Inquest into the death of Graham Lawson

CORONERS COURT OF NEW SOUTH WALES Inquest: Into the death of Graham Lawson File number: 2018/287982 Hearing dates: 15 July 2019 Date of findings: 15 July 2019 Place of findings: Coroners Court, Lidcombe Findings of: Deputy State Coroner E.Truscott Catchwords: Coronial Law-Cause and manner of deathRepresentation: Advocate Assisting: Mr D Welsh Department of Corrective Services NSW: Ms A Smith Justice Health & Forensic Health Network: Mr M Sterry Findings: Identity The deceased person was Graham Lawson.

Date of Death 19 September 2018.

Place of Death Long Bay Hospital, New South Wales.

Cause of death Metastatic hepatocellular carcinoma Manner of death Natural causes whilst serving a custodial sentence.

Recommendations: Nil

Non-Publication Orders: 1 That the following information contained in the brief of evidence tendered in the proceedings not be published under section 74(1)(b) of the Coroners Act 2009 (NSW): a. The names, addresses, phone numbers and other personal information that might identify any member of Graham Lawson’s family.

b. Any information which may tend to identify any of Graham Lawson’s victims.

c. The names, personal information and Master Index Numbers (MIN) of any persons in the custody of Corrective Services New South Wales (CSNSW) other than Graham Lawson.

This includes, but is not limited to, Medical documents, and the Inmate Profile documents for the following inmates:  Daniel Little;  Moussa Moussa; and  Michael Patrick Murphy.

d. The direct contact details of CSNSW Officers, and Justice Health staff not otherwise publicly available.

e. Any information which may tend to identify private contractors retained by CSNSW.

f. The identification/serial numbers of CSNSW correctional officer equipment such as, revolvers and handcuffs.

g. The following CSNSW policies: i. The CSNSW Custodial Operations

Policy and Procedures (COPP) ‘Section 13.3 Deaths in custody’ (version 1.0,

2017. which has not been made publically available; and ii. COPP ‘Section 13.8 Crime Scene Preservation’ (version 1.0, 2017) which has not been made publically available.

h. Recordings of the Offender Telephone System contained on USB at Attachment 14 of Mr Peter Jones’ report.

i. Volume 2, Tab 20: Crime scene photographs and CD containing images of the deceased.

j. Volume 2, Tab 21: CCTV footage of the Medical Subacute Unit in Long Bay Hospital 1 which is also contained at Attachment 14 of Mr Peter Jones’ report.

2. Pursuant to section 65(4) of the Coroners Act 2009 (NSW), a notation be placed on the Court file that if an application is made under section 65(2) of that Act for access to CSNSW or Justice Health documents on the Court file, that material shall not be provided until those parties have had an opportunity to make submissions in respect of that application.

IN THE CORONERS COURT LIDCOMBE NSW Section 81 Coroners Act 2009

REASONS FOR DECISION

1. This is an inquest into the death of Mr Lawson 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.

2. The role of a coroner, as set out in s 81 of the Coroners Act, is to make findings as to the following:

(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

3. Pursuant to s 82 of the Act a coroner can make recommendations concerning any public health or safety issues arising out of the death.

4. Graham Lawson was 68 years of age at the time of his death at 11:00 p.m. on the 19 September 2018. Mr Lawson was an inmate of Long Bay Correctional Centre and was receiving palliative care within Long Bay Prison Hospital for metastatic hepatocellular carcinoma. He suffered from pre-existing Hepatitis C and cirrhosis at the time of his cancer diagnosis.

He also suffered from congestive cardiac failure, hypertension, dyslipidaemia and benign prostatic hyperplasia.

5. Mr Lawson was sentenced on 1 February 2017 for two serious offences that resulted in two sentences of full-time imprisonment: the first sentence was for a period of 18 months from the 21 February 2016 to the 20 August 2017; the second sentence was for a total of 7 years from the 21 August 2016 to the 20 August 2023, with a non-parole period of 3 years 6 months from the 21 August 2016 to the 20 February 2020. Records indicate that he was held in multiple correctional facilities between 2016 and 2018.

6. Justice Health & Forensic Health Network (JH&FHN) clinical notes indicate that on the 24 September 2017, Mr Lawson attended the gaol clinic and complained of feeling weak as well as unexplained weight loss, approximately 10 kilograms over the past 3 months. The notes indicate that Mr Lawson was otherwise experiencing no new pains or symptoms.

7. On the 26 November 2017 Mr Lawson was seen in the gaol clinic and was still losing weight and feeling weak. On the 6 February 2018 a medical note was made that a request form for a liver ultrasound had been written and Mr Lawson was awaiting an appointment.

8. Clinical notes on the 13 February 2018 record that Mr Lawson was very underweight. Blood tests were undertaken the following day but did not immediately disclose any issues.

9. On the 16 February 2018, the clinical notes record that a test had returned an elevated AFP result, suggestive of the possibility of liver cancer. Due to Mr Lawson having a history of Hepatitis C and rapid weight loss, an urgent ultrasound arranged.

10. On the 20 February 2018, Mr Lawson reported he had suffered central abdominal pain the previous night.

11. On the 21 February 2018, Mr Lawson underwent an abdominal ultrasound at Lithgow. Dr Healy, the attending physician, identified numerous liver lesions and a large mass that he described as concerning for hepatocellular carcinoma. Dr Healy suggested further investigation via multi-phase CT.

12. An abdominal CT was conducted on the 7 March 2018. The results were suggestive of multifocal hepatocellular carcinoma, complicated by a left portal vein tumour thrombus.

13. Mr Lawson was henceforth treated as an outpatient in the clinic of Professor Goldstein, Senior Staff Specialist in the Department of Medical Oncology at Prince of Wales Hospital. Correspondence approved by Professor Goldstein and signed by Gary Tincknell, a Medical Oncology Trainee, records in notes made on 15 March 2018 that multifocal hepatocellular carcinoma is an incurable disease and that Mr Lawson had an estimated life expectancy of six months. The median survival in trials on Sorafenib, a drug later used to treat Mr Lawson, was in the region of 11 months.

14. Correspondence dated 29 March 2018 to Professor Goldstein from Dr Charlotte Knox, palliative care registrar under Dr Victor Sze, records that Dexamethasone was initiated to manage Mr Lawson’s pain. She records that Mr Lawson said that if further treatment was not able to significantly prolong his life and was to cause him significant side effects, he would opt not to have treatment. Mr Lawson expressed his wish that he not be for CPR, intubation or ICU. Dr Spasojevic documented a Not-ForResuscitation form to that effect.

15. The no cardiopulmonary resuscitation order in question was discussed with Mr Lawson on the 21 March 2018 and on the 22 March 2018 it was put into place under the authorisation of Dr Spasojevic.

16. A segmental Transarterial chemoembolization (TACE) procedure to treat Mr Lawson’s liver cancer was done at Prince of Wales Hospital on the 24 April 2018. The consulting clinician was Professor Goldstein. A postprocedure CT scan completed on the 27 April 2018 revealed “marked hypoattenuation within many of the previously demonstrated arterially enhancing lesions”.

17. A further CT completed on the 13 June 2018 revealed expected improvement in the treated areas but progression of enhancing lesions in the left liver lobe (which was untreated) along with increased tumour thrombus in the left portal vein.

18. Professor Goldstein records on the 5 July 2018 that the repeat CT scan showing the response to the TACE treatment showed a rapid progression of the left lobe of the liver. As a result, Mr Lawson was no longer suitable for further TACE treatment. Dr Goldstein recommended switching to the drug Sorafenib as a treatment option. Side-effects were discussed with Mr Lawson. Dr Goldstein also recommended an increase to the Endone dose to better manage Mr Lawson’s pain.

19. Correspondence dated the 12 July 2018 under the hand of Dr Victor Sze, Staff Specialist Pallliative Care, records that Mr Lawson was told his prognosis was poor and that his malignant disease had progressed. Dr Sze was going to trial Sorafenib, but Mr Lawson stated that if he developed any undesirable side effects he would like to stop the treatment and opt for best supportive care/comfort measures instead. Mr Lawson’s

pain treatment was changed from MS Contin to regular Oxycontin.

Breakthrough Endone was also prescribed for pain treatment.

20. On 3 August 2018, Mr Lawson was transferred into palliative care within the Long Bay Hospital. Due to complaints about pain from the the underlying malignancy, Dr Sze, Staff Specialist Pallliative Care, converted his regular Oxycontin to regular hydromorphone.

21. Correspondence for the 9 August 2018 under the hand of Dr Victor Sze records that Mr Lawson did not want further anti-cancer treatment and had ceased Sorafenib the previous week complaining of increased fatigue, nausea and diarrhoea. Dr Sze records that Mr Lawson wished to remain in the Medical Sub-Acute Unit in Long Bay Gaol for his end of life care and did not wish to be transferred back to the acute hospital. He was complaining of increased fatigue over the previous weeks and while still independent for daily living would exhaust easily and feel dizzy when mobilising. His appetite was reduced with further weight loss.

22. On the 19 September 2018, Mr Lawson was being cared for in room 30, a private room. Notes recorded at 4:00 p.m. suggest he was lethargic and his condition was deteriorating. His medications included regular hydromorphone for pain relief and cyclizine for nausea and vomiting. At 10:45 p.m. Nurse Maher records that Mr Lawson was checked and exhibited a minimal response when attempting to verbally engage. At 11:00 p.m. Nurse Maher again checked Mr Lawson and found him not breathing. Due to the no CPR order in place, no CPR was attempted and Mr Lawson passed away.

Findings Identity The deceased person was Graham Lawson.

Date of Death 19 September 2018.

Place of Death Long Bay Hospital, New South Wales.

Cause of death Metastatic hepatocellular carcinoma Manner of death Natural causes whilst serving a custodial sentence.

E. Truscott Deputy State Coroner 15 July 2019