Deceased
Dat Nhieu HA
Demographics
45y, male
Coroner
Decision ofDeputy State Coroner Forbes
Date of death
2019-03-04
Finding date
2020-06-12
Cause of death
abdominal sepsis on a background of metastatic lung carcinoma
AI-generated summary
A 45-year-old man with advanced metastatic lung cancer died from abdominal sepsis secondary to bowel perforation while imprisoned. He presented with respiratory symptoms in January 2019, was diagnosed with terminal lung cancer following bronchoscopy, and received radiotherapy. In February, he developed acute abdominal pain from small bowel perforation, managed conservatively with fluids, antibiotics, and analgesia given his terminal cancer diagnosis. He subsequently developed hospital-acquired pneumonia and died in palliative care. The coroner found his care and treatment were appropriate throughout his illness. This case highlights the complexity of managing advanced cancer in custodial settings and the importance of early recognition of abdominal complications in cancer patients, though active intervention may not be appropriate in terminal disease.
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Specialties
STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Dat Nhieu HA Hearing dates: 12 June 2020 Date of findings: 12 June 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: 2019/69926 Representation: Sergeant K Mackay, Coronial Advocate Assisting the Coroner Ms McKinlay, instructed by Legal, Department of Communities and Justice New South Wales, representing Corrective Services Mr H Norris representing Justice Health and Forensic Mental Health Network
Findings: Identity of deceased: The deceased person was Dat Nhieu HA Date of death: He died on 4 March 2019 Place of death: He died at Prince of Wales Hospital, Randwick, New South Wales Cause of death: The death was caused by abdominal sepsis on a background of metastatic lung carcinoma Manner of death: natural causes
INQUEST INTO THE DEATH OF Dat Nhieu HA
This is an inquest into the death of Dat Nhieu Ha. Mr Ha was serving a term of imprisonment at Long Bay Correctional Centre at the time of his death. He died at Prince of Wales Hospital, Randwick on 4 March 2019 aged 45.
The role of a Coroner as set out in s.81 of the Coroner’s Act 2009 (“the Act”) is to make findings as to: 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, in other words, the circumstances surrounding the 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.
Mr Ha was born in Vietnam on 10 April 1973. At the age of 5, during the Vietnam War, he came to Australia with his parents and younger brother.
Prior to his incarceration, Mr Ha lived with his elderly mother and adult nephew. He never married and had no children.
On 21 September 2018 he was sentenced to a term of imprisonment of 3 years and 11 months, with a release date of 30 November 2021.
Mr Ha was classified as minimum security, he was transferred between Amber Laurel Correctional Centre, the Metropolitan Remand and Reception Centre, John Maroney Correctional Centre, Goulburn Correctional Centre and Long Bay prison, at each interval of his incarceration movements Mr Ha was assessed by justice health and claimed to have no health issues.
Findings in the Inquest into the death of Dat Nhieu HA
Mr Ha had a long history of drug abuse; heroin, cannabis and methyl-amphetamine commencing in the late 1990’s. He was also a heavy cigarette smoker.
On 11 January 2019 Mr Ha was admitted to Goulburn Hospital following a referral from Justice Health attached to Goulburn Correctional Centre. He complained of a pain to his right armpit, a 4 – 5 kilogram weight loss, a 4-week cough with white sputum, night-time sweats and shortness of breath on exertion.
A chest x-ray identified a partial lung collapse on the left side. A CT scan identified a mass sized 39mm by 50mm by 52mm located adjacent to the left lung. Mr Ha’s right lung was clear, a cyst was located on Mr Ha’s right kidney. He was referred to see a respiratory physician and have a bronchoscopy at The Canberra Hospital.
Mr Ha was prescribed antibiotics, Ibuprofen, Endone, Paracetamol and Clexane for treatment of likely pneumonia.
Mr Ha remained at Goulburn hospital until the 16 February 2019 due to the risk he was suffering tuberculosis. He complained of minor rib pain however was eating a normal diet with fluids, was showering himself and passing urine as required.
On 16 January 2019, Mr Ha was admitted to The Canberra Hospital. On 18 January 2019, he underwent a bronchoscopy, he was diagnosed with terminal lung cancer. The cancer prognosis was described as treatable with a 1-2-year prognosis of life. He was discharged from The Canberra Hospital on 23 January 2019 and returned to Goulburn Prison. He continued treatment as an outpatient with a prescription for antibiotics, pain relief medication and steroids ahead of radiation treatment.
On 1 February 2019 an examination of Mr Ha’s brain revealed multiple lesions at the greywhite matter junction, this was considered in keeping with a diagnosis of metastasis, commonly known as secondary cancer.
On 4 February 2019 a further PET scan noted a pathological fracture of Mr Ha’s seventh right-side rib. A pathological fracture is a fracture caused by disease, in lieu of an injury.
Mr Ha consented to semi-urgent radiotherapy and received five treatments of radiotherapy to the lesions on his lung and lower right rib.
Findings in the Inquest into the death of Dat Nhieu HA
On 7 February 2019 Mr Ha was transferred to Long Bay Correctional Centre Hospital to undergo chemotherapy for his brain cancer, this also placed him closer to his family.
On 15 February 2019 Mr Ha complained to the Justice Health Nurse of abdominal pain, he had not had a bowel movement in four days prior and suffered a distended abdomen. He was given two enemas which had a minimal effect.
Mr Ha was admitted to the Prince of Wales Annexe Ward suffering a small bowel perforation related to his cancer diagnosis. He was considered unsuitable for surgery due to his advance cancer diagnosis. The bowel perforation was managed by pain relief, intravenous fluids and antibiotics. He was considered too unwell for any form of active cancer treatment.
On 25 February 2019 Mr Ha was diagnosed with hospital acquired pneumonia, he was treated with antibiotics until the 1 March 2019.
On 1 March 2019, Mr Ha’s oxygen levels began to decrease, he was suffering shortness of breath and fluid retention in both feet. Mr Ha’s treatment continued in palliative care with pain management. His nephew was advised by treating doctors of the regression in his health.
On 3 March 2019, Mr Ha’s health had markedly deteriorated, he was no longer conscious however appeared comfortable. His nephew was informed, and his treatment changed from active treatment to comfort care.
At 10:30pm Mr Ha was non-responsive but appeared comfortable, his breathing was shallow and laboured. At 11:15pm Mr Ha became agitated and appeared in pain, he was repositioned and administered pain relief, Mr Ha settled, his respiration remained shallow and laboured. Observations continued by medical staff with no change to his condition.
She determined that Mr Ha died due to abdominal sepsis on a background of metastatic lung carcinoma.
Findings in the Inquest into the death of Dat Nhieu HA
Findings required by s 81 (1) The identity of the deceased The deceased person was Dat Nhieu HA Date of death Died on 4 March 2019 Place of death Died at Prince of Wales Hospital, Randwick, NSW Cause of death The death was caused by abdominal sepsis on a background of metastatic lung carcinoma Manner of death Natural causes Deputy State Coroner Carmel Forbes Lidcombe Coroners Court Date 12 June 2020 Findings in the Inquest into the death of Dat Nhieu HA
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