Inquest into the death of Neal Richardson

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Into the Death of Neal Richardson Hearing dates: 17 February 2015 Date of findings: 17 February 2015 Place of findings: State Coroners Court, Glebe Findings of: Deputy State Coroner E. Truscott Catchwords: Natural death of person in Custody File number: 2014/221203 Representation: Sgt D Welsh, Police Advocate Assisting Coroner Mr Singh for Justice Health, NSW Mr Griffiths for Commissioner of Corrective Services, NSW Findings: That Neal Richardson died on 26 July 2014 at Prince of Wales Hospital Randwick. His cause of death was natural, namely large cell carcinoma of lung with metastases; he died in palliative care.

Recommendations: Nil

IN THE STATE CORONER’S COURT GLEBE NSW SECTION 81 CORONERS ACT 2009 REASONS FOR DECISION

1. This is a mandatory Inquest into the death of a person in custody pursuant to section 23(d) of the Coroners Act 2009.

2. Neal Richardson was born on 14 May 1966 in United States of America. His family relocated to Australia, his father died in 1985 and his mother in 1996. He has a brother Craig who is aware of today’s proceedings.

3. In about 1997 Neal Richardson became addicted to heroin and in about 2002 he commenced the methadone programme. He worked for 12 years in the Qantas library and also as a labourer in the building industry. From about 2005 he lived in Wyee Place Malabar. Over a period of about 13 years, Neal Richardson was arrested and charged on 13 occasions. He spent 2 periods of less than a month respectively in custody during that time. On 4 May 2010 he was arrested and charged with the murder of his de facto wife Nicole Grant with whom he had associated on and off since about 1997. He was ultimately convicted and sentenced to 28 years imprisonment with a 21 year non-parole period. He was serving that sentence when he died.

4. Prior to entering prison on this last occasion, Neal Richardson had a history of a medical condition referred to as renal calculus. He also had diabetes mellitus treated with insulin delivered by injection. On 29 April 2014 he had an appointment at Lithgow Base Hospital to undergo X-ray and attend an urologist. This appointment was made as 2 days prior a CT scan had revealed calculus in the wall of the bladder and multiple small intra-renal calculi within the medullary pyramids of both kidneys. Mr Richardson cancelled the appointment as it coincided with another arrangement he had. He said he had no further pain or haematuria.

5. The sequence of events which follows is set out in a letter dated 27 August 2014 to Peter Severin Commissioner of Corrective Services NSW from Dr Karin Lines, Acting Chief Executive Justice Health and Forensic Mental Health Network. This is located at Tab 6 of the brief identified as “Justice Health (JHFMHN) Patient Health Record.

6. Between 30 May and 23 June 2014 Neal Richardson attended the Health Centre at Lithgow prison primarily for pain, originally associated with a kidney stone which he passed on 6 May. He also had an infiltrating basal cell carcinoma removed from his nose.

On 4 June and 11 June he complained of chronic pain to his hands, shoulders, back, hips

and most joints for which he was prescribed Panadeine. He was unable to be reviewed on 19 June as the visiting medical officer was not available.

7. On 23 June 2014 Neal Richardson complained of severe back and central abdominal pain.

He was transferred to and admitted to Lithgow Base Hospital and underwent CT scans. It was identified then that since his scan on 27 April 2014, metastatic disease with multiple liver lesions and lung lesions had developed. There was also a left adrenal lesion and a bony metastasis of the L4 vertebrae. That day he was transferred to Long Bay Prison Hospital.

8. On 24 June 2014 Neal Richardson was transferred to Prince of Wales Hospital where he remained until his death on 26 July 2014. He received appropriate palliative care and treatment. He was last attended at 0300 a.m and at 0400 a.m he was found in bed unresponsive. He was declared deceased at 0420 a.m.

9. His death was reported to the Coroner and upon medical review an autopsy was dispensed with and a coronial certificate was issued.

10. There are no issues arising from this Inquest. Accordingly I now make my formal findings: Neal Richardson died on 26 July 2014 at Prince of Wales Hospital Randwick. His cause of death was natural, namely large cell carcinoma of lung with metastases; he died in palliative care.

E Truscott Deputy State Coroner 17 February 2015