Inquest into the death of Clifford Deas

CORONERS COURT OF NEW SOUTH WALES

Inquest: Inquest into the death of Clifford Deas

Hearing dates: 22 March 2018

Date of findings: 22 March 2018

Place of findings: NSW Coroner Court - Glebe

Findings of: _ ; Magistrate Paula Russell Deputy State Coroner Catchwords: . “CORONIAL LAW — Cause and manner of death

File number: 2016/71814

Representation: Sgt Ben Hart, Coronial Advocate, assisting the Coroner

Ms Mena Katawazi, Office of General Counsel for NSW Department of Justice

Findings in Inquest into the death of Clifford Deas

Findings: Identity | Clifford DEAS

Date of death: 5 March 2016

Place of death: ‘Long Bay Hospital Correctional Centre, 1300 Anzac Parade, Malabar, New South Wales

‘Manner of death: ‘Natural causes

Cause of death:

Direct Cause:

Arteriosclerotic coronary artery and hypertensive heart disease

Other significant cause contributing to the death:

Chronic renal failure (end-stage renal disease)

Non —Publication Order S74 (1)(b)non publication order on attached document

Findings in Inquest into the death of Clifford Deas

At the time of his death Clifford Deas was in custody on remand on a warrant from Port Macquarie Local Court. He had been in custody since 10 December 2015, having been charged with an offence of knowingly contravening a prohibition or restriction in a personal violence order and was said to have breached his bail undertakings.

He was, then, within the meaning of section 23 of the Coroners Act 2009, in lawful custody. An inquest in such circumstances is mandatory pursuant to section 27(1) of that Act.

Background

Mr Deas was born on 1 August 1951. He grew up in Padstow and, on finishing school, joined the armed forces. He later worked as a lithographer at Halstead Press in Kingsgrove.

In more recent years he had been on a disability pension and had lived with his parents until his mother died in 2006, his father having died in 1995.

Mr Deas lived in Port Macquarie prior to his being taken into custody in 2015.

Health

Mr Deas had many health problems. On 12 December 2015 he was transferred to the Aged Care Rehabilitation Unit of the Long Bay Hospital and, from there, to the Prince of Wales Hospital Emergency Department. He was suffering arteriosclerotic coronary artery disease, acute myocardial infarction, pneumonia, emphysema, anxiety, hyperlipidaemia and hyperparathyroidism.

On 13 December he was transferred back to the Long Bay Hospital.

Mr Deas was, on a number of other occasions during the time he was in custody, admitted to Prince of Wales Hospital for conditions including cellulitis. He had a large hiatus hernia, previous gastrointestinal bleeding, had had TB in 2009 and was normally hyperkalaemic.

Mr Deas had end stage renal failure secondary to IgA nephropathy. He required haemodialysis 3 times a week and was taken to the Prince of Wales Hospital for that purpose. Mr Deas was, on numerous occasions, non-compliant with ffuid and diet restrictions and would often refuse to continue a dialysis session to completion.

On 2 March 2016 Mr Deas was 15.4kg above his ideal weight before commencing

dialysis but completed only 1 % hours of a scheduled 5 hour dialysis session after refusing to continue.

Findings in the Inquest into the death of Clifford Deas

On 3 March 2016 Mr Deas was 20kg above his ideal weight and had increased swelling because of fluid overloading. Strict fluid restrictions and monitoring were recommenced.

Hours leading up to death

At about 12:30pm on 5 March Mr Deas was found lying on the floor of his cell by corrective services staff. He said that his legs had collapsed underneath him and said he had no pain or injury.

At about 2:25 pm Mr Deas was observed lying on his bed resting. At ward checks prior to dinner he was again observed resting on his bed. At about 5:30pm he was given dinner and, at about 6:20pm, his blood pressure was checked and he appeared to be in good spirits. At about 8:30pm he was given his medications and again appeared to be in good spirits.

At about 10:55pm he was located unresponsive on the floor of his cell. CPR was commenced but he could not be revived.

Mr Deas’ cell was fitted with a cell alarm but he had not activated it.

The cause of death

An autopsy was performed by forensic pathologist, Dr Liliana Schwartz who determined that the direct cause of his death was arteriosclerotic coronary artery and hypertensive heart disease. A significant condition contributing to his death was chronic renal failure (end-stage renal disease).

Mr Deas was 64 years old at the time of his death.

Findings required by s81(1)

Clifford Deas died at Long Bay Hospital Correctional Centre, 1300 Anzac Parade, Malabar, New South Wales on 5 March 2016.

Mr Deas died as a result of arteriosclerotic coronary artery and hypertensive heart disease. A significant condition contributing to his death was chronic renal failure (end-stage renal disease).

He died of natural causes.

Findings in the Inquest into the death of Clifford Deas

| close this inquest.

Magistrate P Russell Deputy State Coroner Glebe

Date: 22 March 2018

Findings in the Inquest into the death of Clifford Deas

Form 16

Coroners Act 2009, Section 74

COURT DETAILS Court Registry

Case number

PROCEEDINGS

Inquest into the death of

DATE OF ORDER

Date made or given

TERMS OF ORDER

NON-PUBLICATION ORDER

State Coroner's Court of NSW 44-46 Parramatta Road, Glebe NSW 2037 2016/71814

Clifford Deas

22 March 2018

1. That the following information contained in the brief of evidence tendered in the proceedings not be published under paragraph 74(1)(b) of the Coroners Act 2009 (NSW):

a. The names, addresses, phone numbers and other personal information that might

identify any member of Clifford Deas’ family;

b. The direct and personal contact details of Corrective Services New South Wales

staff.

c. The names, personal information and Master Index Numbers of any persons in

the custody of Corrective Services New South Wales, other than Clifford Deas;

d. The portions of the Inmate Accommodation Area Journal, C Watch OIC’s Journal,

and B Watch OIC’s Journal concerning checks conducted and daily search tasks.

SIGNATURE

Signature Name Capacity

Date

= pa Bos

CAE

er Magistrate P. Russell Deputy State Coroner 22 March 2018