Inquest into the death of Peter SIMPSON

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Peter SIMPSON Hearing dates: 21 February 2020 Date of findings: 21 February 2020 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: 2018/283647 Representation: Sergeant Simone Kelly, Coronial Advocate Assisting the Coroner Mr 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 Peter Simpson Date of death: He died on 15 September 2018 Place of death: He died at Long Bay Hospital, Malabar, New South Wales Cause of death: Terminal lymphoma Manner of death: Natural causes

INQUEST INTO THE DEATH OF PETER SIMPSON

1. This is an inquest into the death of Peter Simpson who died at Long Bay Hospital on 15 September 2018.

2. 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.

3. 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.

Peter Simpson

4. Peter Simpson was born on 13 April 1950. He was the middle child of three sons, born and raised in Launceston Tasmania.

5. On 5 June 2007, Mr Simpson was arrested and charged with offences under Section 61N (1), 61O (1), 66C (1) and (3) of the Crimes Act 1900 (NSW). On 12 September 2008 he was sentenced to a cumulative sentence of 17 years and six months prison, which was reduced on appeal to 14 years and six months prison. On 15 July 2016, whilst still serving his sentence, Mr Simpson was charged with six counts of similar offences, and bail refused on these matters. These offences were still before the court at the time of Mr Simpson’s death.

Medical History

6. While he was in custody Mr Simpson was diagnosed and treated for acute and chronic medical problems including arthritis, chronic obstructive pulmonary disease and Hypertension.

7. In 2014 a basal cell carcinoma was identified and treated. In January 2015, Mr Simpson was diagnosed with facial sarcomas and treated with radiotherapy.

8. In May 2015, Mr Simpson was diagnosed with mantle cell lymphoma and kept under active surveillance. A lymphocyte cell surface marker analysis was completed on Mr Simpson, along with numerous investigations including a core biopsy of his lymph nodes. Throughout 2015, Mr Simpson attended the Prince of Wales Hospital eight times for surgical procedures and routine checks. In January 2016 he began chemotherapy.

9. Throughout 2016 and 2017, there were clear features of progression of his mantle cell lymphoma. In January 2017, Mr Simpson had a right hemicolectomy due to adenocarcinoma. This was followed up by the consultants at Prince of Wales Hospital and by Justice Health Network staff.

10. In November 2017, Mr Simpson had multiple facial squamous cell carcinomas, requiring extensive excision and skin grafting. He also experienced a relapse of mantle cell lymphoma with a poor prognosis. In December 2017, Mr Simpson signed an advance care life directive stating he was not for cardiopulmonary resuscitation.

11. On 26 August 2018, Mr Simpson was transferred to Long Bay Hospital Medical Sub-Acute Unit. Mr Simpson was reviewed by the palliative care team on 31 August 2018 and it was noted that terminal care for a deteriorating patient was planned. Mr Simpson again

confirmed the previously signed advance care directive that he was not for cardiopulmonary resuscitation.

12. On 12 September 2018, Mr Simpson was reviewed by the palliative care team who continued with his palliative care plan, including morphine for pain.

13. At 10am on Saturday 15th September 2018, Mr Simpson was last seen alive by Registered Nurse Dimity Brannon who was one of his primary carers. About 10.15am, Nurse Brannon returned to Mr Simpson’s room and found him unresponsive. Nurse Brannon checked Mr Simpson for a pulse and breath sounds using a stethoscope, life extinct was declared at 10.15am.

Investigation following the death of Mr Simpson

14. About 11:10am on 15 September 2018 police attended Long Bay Correctional Centre. A Crime Scene was established and maintained. CCTV Footage was later obtained and reviewed and was in accordance with the accounts of Corrective Services and Police Officers.

15. Photographs were taken, and Mr Simpson’s body was transferred to the Department of Forensic Medicine, Glebe Morgue.

16. Mr Simpson’s family did not raise any issues about the medical care and treatment he received whilst in custody.

17. A limited autopsy was performed by Doctor Istvan Szentmariay on 20 September 2018.

Doctor Szentmariay concluded that the direct cause of death was determined to be terminal lymphoma.

Findings required by s 81 (1) The identity of the deceased The deceased person was Peter Simpson Date of death Died on 15 September 2018 Place of death Died at Long Bay Hospital, Malabar, NSW Cause of death The death was caused by terminal lymphoma Manner of death Natural causes Deputy State Coroner Carmel Forbes Lidcombe Coroners Court Date 21 February 2020