane was aged 75. He was a resident at the MasonicCare Queensland (MCQ) facility at 60 Wakefield Street, Sandgate. Hehad been diagnosed with bladder cancer in late 2013 and had twosurgical procedures. In early January 2014, he started receivingchemotherapy and radiotherapy.2. In the afternoon of 9 January 2014, he had returned from his second setof radiotherapy and first set of chemotherapy. He was wearing achemotherapy infuser attached to a catheter inserted in his arm. He wentto the smoking room set up at MCQ and was seen by cleaning staff tobe smoking. Ten to fifteen minutes later he was seen to be sitting in achair with his clothes from bottom to top on fire. The fire wasextinguished by staff, with some difficulty. He was taken by ambulanceto the Royal Brisbane Hospital Burns Unit, but died from his burns laterthat night.3. Investigations commenced as to the cause of the fire involving theQueensland Police Service (QPS) and Queensland Fire and EmergencyService (QFES). Workplace Health and Safety Queensland (WHSQ)also investigated whether MCQ had fulfilled its obligations underworkplace health and safety legislation. The conclusion of the QPSreport provided to the coroner was that the fire occurred when a cigarettebeing smoked by Mr Drane dropped into his lap and ignited his clothing.4. Concerns were reasonably raised by Mr Drane’s family as to how suchan event could occur in such a public environment. Issues were raisedconcerning whether appropriate risk assessments were conducted byMCQ regarding smoking by residents.5. A decision to hold an inquest was made. At a pre-inquest hearing thefollowing issues were determined:i. The findings required by s. 45 (2) of the Coroners Act 2003;namely the identity of the deceased, when, where and how hedied and what caused his death.ii. The circumstances leading up to the death.iii. The appropriateness of the care provided to the deceased atthe residential care facility; in particular, the identification,assessment and management of risks associated with thedeceased’s recent medical treatment and smokingbehaviours.iv. Whether any additional risk management strategies should beimplemented in facilities where elderly persons reside so as toensure their safety in the event of a fire.Findings of the inquest into the death of John Edward Drane 26. As will become evident, two weeks before the commencement of theinquest, an issue was raised in a report prepared by the QFESinvestigator as to whether the manner in which Mr Drane became alightwas accidental or whether he had been deliberately set on fire, througheither a third party or intentionally by himself. That report had not becomeavailable to the QPS or the coroner until the QFES investigator wasinformed an inquest was listed. This raised further issues as to thecommunication and exchange of information between QPS and QFESgiven their concurrent investigations.7. The following witnesses were called to give evidence at the inquest: Detective Senior Constable Janelle WALSH Queensland Fire and Emergency Service (QFES) InvestigatorGreg JONES Sergeant Shane SCARINCI Ms Heather GAMBETTA, Domestic Assistant, employee ofresidential care facility Ms Isabel HUDSON, Registered Nurse, employee of residentialcare facility Ms Lynda JOHNSTON, Domestic Assistant, employee ofresidential care facility Dr Peter BALTHES, General Practitioner Dr Kieron BIGBY, Consultant Medical Oncologist, RedcliffeHospital Dr Michael MULLER, Senior Visiting Medical Officer, RoyalBrisbane and Women’s Hospital Inspector Deborah DARGAN, Workplace Health and SafetyQueensland Ms Carol TIPPER, Manager, employee of residential care facility Ms Sue BEASLEY, Executive Manager, employee of residentialcare facility Ms Pam BRIDGES, aged care industry consultantBackground8. John Drane was aged 75 at the time of his death. He had never marriedand had no children. He remained very close to his brother, Frank andFrank’s wife Gay and their children. He had at one time taken on the fulltime role as a carer for his mother. He was well loved and supported byhis family when his health had deteriorated. His family described him asvibrant, engaging and a ‘gentleman’, a view supported by statements ofMCQ staff describing his sociability, independence and helpfulness.9. Mr Drane became a resident at the MCQ in early 2012. The facilityprovided residential aged care facilities and a retirement village. The sitecatered for low care, high care, dementia care, respite care, palliativecare as well as retirement living. Mr Drane was assessed as requiringlow care. He was a long-term cigarette smoker and continued to smoke.Findings of the inquest into the death of John Edward Drane 3As part of his care plans, smoking assessments were conducted byMCQ, which largely permitted him to smoke unsupervised. He had beenprovided with a smoking apron.10. Mr Drane’s recent medical history included cancer of the bladder withthe discovery of a tumour during the course of investigation of ongoingsymptoms over a few months. This had been diagnosed inAugust/September 2013 and was initially treated with two (2)transurethral resection procedures. The next stage of treatment involvedhim receiving a combination of chemotherapy and radiotherapy. Hisother medical history included smoking induced emphysema, somecognitive impairment, poor mobility, osteoarthritis and right bundlebranch block.11. Dr Bigby, Mr Drane’s oncologist, stated he was a frail but independentman with some memory issues. Dr Bigby had some concerns about howMr Drane would tolerate the treatment but believed the combination ofradiotherapy and chemotherapy would add some benefit. Mr Drane wasable to and did consent to the treatment. His cancer had not spread toother organs and there was some potential of a cure.12. According to his brother, Mr Drane’s well-being had deteriorated in thelatter part of 2013, in large part due to incontinence arising from a sideeffect of the surgical interventions. His regular walks to the Sandgateshops were curtailed. He had lost a lot of weight. Notwithstanding hisdeteriorating health, there is little evidence that Mr Drane was particularlysad about his predicament. He had expressed some optimism about thefuture, and had made future plans. He had enjoyed being with familyover the Christmas period. He had certainly never mentioned taking hisown life to family and there is no reference in his hospital records or MCQrecords, which would remotely suggest this as a possibility. There is nosuggestion in the records that a diagnosis of clinical depression was evercontemplated.13. On 7 January 2014, Mr Drane had a peripherally inserted centralcatheter (PICC line) inserted at Redcliffe Hospital to facilitate thechemotherapy infusions. Frank Drane had taken him to RedcliffeHospital. He said Mr Drane’s mood was, under the circumstancesrelatively up-beat.14. On 8 January 2014, Mr Drane attended by organised patient transferwith the Queensland Ambulance Service (QAS) at Royal Brisbane andWomen’s Hospital (RBWH) for his first treatment of radiotherapy. He wastoo late to receive his first set of chemotherapy at Redcliffe Hospital andreturned to MCQ.15. On 9 January 2014, Mr Drane received his first set of chemotherapy atRedcliffe Hospital in the morning and then a second set of radiotherapyat RBWH. He returned via an ambulance from RBWH to the MCQ facilityat about 13:42 hours. It is apparent that a short time later he went to aFindings of the inquest into the death of John Edward Drane 4smoking room located on level 2. It is evident he was not a regular userof the smoking room, preferring other designated outside areas tosmoke. He was observed by domestic cleaning staff, Lynda Johnston tobe smoking a cigarette at around 14:10 hours. Mr Drane was not usinga smoking apron.16. Mr Drane was again seen by Ms Johnston when she returned to thesmoking room between 14:20 and 14:30 hours. At that time his clotheswere on fire. It was unclear as to how he had become alight. There wasone other resident in the room at the time. The fire was eventuallyextinguished by staff members. QFES were called and may have playeda part in dousing the flames. The fire investigator contacted police. QASwere first contacted at 14:34 hours, perhaps indicating the incidentoccurred at closer to 14:30 hours. QAS arrived at 14:37.17. Mr Drane was taken by QAS at about 15:00 hours to the Burns Unit atRBWH. On admission he was noted to have received burns to anextensive part of his body (estimated at up to 65%), which wereconsidered non-survivable. This poor prognosis was discussed with MrDrane, who had remained conscious, and his brother Frank, andpalliative care was agreed to and was provided. He died shortly after22:00 hours.Autopsy results18. A partial internal and external only autopsy examination was ordered.19. There was significant pre-existing natural disease with severe narrowingof the arteries of the heart (coronary atherosclerosis) associated withenlargement of the heart, emphysema and cancer of the bladder. Therewas no evidence of distant spread of the cancer.20. The external examination showed burns involving approximately 45% ofhis total body surface. There were no burns within the respiratory tract.It was the pathologist’s view that the cause of death was due to thesignificant burns. His other significant conditions including coronaryatherosclerosis, emphysema (associated with smoking) and cancer ofthe bladder would have made him more susceptible to the effects ofburns.Concerns of family21. Frank Drane, understandably expressed a number of concerns as tohow these events could occur to his brother in such a short space oftime, with such intensity, in a public room, and without an alarm beingraised until it was evidently too late.22. The circumstances certainly suggested that Mr Drane may have fallenasleep whilst smoking, which could explain why the incident occurredwithout him having called for help or endeavoured to put the fire outFindings of the inquest into the death of John Edward Drane 5himself. There were questions as to whether the use of a ‘smoker’sapron’, which was able to be supplied by the facility was enforced.23. The family do not believe John Drane would have deliberately set himselfon fire and throughout the investigation, including the recent revelationsof the opinion of the fire investigator, maintained their concerns.The investigationsQueensland Police investigation24. QPS attended at approximately 15:00 hours on 9 January 2014. It isapparent QPS were called by fire investigator Gregory Jones who hadbeen called to the incident. By that time Mr Drane had been taken toRBWH and the smoking room had been cleaned by domestic staff.There were apparently concerns about the toxicity or otherwise of thechemotherapy infusion. Nursing management staff took and providedphotographs of the scene taken prior to any cleaning.25. The photographs showed one burnt chair with what appears to be towelsdraped over the back. Photographs showed fire extinguisher residuecovering the floor, one lighter on the floor and one white cigarette lighteron an adjacent chair.26. The police investigation was conducted by Detective Senior ConstableJanelle Walsh. She told the court she was assisted by Scenes of Crimeforensic officer, Shane Scarinci and QFES investigator, Gregory Jones.27. Police were informed that at approximately 14:30 hours one of thecleaners opened the door to the smoking room and observed John to beon fire. A female resident was also in the smoking room at the time. DSCWalsh stated she was informed that the female resident suffered frompoor mobility, was reliant on a walking frame, and suffered from levels ofdementia and a brain injury.28. DSC Walsh spoke with the female resident who was extremelydistressed and difficult to communicate with, she thought due to her braininjury and onset of dementia. She was only able to say that ‘he lit himselfon fire’ and she had seen ‘his pants on fire’. She also provided a videorecorded statement some weeks later. On that occasion she stated ‘I didremember him setting fire to himself. That’s all I remember’. She did statehe was standing up at one stage although this evidence was a responseto a question where she was asked if Mr Drane was standing and shereplied ‘he was standing’.29. The versions of events given on both occasions were consistent. Anumber of witnesses such as Nurse Hudson and Ms Johnston describedthe female resident as being in a state of shock at what she was seeing.30. Although it was raised as a possibility that this resident intentionally litMr Drane’s clothes, DSC Walsh stated this is highly unlikely given herFindings of the inquest into the death of John Edward Drane 6poor mobility. It is apparent the issue of her cognitive impairment as aresult of the suggestion of dementia was not explored in any detail andwas accepted at face value and the statements of the resident notregarded as reliable.31. In fact it is now apparent that the resident had only weeks later beenassessed at MCQ with a minimal level of cognitive impairment based onthe use of a Psychological Assessment Scale tool. She did have difficultyin communication due to the hypoxic brain injury but Nurse Hudsonstated in evidence that at the time of the incident the resident had a goodmemory, could give answers to direct questions and she would notdiscount something she said. Her dementia has since seriouslydeteriorated and she was not called to give evidence..32. The report of DSC Walsh also stated medical staff at RBWH believedthe injuries were not a result of self-harm or assault. On the burn patternsustained they were of the opinion that the injuries were likely caused asa result of him smoking a cigarette as there was no sign from his burnpattern injuries that any accelerant was involved. The report stated thatfrom his injuries it appeared to have been a slow burn starting on thelower shirt, and that it was probable Mr Drane was slow to react due tohis existing medical conditions.33. Professor Michael Muller treated Mr Drane at RBWH. He stated that hedoes not recall discussing the pattern of burns with police. He did notsmell any accelerant. Professor Muller was only recently asked toprovide a statement but in that statement he did say, there was noindication from the patient having been assaulted and he described hiscigarette causing the fire. It is entirely plausible that his combination ofillness, frailty, cognitive impairment, and type of clothing led him to beingslow to react and not preventing the fire from spreading.”34. Given the similarity in the words of Professor Muller and those adoptedby DSC Walsh in her report, it is likely she spoke to Professor Muller andrecorded that opinion in her report.35. On examination by forensic investigators and QFES investigators, it wasnoted there were no traces of accelerants found at the scene. The firedamage was localised to the chair where Mr Drane had been sitting atthe time of the fire and neither cigarette lighter had suffered fire damage.36. Statements were taken from nursing and management staff. A domesticstaff member, Ms Lynda Johnston told police she entered the smokingroom at approximately 2:10–2:15 hours and had a brief conversationwith Mr Drane who told her he had just been to hospital and he waswanting to have a cigarette. She then left the room. She said Mr Dranelooked terrible, weak and sick and not as she had seen him in the past.37. Around 5-10 minutes later she returned, opened up the door and saw MrDrane on fire. She described him sitting in the chair looking at her withFindings of the inquest into the death of John Edward Drane 7his hands on the arm of the chair. Prior to opening the door she had notseen or smelt any smoke.38. She then ran down the corridor looking for assistance and attempted tosmash the fire alarm, which was behind a pane of glass. She was unableto smash the glass panel to access and press the fire alarm. In any eventother staff members had been alerted and arrived to assist. Fire blanketswere placed on John in an attempt to put out the flames. Multiple fireblankets were ineffective and fire extinguishers were then deployed,followed by the domestic staff forming a human chain passing wet towelsalong the lines of nursing staff to place on John to extinguish the flames.Witness accounts described the flames as extremely difficult toextinguish.39. Mr Drane’s family have expressed their gratitude to the staff in theirendeavours to extinguish the flames.40. Most of the witnesses had no recollection of Mr Drane saying anythingnor did he move while sitting in the chair as they were attempting toextinguish the flames. He was not seen to move his hands to his eyes,something Professor Muller said was often an instinctive reaction.Professor Muller also said Mr Drane was very calm in hospital but this isnot unusual as the pain has usually abated because nerve endings havebeen burnt through and morphine had been administered.41. Ms Heather Gambetta stated she heard John saying ‘help, help, I’m onfire’. Nurse Hudson recalls he was sitting in his chair and said ‘Help me,help me’. It is noted that there were no burn injuries to his hands,indicating no attempt was made by Mr Drane to try and extinguish thefire. Professor Muller did say it was unusual that the palms of the handsand the front of the left arm were not burnt. This could indicate a lack ofprotective action, which was unusual and occurs usually where theperson is frail or affected by alcohol or drugs.42. DSC Walsh noted similar incidents have occurred in other nursing hometype facilities. She considered that a phenomenon called the ‘wick effect’played a possible role. This refers to the concept that once clothing hascaught fire, the skin is split, thereby releasing flammable fats. Theclothing then allegedly acts like a wick and the body burns as long as asource of fuel, i.e. fat remains. Fire Investigator Jones discounted thistheory as this phenomenon does occur, but generally later in a firedevelopment where considerable heat is involved and is not reallyconsistent with a quick burning fabric fire.43. DSC Walsh considered domestic and nursing staff acted effectively andquickly once Mr Drane was discovered on fire, to manage and containthe situation.44. DSC Walsh concluded this was an accidental ignition. She concludedthe likely source of the ignition was caused while Mr Drane was smokingFindings of the inquest into the death of John Edward Drane 8a cigarette, causing part of the red hot ash to fall, igniting his shirt aroundthe waist area. Initial smoulder spread quickly to flames covering hisbody, due to his clothing acting as an accelerant. His health and poormobility inhibited him from extinguishing the initial ignition.Queensland Fire and Emergency Service investigation45. Gregory Jones carried out an investigation as to the cause of the fire. Hehas internal organisational training and accreditation as a fireinvestigator. He said the investigation was carried out in conjunction withQPS who were the lead agency. The fact the two organisations did notprovide the other with their respective reports is a matter of considerableconcern.46. Mr Jones stated the integrity of the fire scene and the room of origin wasdamaged as the staff of the facility had thoroughly cleaned the area priorto the arrival of all investigators.47. A number of photographs were taken at the scene by staff beforecleaning the room and by Scenes of Crime officer Scarinci. Mr Jonesattended at the scene on 9 January 2014. The designated smoking areais accessed via a pair of hinged doors, which open into the smokingroom. The smoking area displayed no fire, heat or smoke damage. Theonly indication of any fire activity was some residue of the extinguishingmedium after the use of a dry powder extinguisher and a number of darkhand prints on the wall on the western side of the middle windows thatMr Jones considered were most probably from Mr Drane’s hands postfire or persons assisting Mr Drane. The limited amount of heat producedby this quickly evolving fire involving the clothing did not activate thethermal detector located within the smoking area where the fire hadoriginated.48. The remains of Mr Drane’s clothing in the chair he was sitting on wererecovered and repositioned within the area of origin as they had beenremoved when the area was cleaned.49. Mr Jones stated the fire damage observed on the chair is consistent withthe damage on the two armrests with more damage on the left side thanthe right side; the lower left side of the back rest displays an area ofpartially consumed vinyl covering with exposed and partially consumedfoam padding; the remaining vinyl covering surrounding and extendingabove this exposed foam is deeply charred and discoloured with areasof blistering surface extending to the top of the back rest on this sideonly. The right side back rest displays less damage with a small area ofexposed foam padding and charred and blistered vinyl extending upwardapproximately 200mm. This damage indicated there had been directflame contact extending from the lower to upper areas of this chair.50. Mr Drane’s clothing was examined. The under and over shirt wereconstructed of a cotton blend t-shirt type material. His long trousers wereFindings of the inquest into the death of John Edward Drane 9of a polyester cotton blend. Mr Jones opined the fire damage displayedwas consistent with the bottom of the trouser legs being ignited andsubsequent upward fire progression due to convection and direct flamecontact from Mr Drane’s shoes and socks up the front of the trouser legsto the crutch area, where it has then ignited the upper body garments.Mr Jones stated that fire extends upwards. If the fire had originated inthe lap he said the fire would go up the upper body but would not godown the legs.51. The path of fire travel was from the top of each of Mr Drane’s shoesupward to shoulder level to the front surfaces of his clothing. The fire didnot extend beyond Mr Drane and the chair he had been sitting on.52. Tests were carried out on similar fabrics with medication obtained fromthe Redcliffe Hospital oncology unit. Mr Jones stated the medicaltreatment received on the morning of the fire has not been identified tocause the emission of flammable liquid vapour or gases from the skin orbody, and the medication carried as part of the treatment was not foundto promote fire growth or ignition of similar clothing to that worn by MrDrane. The investigator conducted atmospheric testing in contiguity tothe clothing that Mr Drane was wearing at the time of the fire. Noelevated levels of volatile organic compounds were detected.53. Mr Jones repeated on a number of occasions in his evidence that therewere very unusual aspects of the case. He believes the possibility offlammable gases/vapours exuding from the skin or body after this typeof treatment needs further research, as the rate of fire growth and thepartial consumption of Mr Drane’s clothing from his shoelaces to his shirtcollar is unusual for a person who was in the seated position.54. It was the opinion of the investigator that the fire damage observed onthe clothing and the chair Mr Drane had been sitting on at the time of thefire could have been caused by direct flame contact (by the twodisposable lighters that were found) to the front lower sections of histrousers legs, with legs extended whilst in a seated position, and the firehas progressed upward to involve the front only of his trousers. Due tothe extra fabric gathered at his lap whilst in the seated position, the firehas intensified in this area causing the damage observed on the chairand on the front of the upper body clothing.55. The investigator opined that it was highly unlikely that a droppedcigarette would ignite the clothing worn by Mr Drane and a fire ignited ina person’s lap would not cause the fire damage to the lower sections oftrousers and socks as observed on both left and right legs.56. As two persons were in the room at the time of the fire, Mr Jones statedeither person may have ignited the clothing, although it is possible thatMr Drane has ignited his own clothing intentionally using the lightersfound on either side of his chair. He repeated that rapid fire growth andFindings of the inquest into the death of John Edward Drane 10partial consumption of Mr Drane’s clothing from his shoelaces to the shirtcollar is unusual for a person in a seated position.57. Mr Jones provided an addendum report. Further tests were conductedon 13 May 2016 as to the path of fire travel. A further series of small fireswere ignited on the clothing placed on a canvas clad dummy. Theclothing obtained was of the style and of similar materials worn by MrDrane. The clothing used for these tests was the same for all three flameignited tests, and the one set of clothing was used for all cigarette ignitiontests. The cigarette used for the ignition tests were Marlboro Red,Australian fire risk compliant, reported to be the same as used by MrDrane.58. Five tests for flaming ignition caused by placing a lit cigarette on multipleareas of the clothing and on the seat cushion between the legs of thedummy, did not attain flaming ignition. One cigarette that was placed onthe seat cushion between the legs self-extinguished within eight minutesleaving a 1.5 cm melted section of vinyl seat covering. Four othercigarettes burnt to the butt and left holes in the fabrics on which theywere placed only. The fabrics located under the layer that cigaretteswere placed on, displayed heat and smoke damage only. The tests in noway prove that a cigarette dropped on clothing or upholstery cannotignite these items, as it is well documented that this can occur and cottonand cotton blends are more susceptible to ignition than most fabrics.59. The three targeted ignition tests displayed similarity where rapid fireextension was observed on vertical or near vertical surfaces and minimalfire spread on downward angled surfaces. No drop down of ignited fabricmaterials was observed, only the drop down of the internal rubber fillingof the dummy in video 2 can be seen.60. The test burn observed in video 3 best replicates the damage to MrDrane’s clothing and body above the knees. The approximate time ofignition at the knees to the level of fire involvement of his clothing thatwas exposed to flaming combustion was 4 to 5 minutes. This path of firetravel does not explain the fire damage displayed on Mr Drane’s lowerlimbs, trousers, socks and shoes.61. Test 2 was ignited at the dummy’s feet and displayed extensive damageto the front and underside of the chair and a prolonged period of time atthe transition from vertical flame travel from the feet to knees to thehorizontal travel from knees to waist. Nine (9) minutes elapsed beforefire had extended to the head and chest.62. Test 1 extended from the lap of the dummy to the head and chest withinthree minutes and less than 200 mm of the lateral fire spread wasobserved towards the knees of the dummy.63. In Mr Jones’ opinion the only way fire could have extended from a singlepoint of origin to damage the clothing and body of Mr Drane as observed,Findings of the inquest into the death of John Edward Drane 11would have been from a point of ignition at or near the trouser hem linewhilst he was standing, or he has stood up whilst the fire was extendingup the legs past the level of the knees.64. Mr Jones opined the alternative hypothesis would be multiple seats offire. He said it would be unlikely that multiple seats of fire could havebeen ignited by discarded or mishandled smoker’s materials. The firedamage and directional indicators observed at the fire scene and testingfires indicate that accidental ignition by discarded or dropped smoker’smaterial of the clothing worn by Mr Drane is unlikely but possible. Themost probable source of ignition would have been by direct flame contactby a person or persons unknown either accidentally or intentionally.Office of Fair and Safe Work Queensland65. Office of Fair and Safe Work Queensland (OFSWQ) conducted aninvestigation. Inspector Deborah Dargan completed the report. MsDargan had been informed by Police that the initial view was this was acase of suicide and she acknowledged this impacted somewhat on theinvestigation conducted.66. The facility advised that upon admission a ‘Smoking AssessmentResident Safety Status’ document was completed by a registered nurse.This document revealed that Mr Drane had an initial smokingassessment completed on 15 February 2012. The facility was advisedthat Mr Drane had a history of alcohol abuse and while under theinfluence of alcohol, a cigarette had set fire to furniture in his privateresidence. This incident precipitated his moving to care.67. Upon admission Mr Drane was put into a high dependency area andmonitored for alcohol use. After a period of time it was determined therewere no significant behavioural issues and he had no trouble smoking.As a result he was moved upstairs where residents were moreindependent.68. A Smoking Assessment Resident Safety Status document was thenupdated with ongoing assessments performed on 4 April 2012, 3 March2013 and 23 August 2014.69. The smoking assessment determined: He could be in possession of his own cigarettes in his room andsmoke them in the smoking area; He could not possess a lighter in his room; and He did not require a smoking apron or assistance when in thesmoking area.70. The investigation revealed that medically, Mr Drane had no mobility ormanual dexterity problems. The investigation did not reveal the exactcircumstances as to how Mr Drane became alight.Findings of the inquest into the death of John Edward Drane 1271. The investigation noted that since the incident a number of post incidentinterventions were implemented.72. OFWSQ made the following relevant conclusions: Upon admission to the facility Mr Drane was assessed and asmoking assessment document was completed; The assessment tool addressed physical and cognitive capacityfor smoking and identified any intervention requirements; Mr Drane was identified as able to possess cigarettes in his roomand smoke unsupervised, however he was not permitted a lighterin his room; The care plan was updated on 4 April 2012, 3 March 2013 and 23August 2013 with no changes to his unsupervised status; Mr Drane was an independent resident with no indication that hewas physically incapable of holding a cigarette or extinguishinghis cigarette, he was able to mobilise to and from smoking areaswithout assistance; The investigation concluded there is insufficient evidence that MrDrane had a reduced cognitive ability or functional capacity thatwould make smoking without supervision intrinsically unsafe; theinvestigation considered the facility had correctly identified thehazard, adequately assessed the risk and subsequentlyimplemented satisfactory controls to ensure the safety of smokingresidents at MCQ; Post incident changes to documentation have been made to allowassessment by a General Practitioner when certain risk factorsare identified in residents, however there is no evidence that a GPreview would have identified the need for supervised smoking byMr Drane.Review of Masonic Care Queensland records73. An Aged Care and Assessment Team (ACAT) record dated 16 January2012 recommended Mr Drane have low-level residential care to supportthe needs of himself and his current carers. It specifically noted thatsupport required included a monitored environment for cigaretteconsumption and ongoing management of alcohol intake.74. A comprehensive medical assessment was conducted when Mr Dranewas admitted. This noted that he was a smoker and a smokingagreement was put in place and signed on 15 February 2012. ASmoking Assessment Resident Safety Status form was completed. Thisseems to suggest the form was completed on 15 February 2012,updated on 4 April 2012, 3 March 2013 and 23 August 2013.75. This documentation noted a past history of cigarette burns to furniture.At least one of the forms indicated that with that history a number ofFindings of the inquest into the death of John Edward Drane 13strategies should be put in place including being supervised one-on-oneby a staff member, wearing a smoking apron and not to be allowed tokeep cigarettes in his possession. It is apparent that subsequentassessments indicated he was able to have cigarettes in his room withno lighter and no other specific needs were required including those ofvisual supervision or a smoking apron.76. The records note the history of diagnosis of a bladder tumour. This notedan intention for radiotherapy and chemotherapy.77. It is common knowledge that chemotherapy and radiotherapy can havedebilitating side effects. Prior to the commencement of therapy it wasnoted by Mr Drane’s oncologist in correspondence to the GP, care of theMasonic Care Queensland, that he was rather frail and they intended tobe very circumspect as to tolerability given he was not as robust as heonce was. Dr Bigby explained in evidence that there were concerns asto how Mr Drane would tolerate treatment but they came to the viewthere would be benefit in combining the two treatments and felt that withthe supported accommodation he was in there would be adequatesupervision to allow it to go ahead. Mr Drane had in his view somememory issues but understood the treatment proposed and was keen toproceed as it gave him potential for a cure.78. The facility was advised in writing by Redcliffe Hospital and RBWH aboutthe proposed treatments, which were to commence on 8 January 2014.The facility records in fact are quite complete and have copies of anumber of letters from his oncologists, addressed to his GP, noting theproposed treatment.79. The issue of reviewing and assessing Mr Drane in light of this treatmentwas raised by Nurse Hudson. She made an entry in the nursing notes at7am on 9 January 2014 that he needed to be assessed. The evidencefrom Nurse Hudson and of Ms Susan Beasley, the newly appointedExecutive Manager for Residential Care, was that this review wouldnecessarily have to take place after treatment commenced to ascertainhow it had impacted on Mr Drane. Unfortunately Mr Drane arrived backat the facility unannounced and within thirty minutes was on fire. Therewas practically no time for a review.80. Post incident changes were made to ensure the Smoking AssessmentResident Safety status form was updated six monthly for residents aswell as after a change in medical or physical circumstances. As well aregistered nurse has been overseeing the reassessment and review ofresidents who currently smoke at the facility. An additional section wasadded to the form. If the resident has any of the items on the list such asdementia, signs and symptoms of depression, decreased dexterity, lossof smell or loss of cognitive function, then the resident must be reviewedby their General Practitioner to establish if the resident can smokewithout direct supervision.Findings of the inquest into the death of John Edward Drane 1481. Informal education sessions would continue to be provided to registeredstaff to remind them of their responsibilities for ensuring the care-staffsupervise residents who smoke and to reinforce care-staffresponsibilities for monitoring resident safety.82. Subsequently MCQ have also determined that from 1 October 2014 allMCQ sites became smoke free environments and smoking is no longerpermitted within associated buildings or grounds.83. For residents who resided in MCQ facilities prior to 1 October 2014, andwho continued to wish to use smoking products, those residents will beassessed regarding their capacity to comply with the smoking policy andtheir ability to smoke safely. Assessments will be conducted on a sixmonthly basis and as the resident’s condition changes. Smoking mayonly take place in designated smoking areas.84. All residents currently residing in MCQ facilities, who use smokingproducts, have also been given the opportunity to engage in a QUITprogram or consult with a GP to discuss the use of nicotine replacementproducts.Report by Pam Bridges85. MCQ helpfully commissioned an independent expert review by PamBridges. She has a nursing background but more particularly has veryextensive experience in the aged care sector at managerial level and isnow a consultant to the industry.86. Ms Bridges gave evidence about residential aged care generally and thatit is governed by the Aged Care Act 1997 and a Charter of Resident’sRights and Responsibilities (the Charter).87. Ms Bridges stated it is the responsibility of an aged care provider toassess the care needs of all residents and to monitor and review careplans on an ongoing basis. It is normal practice to review care plansevery three months or at any time when the resident’s health status haschanged significantly.88. Ms Bridges stated that Mr Drane was appropriately assessed as lowcare, and in fact his care needs were at the lower end of low care needs.Relevantly in relation to depression, the Cornell Scale Assessment wasundertaken on 28 August 2013 and scored 1 (minimal impairment).89. There were no behaviours identified under wandering, verbal behaviourand physical age. It was noted Mr Drane was a smoker. A smokingassessment was undertaken on the day he was admitted in 2012 and afurther review was undertaken on 23 August 2013. It was noted that MrDrane was able to self-mobilise to the smoking area and there were noproblems identified with dexterity or smoking. His preferred times forsmoking were during the day and after meals.Findings of the inquest into the death of John Edward Drane 1590. However, Ms Bridges noted the smoking assessment form states that ifany items were listed on the form, including relevantly in this case a pasthistory of cigarette burns to furniture, then certain strategies should havebeen implemented. These included either being supervised by staff; astaff member being in close proximity when smoking; wearing a smokingapron and not being allowed to keep cigarettes in their possession.Accordingly strategies listed above should have been implemented.91. Ms Bridges noted that Mr Drane was very independent and had settledhappily into life at MCQ. He was by all accounts a much loved residentwho interacted well with staff and other residents. There wereinconsistencies in the smoking assessment tool, which were regrettable.It appears he was assessed overall as being able to smokeunsupervised, and this assessment was confirmed on two laterassessments. Mr Drane smoked on the premises largely unsupervisedfor almost two years without any recorded incident. Although thesmoking assessment tool suggested he have no cigarettes in hispossession and no lighter, as Mr Drane walked to the shops most days,he had the ability to smoke away from the premises as he pleased andbring back unsecured lighters and cigarettes.92. Ms Bridges stated that otherwise in the documentation provided, shefound evidence of ongoing assessment and care planning for Mr Drane.93. In Mr Drane’s circumstances, his health remained relatively stable up toand including the commencement of radio-chemotherapy treatments. Heappeared to have maintained his independence and although additionalassistance was offered by staff, he did not wish staff to assist.94. Ms Bridges stated the documentation shows evidence of staff monitoringhis specialist appointments, treatments and transport needs during thelast few months. During this time his brother Frank routinely escorted MrDrane to appointments and at other times QAS services were arrangedby staff.95. By all accounts from the documentation reviewed, Mr Drane was veryhappy living at MCQ and with the level of staff support and assistancehe was offered and received. She believes that the responsibilities ofMCQ as set out in the Charter appeared to have been met and his rightsunder the Charter appeared to have been respected.96. Ms Bridges noted that the documentation demonstrated Mr Dranemoved around the complex without restriction as well as taking almostdaily walks to Sandgate or to the shops. These activities were recordedin his care plan or in progress notes on a regular basis. Mr Drane alsoattended the Men’s Shed activities and regular bus outings. He left onsocial leave on many occasions, usually in the company of his brother.Findings of the inquest into the death of John Edward Drane 1697. Mr Drane was free to come and go as he pleased, but there wasevidence staff were prepared to assist him if he so wished. He remainedfiercely independent and in such a case the Charter requires he bepermitted to exercise independence. He was not left to merely reside atthe facility, as there is also evidence that information was relayed toMCQ and Mr Drane’s GP following specialist appointments and evidencethat his GP attended on the average weekly and as needed as well asreviewing all specialist feedback.98. The issue of Mr Drane’s coming and goings on social and medicalappointments was considered. Ms Bridges stated there is no need underthe applicable legislation or in accordance with proper practice todocument the movements of low care residents other than to ensure theresident signs in or out to alert staff as to his whereabouts.99. The progress notes do indicate when Mr Drane departed the facility forsocial leave or for medical appointments. Staff appeared to be wellaware of what was arranged and recorded this information.100. The records show that Mr Drane’s health status was monitored closelyby staff, from when he first commenced investigations for his cancer, andsubsequently during his treatments. Because his functional abilityappears to have altered very little during this time, there was no pressingneed or occasion to formally reassess him. Ms Bridges stated that in thedocuments reviewed there was no apparent time or event that wouldlead her to conclude that a further re-assessment or risk assessmentwas required. Such a reassessment would only ordinarily occur outsidethe three month cycle once a significant change in condition has beenobserved. She considered that the records show that staff were veryattentive to Mr Drane’s condition and needs during this time.101. Ms Bridges was asked to review the letter from Dr Bigby dictated on 18December 2013 and received at MCQ addressed to Dr Balthes his GPon 8 January 2014. She stated there was nothing in this communicationthat would necessitate or prompt staff at MCQ to undertake anyadditional care over and above the care already been provided. There isno indication in the letter that there was likely to be any significantchange in care needs, or the need or extent of any need.102. Ms Bridges stated that in terms of assessments to decide whether a careplan should be changed, that process must necessarily react to theobserved condition of the resident once the treatment had beenadministered and he had returned to the facility. Progress notes dated 9January 2014, state that assessments were to be reviewed. Ms Bridgesstated that the flagging of the need for nursing staff to reviewassessments was very appropriate, as this ensures that the issue shouldreceive prompt attention when the resident returns after treatment, whichis the first opportunity to do so in such a case.Findings of the inquest into the death of John Edward Drane 17103. Ms Bridges was of the opinion that the care provided for Mr Drane wasconsistent with his assessed care needs at that time. There wasevidence that his condition was altering since he commenced hisradiation and chemotherapy and she feels confident, having reviewedhow staff were monitoring his condition, that any changes or futureneeds would have been managed appropriately when the time arose.104. Ms Bridges does not believe a different approach to his care orsupervision prior to the fatal incident would have changed the ultimateoutcome. This is particularly so because up until a few days before hisdemise, Mr Drane apparently continued to function at his usual level.105. A Patient Self Reporting Health History conducted by RBWH on 16December 2013 indicated that he was enjoying life and felt cheerful mostof the time. He reported some difficulties with shopping and mobility. Hedid not have any increasing fatigue. Ms Bridges did note the earlierPatient Self Reporting conducted at Redcliffe Hospital on 4 December2013 showed Mr Drane may have been struggling a bit, which on thebasis of the score warranted a Social Work referral. She stated that thistool is a useful one and considers it could be utilised in the aged caresector in appropriate patients. The fact that there was a more optimisticself-assessment 12 days later in itself would have been usefulinformation to have been communicated to the nursing home.106. This raised the issue of how there could be better communicationbetween aged care facilities and hospitals/GPs both ways in caseswhere there may be an increased risk of self-harm.Conclusions on the issues107. It is incumbent on a coroner to endeavour to make a finding wherepossible of whether a death has been caused by accident, by intent of athird party or that the deceased intended to take his own life. A coronershould apply the civil standard of proof, namely the balance ofprobabilities but the approach referred to as the Briginshaw sliding scaleis applicable.1 This means that the more significant the issue to bedetermined, the more serious an allegation or the more inherentlyunlikely an occurrence, the clearer and more persuasive the evidenceneeded for the trier of fact to be sufficiently satisfied that it has beenproven to the civil standard.2 108.Hence I need to have a high degree of satisfaction before making afinding of intentional harm by a third party or one of suicide as distinct from accident, and if that is not possible an open finding may need to beconsidered. 109.I am satisfied that a third party was not directly involved in Mr Drane’sdeath. The other resident in the room was not involved in setting Mr 1 Anderson v Blashki [1993] 2 VR 89 at 96 per Gobbo J2 Briginshaw v Briginshaw (1938) 60 CLR 336 at 361 per Sir Owen Dixon JFindings of the inquest into the death of John Edward Drane 18Drane alight. There did not appear to be any defensive action by MrDrane, as it is evident he did not use his hands to try and extinguish theflame. He made no mention of being assaulted or set alight to MCQ staff,to QAS, to hospital staff or his brother. He was conscious,communicating, noted to have a GCS of 15 at all times and had ampleopportunity of saying something to that effect.110. There is no account in the medical records as to how the fire startedalthough Professor Muller said his memory was Mr Drane said acigarette lit his clothing. Professor Muller said it was unusual the palmsof his hands were not burnt.111. The only other account came from the other resident in the room. Shehad difficulties in communication due to a brain injury but was notconsidered to have other than mild impairment by dementia. She gavetwo consistent stories to police at different times that ‘he lit himself onfire’ and she had ‘seen his pants on fire’. She repeated in her videointerview that she ‘did remember him setting fire to himself’ and that atsome point he was ‘standing up’.112. I accept this evidence should be somewhat discounted but notdisregarded, because of the paucity of evidence regarding the resident’scapacity to give an accurate version at that time and as well she couldnot be tested on her version at the inquest. The resident was unable toprovide really any more detail, although she accurately described inminor detail the events that followed. However, the version of eventsgiven by the resident is consistent with the hypothesis of the QFESinvestigator that the fire emanated at the feet of Mr Drane. He may havebeen standing, as described by the resident, allowing the flames to morequickly spread to his lap and upper body and then he sat down. This alsoexplains why there was little damage to the underside of the chair. It isfurther possible that in addition Mr Drane lit himself at various points onhis clothing, again consistent with the rapid spread of the fire.113. The QFES investigator’s evidence is that it is highly unlikely a droppedcigarette would ignite the lower sections of the trouser legs. The trousersdid not have cuffed hems which could entrap a cigarette. Tests revealeda dropped cigarette to the lap area was unlikely, but possible (becausesuch an event has been known to occur), to result in a rapid burn seenin this case but not to the legs. It should also be noted that for someyears all cigarettes used in Australia utilise fire retardant bands to thepaper slowing the burn rate.114. The evidence against a finding of suicide largely rests with the fact thatMr Drane had not been noted to be depressed or overly sad at hispredicament; he was well supported by his family and to a some extentthe staff at MCQ; he had some prospects and confidence of a cure; hehad some future plans and he had never expressed such negativesthoughts to his family or nursing and medical staff. There is nosuggestion he was unwell to the extent he did not have capacity to knowFindings of the inquest into the death of John Edward Drane 19what he was doing. As well, although self-immolation is very much alethal method of suicide, to ensure death an accelerant is usually used.115. At the scene he was heard by two persons to request help, but in contrasthe was also said to be quiet and calm and made no effort to use hishands to try and extinguish the fire and just sat in the chair.116. Hence if he did make that decision to take his own life it was completelyunexpected and unpredictable. Unfortunately that is very often the casewhere suicide occurs. There is no warning and often these tragicdecisions are made impulsively and without any planning. It isspeculative but maybe not a coincidence that he made the decisionshortly after having his first combined set of radiotherapy/chemotherapy,was feeling quite unwell and may have decided this was enough for him.117. After reviewing all of the evidence, I have come to the unfortunateconclusion that Mr Drane intentionally set fire to himself in such a fashionto cause a rapid spread of the fire and to cause life threatening injuries.The fire emanated at his lower trouser area after he utilised one or twocigarette lighters. He probably stood at one point which allowed a morerapid spread over his clothing and may have ignited a number of areasof his clothing. I accept the distress this finding will cause to Mr Drane’sfamily who could not have predicted or prevented these events.118. In reviewing the police report, it seemed on the face of it evident that thepolice investigator was not aware of the alternative conclusions of theinvestigation of the Queensland Fire and Emergency Service. It turns outthis was not the case. DSC Walsh says Mr Jones had discussed hisopinion with her and DSC Walsh was aware of it when she prepared herreport to the coroner. It was most unhelpful that the alternative view wasnot included in her report as it would have ensured further investigationby my office would have taken place immediately. It was only inpreparing final witnesses for the inquest that Mr Jones provided hisreport. Mr Jones believes he may have been asked by police to send hisreport but he agrees he failed to do so unintentionally. That also wasmost unhelpful.119. It is also apparent that the suggestion that this was a case of suicide wasconsidered by police initially as this was also relayed to OFSWQInvestigator Dargan and was shared in email communication withOFSWQ. That alternative conclusion was not mentioned in any reportsto the coroner. The OFSWQ investigation was not assisted by either aQPS or QFES report.120. Hence, the coronial investigation focused on the scenario of a droppedcigarette being the cause of the fire and concentrated on the assessmentand management by MCQ of the risks caused by Mr Drane’s smokinghabit, particularly in the context of his recent medical treatment.Findings of the inquest into the death of John Edward Drane 20121. As this office was in regular contact with Mr Drane’s family, includingproviding them with updates and reports, they also presumed this wasan accidental death. It would have compounded their grief to be told overtwo years later there was an alternative conclusion of a particularlydistressing nature being suggested. This should never have occurred.122. I agree with Ms Jarvis’ submission that QPS, QFES and WHSQcollaboratively review their involvement in this matter and identify themost practical and efficient means for ensuring that when the variousagencies are involved in investigating a death or serious injury involvinga fire, that the roles and responsibilities of each agency are clearlydefined and appropriately carried out to ensure relevant information isshared. I am aware QPS and OFSWQ have entered into a Memorandumof Understanding and along with other agencies investigating workplacedeaths meet regularly and it is believed this has improvedcommunication and liaison. A similar model may include QFESinvolvement. It is understood that in fact there may be two projectsunderway discussing these various issues between QFES and QPS.This includes the Reducing Unlawful Fires (including Arson) InvestmentProposal jointly between QPS, QFES and Rural Fire ServiceQueensland approved in 2014 but waiting implementation. QPS havealso looked at the issue in the form of a QPS Reducing Unlawful FiresInitiative Proposal. Given much of the work has been conducted I urgethe agencies to implement and/or complete these proposals.123. It is evident the MCQ facility had conducted assessments over a rangeof Mr Drane’s capacity to undertake daily activities, including smoking.124. I accept that from the time of his admission to the facility in early 2012 toaround August 2013, there was little indication that smoking by Mr Dranewould have been unsafe. He was then diagnosed with bladder cancer.His treatment was to include a combination of chemotherapy andradiotherapy. The facility was appropriately informed and updated aboutthe treatment being provided to him.125. MCQ staff had noted that Mr Drane needed to be further assessed assuch treatment is well known to be debilitating and more so to an elderlyperson.126. It may have been optimal to have re-assessed after his recent diagnosisand surgical procedures. What a re-assessment of his smoking andother capacities would have found is unclear. It is clear an appropriatedecision had been made to review him after chemotherapy hadcommenced. It is evident that the events that occurred took place verysoon after his return from hospital giving no practical opportunity for thatassessment and review.127. MCQ have since changed their policies to require re-assessments eachsix months or as the resident’s condition changes, for current residentsFindings of the inquest into the death of John Edward Drane 21who smoke. No new residents will be permitted to smoke within thegrounds or buildings.128. I find that the care provided by MCQ was appropriate and theimprovements conducted by MCQ are also beneficial, particularly if thefinding had been one of accidental dropping of a cigarette. The fact thatMr Drane would take his own life could not have been predicted by MSQbut raised the issue of the benefit of risk assessments specifically lookingat such an event.Mental Health and Suicide Risk Assessment129. Dr Bigby, Mr Drane’s oncologist, agreed depression and anxiety is amajor issue with patients and such conditions would not be unusual fora person receiving oncology treatment. Dr Bigby stated that hisOncology Department had limited access to resources to address thosereal psychosocial problems. He had no welfare worker, one overworkedsocial worker and a shared psychologist. These limited resources havebeen raised by him as an issue for some time. He is optimistic later thisyear he will have a full time welfare officer, and more social work andpsychologist support.130. Recent media reports indicated concern that suicide rates haveincreased significantly in Australia in recent years. Certainly inQueensland that is the experience of the Coroners Court. In my ownexperience it is of real concern there appears to be increasing numbersof elderly people who are taking their own lives in the context ofdeteriorating physical conditions, almost always on their own, withoutwarning and often violently. Not all are suffering from clinical depression,or if they are, this is undiagnosed.131. A week prior to the inquest, I was made aware by the Queensland basedAustralian Institute for Suicide Research and Prevention of a selectedresearch paper considering physical diseases as predictors of suicide inolder adults.3132. I requested the assistance of the Office of the State Coroner Domesticand Family Violence Death Review Unit (DFVDRU) who haveconsiderable multidisciplinary experience over a wide range of areas ofsocial issues including not only domestic violence, but child protectionand mental health/suicide prevention. A brief literature review wasconducted.133. In summary, I am advised that research indicates that depression andsevere physical health conditions may increase risk of suicide amongstolder persons, with some indication of an elevated risk immediately afterdiagnosis. Suicidal behaviour amongst older persons is often undertaken3 Erlangsen, A., Stenager, E. & Conwell, Y (2015) Physical diseases as predictors of suicidein older adults: a nationwide, register based cohort study, Social Psychiatry and PsychiatricEpidemiology, 50: 1427-1439Findings of the inquest into the death of John Edward Drane 22with greater intent, and greater lethality than amongst younger cohorts.Elderly persons are less likely to discuss their plans prior to death andare more likely to choose more lethal methods.134. The research suggests depression amongst this cohort is underdiagnosed, and therefore under-treated. There is a strong relationshipbetween depression (or the presence of depressive symptoms) andsuicide in older persons. 135.This cohort is in regular contact with health providers because oftreatment of their medical condition (and therefore a captive audience in terms of screening and assessment) and therefore it is an ideal point ofintervention for suicide prevention strategies.136. Similarly, aged care facilities should also be cognizant of suicide riskamongst residents, as well as their physical health, particularly in periodsof known elevated risk (immediately after diagnosis) or where there maybe an absence of protective factors, noting that staff have an importantrole to play in the emotional and social well-being of residents. 137.Training may be of benefit for staff in aged care facilities to assist in thedetection of suicidal ideation or other mental health concerns. 138.A copy of the literature review conducted by the DFVDRU is attached tothis decision, for which I thank them. Findings required by s. 45Identity of the deceased – John Edward DraneHow he died – John Drane took his own life when he set hisclothing alight in such a manner to ensure arapid spread of fire across his clothing. This wasprobably in the context of a deterioration in hisphysical wellbeing due to treatment for bladdercancer. His actions could not have beenpredicted by members of his family or staff at hisnursing home.Place of death – Royal Brisbane Hospital, HerstonDate of death– 9 January 2014Cause of death – 1(a) Burns2 Coronary atherosclerosis; emphysema;smoking; urothelial carcinoma of bladderComments and recommendationsIn light of the research referred to in relation to physical diseases as predictorsof suicide in older adults, and the evidence of Dr Bigby that this is a realFindings of the inquest into the death of John Edward Drane 23psychosocial issue which needs resources to address the issue, I recommendthat the Queensland Department of Health, in partnership with the aged caresector and the general practitioner sector, implement routine screening andassessment for elderly persons diagnosed with and/or undergoing treatment forsignificant physical conditions, together with screening for depression (giventhe correlation between the two).I further recommend that the Queensland Police Service, Queensland Fire andEmergency Service and Workplace Health and Safety Queenslandcollaboratively review their involvement in this matter and identify the mostpractical and efficient means for ensuring that, in future, when the agencies areconcurrently investigating a death or serious injury involving a fire, that the rolesand responsibilities of each agency to inform each other’s recommendationsand to properly advise and put all relevant evidence before the investigatingcoroner, are clearly defined and appropriately carried out. This may includeentering into a Memorandum of Understanding and/or implementing currentinitiatives being the Reducing Unlawful Fires (Including Arson) InvestmentProposal and QPS Reducing Unlawful Fires Initiative Proposal.I close the inquest.John LockDeputy State CoronerBrisbane15 June 2016Findings of the inquest into the death of John Edward Drane 24Attachment ASuicide Risk and Prevention in Elderly Persons with Cooccurring Physical Health Conditions In addition to psychiatric disorders, the presence of physical disease hasbeen linked to increased risk of suicide in older adults, however thisrelationship is not directly causative and the elevated risk may bebecause of pain or feelings of perceived burdensomeness, situationalfactors such as impairments to daily living or temporal factors such asrecent hospital contact or hospitalisation or distress with respect to arecent diagnosis4. It is also suggested that certain physical health conditions, such asstrokes, diabetes, heart disease and chronic obstructive pulmonarydisorders have been linked to a higher rate of depression after diagnosis,the presence of which can be underdiagnosed, and therefore not treatedin older adults5. The under diagnosis of depression also makes it difficult to clearlyestablish the inter-relationship between physical health, co-morbidmental health conditions and suicide risk through research. There is a strong correlation with affective disorders for suicide risk inlater life, with an indication that whilst physical illness and functionalimpairment may increase risk, this relationship is mediated bydepressive symptoms6. Further, whilst common illnesses (inclusive of both psychiatric andphysical illnesses) are independently associated with an increased riskof suicide in the elderly, the risk appears to be cumulative andexacerbated among patients with multiple illnesses7 The trauma associated with a diagnosis of cancer may itself triggerimmediate health consequences independent of the effects of thedisease or the treatment; with estimates of the relative risk of suicidepost-diagnosis being 12.6% during the first week and 3.1% during thefirst year for one study89. This relationship was most notable in thosepatients with a poor prognosis, irrespective of pre-existing, diagnosedpsychiatric conditions.4 Erlangsen, A., Stenager, E. & Conwell, y> (2015) Physical diseases as predictors of suicidein older adults: a nationwide, register-based cohort study, Social Psychiatry and PsychiatricEpidemiology, 50: 1427-1439.5 Lebowitz, B.D> Pearson, J.L., Scneider, L.S. et al (1997) Diagnosis and treatment ofdepression in late life JAMA 278:1186-1190.6 Conwell, Y., Duberstein, P.R. & Caine, E.D. (2002) Risk factors for suicide in later life,Society of Biological Psychiatry,7 David, N., Juurlink, M.D., Hermann, N. (2004) Medical illness and the Risk of Suicide in theElderly, Internal Medicine 2004; 164 (11) 1179-11848 Fang F., Fall, K., Mittleman, M.A. et.al. (2012) Suicide and Cardiovascular Death after aCancer Diagnosis, The New England Journal of Mediicine9 Also see https://allaplusessays.com/order of the inquest into the death of John Edward Drane 25Suicide in nursing homes and long-term care facilities Whilst there has been some research which suggests that suicide risk islower in long term care settings like nursing homes, due in part to levelsof staff supervision, other research indicates that rates are similar to thatamongst older persons in the community10. Given the high prevalence of natural-causes deaths and functionaldecline amongst residents within nursing homes and long-term caresettings, this can be a source of anxiety for other residents11. Although itis not uncommon for residents to discuss death, including suicide, staffmay be reluctant to engage in these discussions12, which may precludeopen discussions about suicidal ideation or intent. Another American study also identified that despite long term care beingseen as a protective factor for suicide, because of the high levels of staffsurveillance, reduced access to lethal means and opportunities forintervention by health care providers, factors such as low social supportand depression may increase risk13. There is however strong evidenceto highlight the positive role that staff play in the promotion ofpsychosocial well-being amongst residents14.Suicidal behaviour in the elderly Notably suicidal behaviour amongst older persons is often undertakenwith greater intent, and greater lethality than amongst younger cohorts15.Elderly persons are less likely to discuss their plans prior to the deathand are more likely to choose more lethal methods16, which means theyare less likely to survive a suicide attempt17. Their deaths by non-violentcauses also may be mistakenly attributed to an illness18 as opposed toan act of intentional self-harm. Whilst suicide rates are disproportionally high in the elderly, and they aremore closely associated with significant mental illness or physical healthconcerns, they are correspondingly less likely to be recognised, oreffectively treated, in those elderly persons who come into contact withservices; indicating a need for health practitioners (i.e. GP’s and10 Mezuk, B., Lohman, M. Leslie, M. & Powell, V. (2015) Suicide Risk in Nursing Homes andAssisted Living Facilities 2003-2011, American Journal of Public Health 105(7) 1495-150211 Ibid12 Davis-Berman, J (2011) Conversations about death: talking to residents in independent,assisted and long-term care settings, Journal of Applied Gerontology, 30(3) 353-369.13 Mezuk, B., Prescott, M.R., Trdiff, K., Vlhov, D. & Galea, S. (2008) Suicide in older adults inlong-term care: 1990 to 2005. Journal of the American Geriatrics Society, 56(11), 2107-2111.14 Nakrem, S., Vinsnes, A.G., & Seim A., (2011) Residents experiences of interpersonalfactors in nursing home residents, Journal of Ageing Studies, 48(11) 1357-136615 Cattel, H (2000) Suicide in the elderly, Advances in Psychiatric Treatment, 6(2), 102-108http://https://allaplusessays.com/order Carney, S.S. Burke, C.L. & Fowler, R.C. (1994) Suicide over 60: the San Diego study,Journal of American Gerontology sSoc. 142, 174-18017 Caine, E.D. & Conwell, Y. (1995) Suicide in the elderly: bias, infirmity and suicide Crisis 16,147-14818 David, N., Juurlink, M.D., Hermann, N. (2004) Medical illness and the Risk of Suicide in theElderly, Internal Medicine 2004; 164 (11) 1179-1184Findings of the inquest into the death of John Edward Drane 26specialist care providers) to be educated regarding suicide risk in thispopulation19.Opportunities for Prevention Understandably a diagnosis of a severe physical disease can beconsidered a stressful life event and greater recognition by healthpractitioners with respect to not only the medical care of the physicalwell-being of the patient, but consideration of the patients psycho-socialsupport mechanisms may be beneficial in alleviating the impact of thisdistress, (including the associated suicide risk).Interventions in health care settings Recommendations have been made to consider suicide risk assessmentafter diagnosis of severe diseases in older adults by health practitionersincluding in specialist medical care settings20. This is particularly salientas the earlier the intervention, the better the outcome with respect toaddressing suicide risk for at risk geriatric patients21. Gatekeeper training, and routine surveillance and monitoring for bothdepression and suicidal ideation, may be effective in these settings asthere is regular contact with health care staff, particularly during theacute phase after diagnosis, as well as through treatment and duringrehabilitation. It is also the case that older persons with physical health conditions arelikely to require, and receive, ongoing medical treatment for theirphysical health concerns and as such this represents a sustainedopportunity for early intervention for those at risk, prior to a situationescalating to a crisis point.Assessment of suicide risk in nursing home and long term care settings Because older persons are less likely to disclose suicidal intent, and areless likely to be diagnosed with a mental health related concern (whereone may be present) routine screening and assessment may bebeneficial in a range of other settings, including nursing homes. Such screening should include the use of standardised assessment tools(i.e. the Geriatric Depression Scale or the Cornell Scale for Depressionin Dementia) upon admission to nursing care settings22. This is salientgiven that a study of nursing home suicides found the presence ofdiagnosable mental disorders prior to the deaths, which indicates that19 Cattel, H. (2000) Suicide in the Elderly, Advances in Psychiatric Treatment, 6(2) 102-10820 Erlangsen, A., Stenager, E. & Conwell, y> (2015) Physical diseases as predictors of suicidein older adults: a nationwide, register-based cohort study, Social Psychiatry and PsychiatricEpidemiology, 50: 1427-1439.21 Ryan, C.W., Hall, M.D., Richard, C.W., et all (2003) Identifying Geriatric Patients at Risk forSuicide and Depression, Clinical Geriatrics, 11(10).22 Reiss, N.S. & Tishler, C.L. (2008) Suicidality in Nursing Home Residents: Part 1.Prevalence, risk factors, methods, assessment and management, Professional Psychology:Research and Practice 39(3), 264-270.Findings of the inquest into the death of John Edward Drane 27these suicides may not have been directly attributable to difficulties incoping with pain and disability, but likely influenced by diagnosable andtreatable mental health disorders23.Strategies for assessment and intervention As with other age-cohorts these strategies should be targeted towardsmales, given they have rates of suicide that are disproportionally highcomparative to females. This elevated risk has been linked to men beingless likely to seek help for emotional distress, services not being ‘malefriendly’ or easily accessible as well as men not wanting to appear weakor wanting to ‘work things out’ themselves24. Despite depression having such a strong association with elevated riskof suicide later in life, interventions targeted at ‘mental health’ issues canoften lead to lack of engagement by men, particularly those who adhereto traditional male roles, because of the stigma associated with mentalillness. It is because of these factors that a proactive, direct and action-orientedapproach, which includes routine screening of men for depression orother mental health concerns, can be beneficial in reducing suicide risk,in combination with assistance in accessing specialist services. Such assessments should take into account the presence of protectivesupports given there is some indication that social supports may mediatethe negative functional or financial impact of an illness25. To be effective, routine screening should only be seen as a structuredguide with the onus on the practitioner to be an effective communicator,following up on any indicators of increased harm with clarificationquestions. For individuals who screen as at imminent risk of harm (i.e. with suicidalideation, a plan and access to lethal means) hospitalisation may benecessary26. For those with expressed suicidal ideation but who screenat lower risk of harm, than permission should be sought to engage withthe patient’s social support system with professional follow-up care andfurther assessment.23 Suominen, K., Henriksson, M., Isometsa, E. et al. (2003). Nursing Home Suicides: aPsychological Autopsy Study, International Journal of Geriatric Psychiatry, 18, 1095-1101.24 Fact sheet 17 Suicide and men LIFE: Living is For Everyone Framework, AustralianGovernment25 Conwell, Y., Duberstein, P.R. & Caine, E.D. (2002) Risk factors for suicide in later life,Society of Biological Psychiatry,26 Garand, L., Mitchell, A.M., Dietrick, A. et.al. (2006) Suicide in Older Adults: NursingAssessment of Suicide Risk, Issues in Mental Health Nursing, 27(4) 355-370.

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