The ABC is reporting that a Tasmanian Coroner questions decision by paramedics to leave Tasmanian woman later found dead (5 May, 2020).  The news story says:

Ambulance Tasmania paramedics left a woman with a history of mental illness alone in her home without electricity, hot water or lighting before she was found dead months later, in a move a coroner has labelled “difficult to understand”.

In the Record of Investigation into Death (Without Inquest) Coroner Simon Cooper noted that in May 2018 police had attend the home of Ms Szemes. Having concerns for her physical and mental health:

… Attending police called for an ambulance, which arrived at 4.31pm. The Police left to attend to other matters. Police indicate that when they left they were under the impression that Mrs Szemes would be transported to the Royal Hobart Hospital by ambulance.

However, the attending paramedics did not take Mrs Szemes to hospital. Instead, because she asked them to leave, they left her in bed and left her residence at 6.16pm. Why they left is difficult to understand – especially given that the Ambulance Tasmania case description records that:

  • the house had no electricity, hot water or lighting;
  • Ms Szemes was difficult to understand and had had poor enunciation;
  • She repeated sentences;
  • Ms Szemes had had minimal fluid intake in recent days; and
  • She was unable to tell paramedics how or when she washed.

In the same records, as part of the secondary survey, the attending paramedics recorded:

  • Ms Szemes refused to move;
  • Her behaviour was ‘bizarre’;
  • Her responses were ‘inappropriate’;
  • Her facial expression was ‘flat [and] non-responsive’;
  • Her concentration was ‘poor [lacking] ability to organise thoughts [and having a] short attention span; and
  • Her speech content was ‘bizarre/irrational [with] repetitive questions/statements [and an] inability to have a coherent conversation’.

Despite these observations, there is nothing in the Ambulance Tasmania records indicating the attending paramedics considered whether Mrs Szemes had capacity to make an informed decision to refuse treatment.

There is no evidence of anyone seeing Mrs Szemes alive after the ambulance paramedics left her in bed at 6.16pm on Monday 28 May 2018.

Ms Szemes was found deceased on 8 October 2018. The exact date of her death could not be determined but the coroner did say: ‘It is likely that she died closer to May than October given the state of decomposition of the body’.

The Coroner did have access to the ‘Ambulance Tasmania electronic patient care report’ but the list of evidence does not include any affidavit from treating paramedics. Because this was a determination without inquest no-one was called to give evidence.

The coroner may have found the decision ‘difficult to understand’ but he made no effort to get evidence to help him understand that decision. It is well known and accepted, and discussed often enough here, that people have the right to refuse treatment even if that refusal will cost their life and, further, people can refuse treatment for whatever reason they want. On the other hand, where a patient is not competent to make a decision their purported refusal is not effective and treatment that is reasonably necessary and in their best interests can be delivered. The presumption is that people are competent. Whilst the symptoms listed might cause someone to think that Ms Szemes was not competent, the presumption in favour of competence means one would expect paramedics to explain why they form a view that a patient is not competent but it’s less surprising not to see why they thought a patient was competent when that is the norm.

It has to be remembered that patient care records are written for many reasons (First aid patient records – who and what are they for? (January 31, 2015). When completing records paramedics cannot know what the future holds and what will become relevant or a concern. If there is something omitted that is relevant, one would need to ask why it was omitted before drawing or implying any adverse conclusion.

Why I think these comments are less than helpful is that some may infer that the Coroner made or intended a criticism of the paramedics. If the Coroner did not understand why the paramedics made the decision they did, he had every resource to find out. He could have asked the paramedics to provide an affidavit or asked police to interview them. As it stands there is a suggestion of incomplete assessment, but it has not been tested.

The role of the coroner is to (s 28):

(1) … find, if possible –

(a) the identity of the deceased; and

(b) how death occurred; and

(c) the cause of death; and

(d) when and where death occurred; and

(e) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999 .

(f) .  .  .  .  .  .  .  .  [Sic]

(2)  A coroner must, whenever appropriate, make recommendations with respect to ways of preventing further deaths and on any other matter that the coroner considers appropriate.

(3)  A coroner may comment on any matter connected with the death including public health or safety or the administration of justice.

The coroner made the findings required by s 28(1). He did not make any recommendations (s 28(2) or comments (s 28(3)). It must follow that the coroner did not determine that the actions of the Ambulance Tasmania paramedics relevantly contributed to Ms Szemes’s death.

With respect to the Coroner, it would have been more useful to delete the comments about decisions being hard to understand if he was not going to explore it. He could have said, consistently with s 28, accurately and without any implication or poor care:

However, the attending paramedics did not take Mrs Szemes to hospital. Instead, because she asked them to leave, they left her in bed and left her residence at 6.16pm. The Ambulance Tasmania case description records that…

He could and should have omitted the comment:

Despite these observations, there is nothing in the Ambulance Tasmania records indicating the attending paramedics considered whether Mrs Szemes had capacity to make an informed decision to refuse treatment.

That comment was not relevant to his finding. If it was relevant he did not seek to explore what observations were made, what conclusions were drawn and why this was not recorded.

Conclusion

My assertion that these comments may lead some to ‘infer that the Coroner made or intended a criticism of the paramedics’ is, I think, supported by the ABC report. If the coroner had not made those comments this report would not have attracted their interest or the headline. In essence the coroner did question the decision by the paramedics, but did not invite them to give an answer. With respect that is less than helpful.