Inquest into the death of John McFerrier

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of John McFerrier Hearing dates: 14 July 2016 Date of findings: 14 July 2016 Place of findings: State Coroner’s Court, Glebe Findings of: Deputy State Coroner Teresa O’Sullivan Catchwords: CORONIAL LAW – Cause and manner of death Death in custody Death in Villawood Immigration Detention Centre Natural Causes Non-publication order: File number: 2014/00341842 Representation: Sgt Sam Ferguson, Coronial Advocate

Findings: Identity of deceased: The deceased person was John McFerrier Date of death: He died on 17 November 2014 Place of death: He died at Liverpool Hospital, NSW Manner of death: He died of natural causes Cause of death: The medical cause of the death was sepsis with multiorgan failure and pneumonia (multi-drug resistant Staphylococcus) was an antecedent cause. Complications of morbid obesity were another significant condition contributing to his death.

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The Coroners Act 2009 (NSW) in s81 (1) requires that when an inquest is held, the 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 John McFerrier.

Introduction: Mr John McFerrier was born on 13 April 1963 in Zimbabwe. At the time of his death he was in the custody of the Department of Immigration at the Villawood Immigration Detention Centre, Villawood.

As Mr McFerrier was in lawful custody at the time of his death, an inquest is required to be held pursuant to sections 23 and 27 of the Coroners Act 2009.

The Inquest: The role of a Coroner, as set out in s 81 of the Coroners Act, is to make findings as to:

(a) the identity of the deceased;

(b) the date and place of the person’s death;

(c) the physical or medical cause of death; and

(d) the manner of death, in other words, the circumstances surrounding the death.

Pursuant to s 82 of the Act a Coroner also has the power to make recommendations concerning any public health or safety issues arising out of the death in question.

The Evidence: Background: Mr McFerrier was born in Zimbabwe and immigrated to Australia in 2008. The International Health and Medical Services (IHMS) Progress Notes mention that Mr McFerrier was very close to his family and that they were a good source of support for him. His sister, Marlien, lives in the United Kingdom and she is his next of kin. His only relative in Australia was an uncle in Perth. He was particularly close to his mother who died in 2008. He was very affected by not being able to attend her funeral. She was only 17 years old when she became pregnant with him and they had a very close relationship. He describes them as being more like close friends than mother and son. Mr McFerrier was a gay man and had some difficulties coming out. He reported to Mental Health staff at Villawood detention Centre that he felt Findings in the Inquest into the death of John McFerrier

stigmatised in Blaxland, the unit in which he was held, because of his sexuality. The IHMS Mental Health Progress Notes mention his feelings that “other blokes don’t engage with him. He feels that he is not welcome here.” The Progress Notes also state that he described himself as a very emotional man with a low tolerance for stress and that he dealt with stress by withdrawing. He loved cooking and enjoyed writing. He reported that he believed that the reason he gained so much weight was due to “institute lifestyle”. He also reported not wanting to go back to Zimbabwe as he had little support there and held fears that he would be imprisoned or killed if he returned.

Custodial History: In August, 2008 Mr McFerrier was convicted for drug trafficking offences and was sentenced to seven years imprisonment with a non-parole period of four years which commenced on 27 August 2008.

Upon his release from custody, Mr McFerrier’s visa was cancelled and he was sent to Perth Immigration Centre on 26 August 2012. He was transferred to the Villawood Detention Centre on the 12th February, 2013 where arrangements were being made for his deportation to Zimbabwe. He was in immigration detention at the time of his death.

Medical history: John Mc FERRIER was morbidly obese weighing approximately 200kgs, however reportedly lost 60kgs prior to his death. Mr McFerrier suffered from a variety of health issues due to his weight and suffered from many ailments including skin sores, and ulcers.

Immediately prior to his death, Mr McFerrier had been housed at Villawood Detention Centre however, during his incarceration in immigration custody, his health was managed by International Health and Medical Services (IHMS).

In the days leading up to his death, Mr McFerrier was bedridden and immobile due to his back pain. He suffered from sleep apnoea and was taking antidepressants.

Medical notes made by IHMS indicate that in the days leading up to his death, nursing staff observed his mental state to be declining due to poor health and back injury. The IHMS notes indicate that Mr McFerrier was seen by nursing staff on an almost daily basis and he was receiving daily medication for a range of medical conditions. He was also receiving support from mental health staff.

Findings in the Inquest into the death of John McFerrier

Liverpool Hospital Admission: On the 14th November, 2014 Mr McFerrier complained of breathing difficulties. An ambulance was called and he was subsequently transferred to Liverpool Hospital Intensive Care Unit (ICU). He was constantly monitored and treated for severe septic poisoning, however his health continued to deteriorate.

The Fatal Incident: Mr McFerrier was being constantly monitored in the Intensive Care Unit at Liverpool Hospital. Despite receiving multi organ support and antibiotic escalation, he suffered a cardiac arrest at about 12:44pm on the 17th November, 2014. The hospital staff commenced cardiopulmonary resuscitation at 12:44pm and the patient was shocked at 12:46pm. Cardiopulmonary resuscitation was continued however all attempts to revive Mr McFerrier failed. He was pronounced life extinct at 12:55 on 17 November 2014.

As Mr McFerrier was in lawful custody at the time of his death, it is a mandatory requirement of the Coroners Act 2009 that his death be reported and an inquest held. Police were notified of his death and they attended Liverpool Hospital.

Care and Treatment: When a person is detained in custody, the responsibility for ensuring that person receives adequate care and treatment rests with the State. Even when a person in custody dies of apparent natural causes, an inquest is required to independently assess whether the State has discharged its responsibility.

A thorough investigation was conducted into the death and all relevant medical and custodial records were obtained and form part of the coronial brief. These records indicate that Mr McFerrier’s care and treatment was appropriate. Mr McFerrier’s death is not suspicious and he died of natural causes.

Medical Record Review A medical record review was conducted by Rebecca Irvine, Senior Staff Specialist Forensic Pathologist, Department of Forensic Medicine. She was of the view that the cause of death was: Findings in the Inquest into the death of John McFerrier

1 (a) Sepsis with multi-organ failure

(b) Pneumonia (multi-drug resistant Staphylococcus) 2 Complications of morbid obesity.

Findings required by s81 (1) As a result of considering all of the documentary evidence and the oral evidence heard at the inquest, I am able to confirm that the death occurred and make the following findings in relation to it: The identity of the deceased The deceased person was John McFerrier.

Date of death John McFerrier died on 17 November 2014.

Place of death John McFerrier died at Liverpool Hospital, Liverpool.

Cause of death The medical cause of the death was sepsis with multi-organ failure; pneumonia (multi-drug resistant Staphylococcus) was an antecedent cause. Complications of morbid obesity were a significant condition contributing to his death.

Manner of death John McFerrier died of natural causes whilst he was in immigration detention.

I close this inquest.

Magistrate Teresa O’Sullivan Deputy State Coroner Date 14 July 2016 Findings in the Inquest into the death of John McFerrier