section 32 detention orders were confirmed. Mr Matthews was spoken to regarding resuscitation plans. He indicated that he did not want to live as a vegetable and that if CPR was required he did not want to be resuscitated. Ultimately a place was secured for Mr Matthews at Linsell Lodge. On 6 February 2015 he moved to that facility. The section 32 detention remained in place. Mr Matthews continued with dexamethasone for ongoing reduction in brain swelling. Haloperidol was also introduced in an effort to control some of his erratic outbursts and behaviour. There were instances of uncooperative behaviour throughout his stay. He refused many of the services that were offered to him at the facility. He continued to smoke throughout this period. On 17 February 2015 Mr Matthews was examined at Linsell Lodge by a visiting general practitioner. He was found to have a moist, chesty cough with decreased oxygen saturations. He was commenced on Augmentin Duo Forte due to the suspicion that he had a chest infection. Over the course of the evening of 21 February 2015 it was clear that Mr Matthews was having trouble breathing. Nurses attended to him and increased his oxygen delivery incrementally over time until it was at a level of 15 litres. However, he still struggled to breathe. At 10:40pm on that day he died at the facility in the presence of nursing staff. Coronial investigation I should pass comment on the excellence of the police investigation in relation to Mr death. The investigation was overseen by Senior Constable Matthew Matthews’ Legge of the Western Adelaide Criminal Investigation Branch. Senior Constable investigation and report of that investigation is as extensive and as thorough as Legge’s I have seen in respect of a matter such as this. I also agree with the conclusions that Senior Constable Legge has expressed in his report. Senior Constable Legge concluded that Mr treatment at the various locations Matthews’ at which his care was administered was of a satisfactory standard. The only blemish in care that Senior Constable Legge identified was the fact that in the three days prior to Mr death at the Linsell Lodge he was not administered the prescribed Matthews’ dexamethasone medication. Staff at the facility identified this omission on the day of Mr death. A locum doctor was called in on that day to review Mr Matthews Matthews’ and his medication chart. It was determined that he could be recommenced on the medication the following day. However, Mr Matthews died a short time later. A
section 32 detention orders were confirmed. Mr Matthews was spoken to regarding resuscitation plans. He indicated that he did not want to live as a vegetable and that if CPR was required he did not want to be resuscitated. Ultimately a place was secured for Mr Matthews at Linsell Lodge. On 6 February 2015 he moved to that facility. The section 32 detention remained in place. Mr Matthews continued with dexamethasone for ongoing reduction in brain swelling. Haloperidol was also introduced in an effort to control some of his erratic outbursts and behaviour. There were instances of uncooperative behaviour throughout his stay. He refused many of the services that were offered to him at the facility. He continued to smoke throughout this period. On 17 February 2015 Mr Matthews was examined at Linsell Lodge by a visiting general practitioner. He was found to have a moist, chesty cough with decreased oxygen saturations. He was commenced on Augmentin Duo Forte due to the suspicion that he had a chest infection. Over the course of the evening of 21 February 2015 it was clear that Mr Matthews was having trouble breathing. Nurses attended to him and increased his oxygen delivery incrementally over time until it was at a level of 15 litres. However, he still struggled to breathe. At 10:40pm on that day he died at the facility in the presence of nursing staff. Coronial investigation I should pass comment on the excellence of the police investigation in relation to Mr Matthews’ death. The investigation was overseen by Senior Constable Matthew Legge of the Western Adelaide Criminal Investigation Branch. Senior Constable Legge’s investigation and report of that investigation is as extensive and as thorough as I have seen in respect of a matter such as this. I also agree with the conclusions that Senior Constable Legge has expressed in his report. Senior Constable Legge concluded that Mr Matthews’ treatment at the various locations at which his care was administered was of a satisfactory standard. The only blemish in care that Senior Constable Legge identified was the fact that in the three days prior to Mr Matthews’ death at the Linsell Lodge he was not administered the prescribed dexamethasone medication. Staff at the facility identified this omission on the day of Mr Matthews’ death. A locum doctor was called in on that day to review Mr Matthews and his medication chart. It was determined that he could be recommenced on the medication the following day. However, Mr Matthews died a short time later. A