Coroner's Court of Western Australia

Inquest into the Death of Louisa Betty RYAN

Inquest into the Death of Louisa Betty RYAN

Delivered on :6 January 2022

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Ms Ryan was 89 years of age when she died on 16 May 2018 from aspiration pneumonia with respiratory failure that was complicated by the medical management of her major depression and her catatonia. Ms Ryan had had a previous episode of aspirational pneumonia, and she also had underlying heart disease at the time of her death. 

Ms Ryan had been an involuntary patient under the Mental Health Act 2014 (WA) and she was deemed a ‘person held in care’ within the meaning of the Coroners Act 1996 (WA). Her death was therefore a ‘reportable death’ and an inquest is mandated.

The coroner’s focus and function at the inquest was to investigate the quality of Ms Ryan’s treatment and care provided to her in her final admission at Fremantle Hospital, as well as the circumstances surrounding her death. 

Later on in her life, Ms Ryan developed a number of comorbidities which included atrial fibrillation, pulmonary oedema, Type 2 diabetes, Parkinsonism, recurrent urinary tract infections and recurrent falls. Ms Ryan moved into an aged care facility in 2016. Her most notable health issue was a long history of relapsing depression with catatonia. Dating back to 1986, Ms Ryan responded well to electroconvulsive therapy (ECT) to treat her catatonic depression. This was administered on an involuntary basis due to her inability to give consent to the treatment and risks to her health.

By late April 2018, Ms Ryan’s health had significantly deteriorated, including resistance to eat or drink.  Due to further rapid decline, she was admitted to Fremantle Hospital on 10 May 2018 and under a recommendation by the inpatient psychiatrist at Fremantle Hospital, she was made an involuntary patient under the Mental Health Act 2014 (WA) for the continued management of her ECT treatment.

After further decline, Ms Ryan was transferred to Fiona Stanley Hospital on 16 May 2018 where she later died at 10.30 pm. Following her latest ECT treatment and complications following, the coroner found Ms Ryan’s death had occurred by way of accident. Given the circumstances surrounding Ms Ryan’s age and comorbidities, the coroner deemed the supervision, treatment and care provided to Ms Ryan during her final ECT treatment was appropriate.

Catch Words : Involuntary Patient : Accident

Last updated: 19-Mar-2022

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