An Adelaide woman was unnecessarily and perhaps illegally detained under the mental health act less than two hours before she died, a coroner has found.
Kay Meredith MacMillian died of end-stage heart failure in February 2013 and shortly before her death an inpatient treatment order was signed on the advice of a doctor at Flinders Medical Centre.
This order detains a patient who is mentally ill and allows the hospital to treat them because they are unable to agree to treatment themselves.
But South Australian Coroner Mark Johns says this order was the result of the doctor's "reprehensible behaviour" and should not have been made.
"I find that Mrs MacMillan's detention was unnecessary and almost certainly unlawful," the coroner said in his findings on Monday.
"It was caused by the inexplicable, erroneous and reprehensible behaviour of one person."
Mrs MacMillan, from Blewitt Springs, had been suffering from terminal heart failure for almost a year before her untimely death.
In the final days of her life she had deteriorated so badly that she was sleeping 22 hours a day, had lost her appetite and was awaiting palliative care.
Mrs MacMillan, her husband and family had decided on a non-resuscitative plan of treatment and had relayed this to her doctors, the inquest found.
But one doctor suggested Mrs MacMillan was depressed and her wishes about resuscitation contradicted the wishes of her family, leading to the detention order being signed.
The coroner slammed these doctor's suggestions as completely false.
"There was no evidence of any such dispute and indeed no such dispute existed," Mr Johns said.
"Mrs MacMillan and the members of her family were all of the same mind in relation to that question.
"It is a very serious matter for a doctor to falsely assert that a family would act against the interests of their loved one."
The coroner made no recommendations in his findings, saying no systemic change could prevent such "errant and unpredictable behaviour" by a doctor in the future.
