Inquest into the death of Patrick HUDD

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STATE CORONER’S COURT OF NEW SOUTH WALES

Inquest into the death of Patrick HUDD

17 February 2074

17 February 2014

State Coroner's Court, Glebe

Magistrate Michael Barnes, State Coroner

CORONIAL LAW — Death in custody; natural causes; care and medical treatment of prisoners

2013/77634 Sgt S. Kelly, Advocate Assisting the Coroner

Mr 8S. Griffiths, representing Corrective Services

Mr G. Singh, representing Justice Health

Table of contents [EPOCUCTION ooo... cccccccceecesscescerseceecesaeeensueeesessanseecesneecesanssesesssesseseeseascarsedesteeesseaanss ThE CVIDONCE Lic cccseccsseesseseseeecesceecenseesseerensesescessessseserssseeeceseeseereestecessesenseesats Social History...

Events Proceeding Death.

The death is discovered...

The Investigation...

Conclusions... ccceceseeee Findings required by s81 (1)...

The identity of the deceased Cause of death...

Manner of death

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The Coroners Act in s87 (1) requires that when an inquiry is held concerning a death, fhe coroner must record in writing his or her findings as to various aspects of the death. These are the findings of an inquest into the death of Patrick HUDD.

Introduction

At 10:15pm on 13 March 2013, a prisoner at the Long Bay Correctional Centre, Patrick Hudd, 75, was found dead in his bed in the Long Bay Hospital.

Mr Hudd had previously been diagnosed with metastatic lung cancer, which had been assessed as untreatable. His death was therefore not unexpected.

As Mr Hudd died while in custody an inquest into his death is mandatory.

The purpose of the inquest is to confirm the death occurred and make findings in relation to the deceased person’s identity, the date and place, cause and manner of the death.

As Mr Hudd was in custody when he died, the inquest will also consider whether the medical treatment provided to him was appropriate and of an equivalent standard to that which he would have received had he not been in custody.

The evidence

Social History

Patrick Hudd was born on 22 November 1937 in Crookwell NSW. He attended the Five Mile Tree School at Crooked Corner. After receiving a basic education Mr Hudd' worked on various regional rural properties as a shearer, farrier and farm hand.

In 1960 Mr Hudd married. In 1965 he and his wife had a son Wayne. Wayne was the only child of the relationship and when his parents separated in 1970, Wayne continued to reside with his father in the Goulburn area.

In 1964 Mr Hudd was convicted of a number of serious criminal offences and was sentenced to a lengthy term of imprisonment.

Thereafter, Mr Hudd was frequently before the courts and frequently sentenced to terms of imprisonment.

Most recently, in December 2002, he was involved in an armed robbery which resulted in the death of a storekeeper. As a result, in February 2005 he was sentenced to a term of 27 years imprisonment. His earliest release date was 22 September 2024.

Events Proceeding Death

In 2012 Mr Hudd was serving his sentence at the Goulburn Correctional Centre.

Throughout the later part of that year, he had persistent chest symptoms suggestive of a cold or flu.

When these did not resolve, further investigations were undertaken which revealed advanced lung cancer.

In October he was transferred to the Long Bay Correctional Centre so that his condition could be further investigated.

In November he was admitted to the Prince of Wales Hospital and he was provided with two courses of chemotherapy. A CT scan after this treatment revealed further progression of the disease. As a result, his treating clinicians formed the view that further aggressive treatment would be unlikely to be helpful. After consultation with Mr Hudd it was decided that only palliative treatment would be provided. Mr Hudd was discharged back to the Long Bay Hospital on 15 January 2013.

Thereafter Mr Hudd remained in the medical wing of the Long Bay Correctional Centre.

Until shortly prior to his death Mr Hudd was relatively comfortable ambulating around the ward and was self-caring. He was visited by his son.

Following further consultation with the patient, in February 2013, a “not for resuscitation” order was made and placed on his medical file.

On 22 February the Commissioner of Corrective Services commenced a procedure to consider early release for Mr Hudd in view of his imminent demise.

The death is discovered

On 9 March 2013, his condition significantly deteriorated. He was described as agitated and confused and he required increased levels of assistance. Mr Hudd was provided with adequate pain relief and was closely monitored.

On the night of 13 March he was cared for in the usual manner by the on-duty nurses. The security manager had agreed to his cell door being left open so that the nurses could more closely monitor him.

The nurse on duty provided a statement saying that at 22:00 hours she checked Mr Hudd and found that he was asleep. At 22:15 she noted his breathing sounded ceased and so she went into his cell to check further on him. She found he was not breathing and was non-responsive. No pulse and no heart sounds could be detected and his pupils were fixed and dilated. A life extinct certificate was completed.

The Investigation

Officers from the Corrective Services Investigation Unit attended the scene and quickly satisfied themselves that no suspicious circumstance’s existed. Photographs were taken of the deceased in sifu.

In view of Mr Huda’s medical treatment, no internal autopsy was considered necessary after an external examination of his body and a review of the records was undertaken to confirm ihe cause of death to be Metastatic Lung Cancer.

Mr Hudd’s niece received a number of notes from him after he had been diagnosed with the cancer. In one of them he raised a concern that a nurse at the Long Bay Correctional Centre had withheld some of his medication. He named her as “Simone”. Searches have revealed no nurse by that name employed at the centre during the period in question.

Further review of the medical charts revealed that it appeared Mr Hudd had been given all the medicines prescribed for him by his treating team including Oxynom, Durogesic Fentanyl and Endone.

In the circumstance’s | am of the view that this concern cannot be substantiated.

Concern was also raised that earlier diagnosis may have led to a prolongation of Mr Hudd's life. The investigating officer explored this possibility with a treating doctor at the Long Bay Hospital who advised that it was apparent from a review of the medical records that at the time Mr Hudd complained of his influenza symptoms it was highly likely that the cancer was already very advanced and no further treatment options would have been available.

Conclusions

In all of the circumstances, | conclude that Mr Hude died of natural causes and that no third party played any part in his death.

| am also satisfied that while he was an inmate in the Goulburn Correctional Centre and the Long Bay Correctional Centre, Mr Hudd received appropriate medical treatment of an equivalent standard to that which he would have been able to access had he been living in the community.

Findings required by s81 (1) As a result of considering all of the documentary evidence and the oral evidence

given at ihe inquest, | am able to confirm that the death occurred and make the following findings in relation to it.

The identity of the deceased The person who died was Patrick Hudd.

Date of death He died on 13 March 2013.

Place of death Mr Hudd died at the Long Bay Correctional Centre, Malabar, NSW.

Cause of death The cause of his death was metastatic lung cancer.

Manner of death Mr Hudd died of natural causes while in custody in Long Bay Jail.

| close this inquest.

M A Barnes

NSW State Coroner Glebe

17 February 2014