Inquest into the death of Anthony WRAY

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‘Hearing dates:

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Pate of findings:

STATE CORONER’S COURT OF NEW SOUTH WALES

{ nquest into the death of Anthony WRAY -

NSW State Coroner’ s Court - Lidcombe

Findings of: Magistrate Carmel Forbes, Deputy State Coroner Konowaut LAW — ~ natural causes death i in n custody i a — ee ne ee owe etn File number: '2018/00039867 A tees Pee oe eee tne yt tt natn ‘Representation: Mr P Bain, Coronial Advocate Assisting the Coroner.

Identity of deceased:

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The deceased person was Anthony Wray /

; iDate of death:

He died on 6 February 2018 j Place of death:

He died at Long Bay Gaol, Malabar, New South Wales |

‘cause of death:

imetastatic lung cancer i

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‘Manner of death: ‘natural causes

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INQUEST INTO THE DEATH OF ANTHONY WRAY

Mr Anthony Wray died at Long Bay Gaol on 6 February 2018. At the time of his death he was in

custody serving a 12 year sentence.

Section 23 of the Coroners Act 2009 makes an inquest mandatory in cases where a person dies whilst in lawful custody. In such cases the community has an expectation that the death will be properly and independently investigated to ensure that the care of that person was appropriate and

adequate.

Between 2013 and 2016, Mr Wray was regularly reviewed by nursing and medical officers whilst he was in custody. In October 2017, he complained of constant coughing, with headaches and facial pain. He was reviewed at the gaol health centre and noted to be coughing blood. Subsequent

testing revealed the presence of significant metastatic lung cancer.

Due to the nature of his illnesses, a management plan was implemented where outside public health

facilities and specialists were utilised to manage his conditions.

On 1 November 2017, Mr Wray was transferred from Goulburn Hospital to the Prince of Wales Hospital (POWH}) Sydney, for further investigations and treatment. Evidence from his treating physician, Doctor Wong, indicates the cancer was at an advanced state and had Spread to Mr Wray’s liver, spleen and brain. The cancer was considered inoperable and irreversible. Chemotherapy was considered inappropriate due to Mr Wray's poor functional status and he was commenced on

palliative radiotherapy for symptom control.

Mr Wray was in and out of Prince of Wales Hospital during November and December 2017. On 30 November 2017, Mr Wray received his first cycle of radiotherapy to his chest however declined to receive further treatment. On 1 December 2017, Mr Wray signed formal documents indicating he wished for no further active treatment of his cancer; he was only to receive treatment to alleviate

his symptoms. A ‘not for resuscitation’ form was signed.

Findings in the Inquest into the death of

Findings required by s 81 (2)

The identity of the deceased

The deceased person was Anthony Wray

Date of death Died on 6 February 2018

Place of death Died at Long Bay Hospital Gaol

Cause of death

The death was caused by metastatic lung cancer

Manner of death

Natural causes

C Deputy State Coroner Carmel Forbes

Lidcombe Coroner’s Court

Date 27 May 2019

Findings in the Inquest into the death of