Inquest into the death of Peter GLEN

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Peter Glen Hearing date: 8 May 2020 Date of findings: 8 May 2020 Place of findings: NSW Coroners Court - Lidcombe Findings of: Magistrate Elizabeth Ryan, Deputy State Coroner Catchwords: CORONIAL LAW – death of inmate at Long Bay Correctional Centre Hospital – death from natural causes.

File number: 2019/248603 Representation: Coronial Advocate assisting the inquest: Sgt K Mackay.

Sydney Local Health District: Corrective Services NSW: K McKinlay, Department of Communities and Justice, NSW.

Justice Health and Forensic Mental Health Network: H Norris.

Findings in the Inquest into the death of Peter Glen

Findings: Identity The person who died is Peter Glen.

Date of death: Peter Glen died on 9 August 2019.

Place of death: Peter Glen died at Long Bay Correctional Hospital at Malabar, Sydney.

Cause of death: The cause of Peter Glen’s death is hepatic failure secondary to hepatocellular carcinoma which developed from cirrhosis of the liver, caused by chronic alcoholism and hepatitis C.

Manner of death: Peter Glen’s died from natural causes, while he was in lawful custody at Long Bay Correctional Centre.

Orders for non-publication of certain material in the coronial brief of evidence were made on 8 May 2020. The orders appear on the coronial file.

Section 81(1) of the Coroners Act 2009 (NSW) [the Act] 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 Peter Glen.

Introduction On the evening of 9 August 2019 Peter Glen aged 52 years died in the Long Bay Correctional Hospital at Malabar in Sydney. He had been an inmate of Long Bay Correctional Centre since 26 February 2019. The following month he was diagnosed with hepatocellular carcinoma, on a background of cirrhosis, secondary to alcohol dependence and hepatitis C.

Since Mr Glen was a prison inmate at the time of his death, an inquest into the circumstances of his death is mandatory pursuant to sections 23 and 27 of the Coroner’s Act 2009.

The role of the Coroner The Coroner must make findings as to the date and place of a person’s death, and the cause and manner of death.

Findings in the Inquest into the death of Peter Glen

In addition, pursuant to section 82 of the Act the Coroner may make recommendations in relation to matters which have the capacity to improve public health and safety in the future, arising out of the death in question.

Mr Glen’s life Peter Glen was born in Melbourne on 25 June 1967. He was a partner in a lengthy de facto relationship which ended in 2013. Following this Mr Glen became the primary carer for the two grandchildren of his former de facto partner.

Mr Glen struggled with alcohol dependence, the consequences of which led to surgery in 1994 for removal of his appendix and lower bowel. He was diagnosed with Hepatitis C in 2004, and cirrhosis of the liver in 2012.

On 25 February 2019 Mr Glen was charged with child sexual assault offences. He was refused bail and the matters were next due in court in September 2019. Due to the nature of the charges, Mr Glen was placed in protective custody.

On 26 February 2019 Mr Glen received an inmate medical assessment. He presented as jaundiced and suffering the effects of alcohol withdrawal. He notified medical staff of his conditions of Hepatitis C and cirrhosis. Following this Mr Glen underwent diagnostic testing at Westmead Hospital, which showed a lesion on his liver consistent with hepatocellular carcinoma.

Thereafter Mr Glen was referred to a hepatic specialist, and had regular clinical reviews which identified on 15 March that his cancer was at end stage. He received transarterial chemoembolization. He was admitted to Westmead Hospital on 27 June into the care of the palliative care team, and then transferred to the medical subacute unit at Long Bay Correctional Hospital on 23 July. Here he was placed on an ‘end of life’ care plan, involving medications for pain relief and for relief of his various symptoms.

In the final week of his life Mr Glen’s condition rapidly deteriorated. On the evening of 9 August 2019 nursing staff found him unresponsive in his bed. Shortly afterwards he was pronounced deceased.

Since being incarcerated in February 2019, Mr Glen’s lifelong friend Xxxxx Xxxxxx visited him regularly. Mr Harvey’s last visit took place six days before Mr Glen’s death.

The post mortem report An external examination of Mr Glen’s body was performed by forensic pathologist Dr Dianne Little. On the basis of her examination and the contents of a post mortem CT scan, Dr Little concluded that the cause of Mr Glen’s death was hepatic (liver) failure secondary to hepatocellular carcinoma which developed from cirrhosis of the liver, caused by chronic alcoholism and hepatitis C.

Dr Little commented that one of the complications of cirrhosis is the development of primary cancer of the liver. External examination showed severe jaundice of Mr Findings in the Inquest into the death of Peter Glen

Glen’s body, and fluid in the abdomen. Dr Little found no injuries or other significant conditions.

Cause and manner of death The cause of Mr Glen’s death is able to be established. The manner of his death is natural causes, while he was in lawful custody at Long Bay Correctional Centre.

Conclusion There is no evidence of any deficiency in the management of Mr Glen’s medical condition after he was incarcerated. The evidence establishes that he received appropriate care and treatment up until his death.

I thank Coronial Advocate Karissa Mackay for her assistance in the preparation and conduct of this inquest.

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.

Identity The person who died is Peter Glen.

Date of death: Peter Glen died on 9 August 2019.

Place of death: Peter Glen died at Long Bay Correctional Hospital at Malabar, Sydney.

Cause of death: The cause of Peter Glen’s death is hepatic failure secondary to hepatocellular carcinoma which developed from cirrhosis of the liver, caused by chronic alcoholism and hepatitis C.

Manner of death: Peter Glen’s died from natural causes, while he was in lawful custody at Long Bay Correctional Centre.

I close this inquest.

Magistrate E Ryan Deputy State Coroner Lidcombe Date 8 May 2020 Findings in the Inquest into the death of Peter Glen