Inquest into the death of Ivan ALLWOOD

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Ivan Allwood Hearing dates: 15 October 2019 Date of findings: 15 October 2019 Place of findings: NSW State Coroner’s Court - Lidcombe Findings of: Magistrate Carmel Forbes, Deputy State Coroner Catchwords: CORONIAL LAW – natural causes death in custody File number: 2019/00058026 Representation: Sergeant B Notley, Coronial Advocate Assisting the Coroner Ms A Smith, instructed by Legal, Department of Communities and Justice New South Wales, representing Corrective Services Mr M Sterry representing Justice Health and Forensic Mental Health Network

Findings: Identity of deceased: The deceased person was Ivan Allwood Date of death: He died on 20 February 2019 Place of death: He died at Long Bay Hospital, Malabar, New South Wales Cause of death: Metastatic squamous cell carcinoma Manner of death: natural causes

INQUEST INTO THE DEATH OF IVAN ALLWOOD This is an inquest into the death of Ivan Allwood who died at Long Bay Hospital on 20 February 2019.

The role of the Coroner is to determine

• The identity of the person who has died,

• The time of that person’s death,

• The location of their death,

• And, the manner and cause of the person’s death.

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.

Ivan Allwood Mr Allwood was born on 15 May 1957 in Tolaga Bay, New Zealand. He had two brothers and a sister.

His parents separated when he was young, and he lived with his mother for a few years before going to live with his father full time. Mr Allwood finished school in year eleven and moved to Australia around 1990. After moving to Australia, he began to use alcohol and drugs excessively. He worked as a furniture removalist until 1996.

In July 2018 Mr Allwood was diagnosed with left tongue base squamous cell carcinoma with bulky left sub-mandibular lymph node metastasis. He commenced radiotherapy. In October 2018 he was fitted with a Percutaneous Endoscopic Gastrostomy (PEG) for supplementing his nutritional intake.

On 15 November 2018, Mr Allwood was arrested by Police and taken to Parramatta Police Station.

While in custody he advised the custody manager that he had a PEG for medical reasons and that he had recently undergone chemotherapy and radiation treatment for throat cancer. He was bail Findings in the Inquest into the death of Ivan Allwood

refused by Police, provided medical clearance by doctors at Nepean Hospital Emergency Department and taken to Amber Laurel Correctional Centre. On 16 November 2018 he appeared before Parramatta Local Court and was remanded to the Metropolitan and Remand Centre (MRRC) until 11 January 2019. He remained at the MRRC where Justice Health provided and coordinated his care and treatment. On 19 December 2018 he was reviewed by Doctor Khoo and his allied health team. A staging scan was ordered by Dr Khoo.

On 11 January he was again remanded by the court until 12 March 2019. On 14 January 2019 he had a PET-CT whole body scan which showed the developed cancer had spread to the lung and heart, and tumour recurrence along the opening of the neck. At this time no further treatment options from an oncology perspective existed and his prognosis was poor. He was given an anticipated life expectancy of 3-6 months. On 24 January 2019 he was moved to Long Bay Hospital and reviewed by the Department of Palliative Care, Prince of Wales Hospital, in the presence of Justice Health Doctor Spasojevic where treatment options were discussed. Given the prognosis, Mr Allwood was provided palliative treatment with a focus on symptom management and comfort care.

On 20 February 2019 Mr Allwood was in cell 31 of the Subacute Unit of Long Bay Hospital. About 2.10am Justice Health nurses attended his cell to provide a gastrostomy tube feed. Mr Allwood was seated on the side of the bed with his eyes open. He appeared drowsy with his head nodding; he was asked to lie down on his bed and as he did became pale and unresponsive. He died at 2.21am.

He was aged 61 years at the time of his death.

The gaol and health records reveal Mr Allwoods’s care and treatment were appropriate. No family member or associate of Mr Allwood have raised any care and treatment issues.

A limited autopsy was conducted on 5 March 2019. The direct cause of death was determined to be metastatic squamous cell carcinoma.

Findings in the Inquest into the death of Ivan Allwood

Findings required by s 81 (1) The identity of the deceased The deceased person was Ivan Allwood Date of death Died on 20 February 2019 Place of death Died at Long Bay Hospital, Malabar, NSW Cause of death The death was caused by metastatic squamous cell carcinoma Manner of death Natural causes Deputy State Coroner Carmel Forbes Lidcombe Coroners Court Date 15 October 2019 Findings in the Inquest into the death of Ivan Allwood