Inquest into the death of Thomas John KEDWELL

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Thomas John KEDWELL 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: 2019/53379 Representation: Sergeant S Kelly, Coronial Advocate Assisting the Coroner Ms Smith, 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 Thomas John Kedwell Date of death: He died on 15 February 2019 Place of death: He died at Prince of Wales Hospital, Randwick, New South Wales Cause of death: The death was caused by respiratory infection on a background of metastic carcinoma Manner of death: natural causes

INQUEST INTO THE DEATH OF THOMAS KEDWELL

1. This is an inquest into the death of Thomas Kedwell. Mr Kedwell 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 15 February 2019 aged 66.

2. 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.

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.

Mr Kedwell

4. Thomas John Kedwell was born on 1st August 1952 in Brisbane, Queensland. Mr Kedwell divorced from his wife about thirty years ago and had eight children. During his employed life he worked as a heavy machinery operator throughout Queensland.

5. On 10 August 2018, Thomas Kedwell was sentenced to 3 years and 8 months imprisonment to commence from 18 November 2017 and conclude on 17 July 2021, with a non-parole period of 2 years and 3 months. His non parole period was due to expire on 17 February 2020.

Findings in the Inquest into the death of Thomas Kedwell

6. Mr Kedwell had a long history of heavy drinking, smoking and intravenous drug use. On admission into custody at Grafton Correctional Centre in August 2018 he reported that he had surgery in 2017 for throat cancer which resulted in a total laryngectomy and tracheostomy followed by radiotherapy. He also reported a history of Chronic Obstructive Pulmonary Disease, hypothyroidism and angina that were managed with medication. The Justice Health and Forensic Mental Health Network report indicates that Mr Kedwell was unable to talk despite having a voice prothesis in situ and communicated by pen and paper.

7. Mr Kedwell also received a prescription of Suboxone as part of an opioid substitution treatment in the community which continued into custody. He was regularly assessed by a Drug and Alcohol nurse specialist and Drug and Alcohol doctor in custody.

8. Whilst in custody at Grafton Mr Kedwell initially refused to attend any medical appointments in Sydney as this was too far for his family to visit him. But, in November 2018 when he was referred to an oncologist and speech pathologist in Sydney he agreed to be transferred.

9. On 4 December 2018, Mr Kedwell was transferred to Long Bay Hospital. On 5 December 2018, Mr Kedwell attended a CT scan at Prince of Wales Hospital which indicated quite extensive and bilateral subcarinal lymphadenopathy. He was transferred to the Medical Subacute Unit at Long Bay Hospital for follow up care.

10. On 14 December 2018, Mr Kedwell was reviewed by an oncologist at Prince of Wales Hospital to discuss further investigations and was referred to the respiratory department for an Endobronchial Ultrasound. This was completed on 20 December 2018.

Findings in the Inquest into the death of Thomas Kedwell

11. Mr Kedwell underwent a Positron Emission Tomography at the Prince of Wales Hospital on 21 December 2018, which showed the appearance of malignancy with extensive nodal involvement of the right cervical, mediastinal, bilateral pulmonary hilar regions along with several nodes below the diaphragm.

12. An urgent appointment was made for Mr Kedwell with the oncologist on 9 January 2019 and he was referred to the palliative care Team.

13. On 24 January 2019, Mr Kedwell was transferred from Long Bay Hospital to Prince of Wales Hospital for the assessment and treatment of his neuropathic pain and bilateral lower leg odema, secondary to lymphadenopathy. He was admitted to the Prince of Wales secure unit and did not return to Long Bay Hospital. Whilst at Prince of Wales Hospital he was regularly reviewed by the palliative care team.

14. On Monday 11 February 2019, Mr Kedwell was scheduled to undergo oesophageal dilation however due to surgical conflicts and Mr Kedwell’s medical condition and health it was rescheduled for the 15th February 2019.

15. Between the 11th and 15th of February 2019, Mr Kedwell complained of chest pains which caused him to undergo a computed tomography scan and X-ray which revealed Mr Kedwell suffered from a collapsed lung, pneumonia and a bowel obstruction. Relevant medical treatment was prescribed and administered.

15 February 2019

16. About 8.30am on 15th of February 2019, Mr Kedwell was transferred to pre-operation where he was assessed by the anaesthetist. Based upon Mr Kedwell’s deteriorating health and his presentation on the day, the anaesthetist decided to cancel the operation. About 9.00am, Mr Kedwell was transferred to Park East 7 Ward.

Findings in the Inquest into the death of Thomas Kedwell

17. Shortly after 9.30am, nursing staff conducted laryngectomy suctioning where a moderate amount of tenacious secretions were noted. Mr Kedwell had previously signed a not for resuscitation order. Around 10am, the nursing staff administered 4mg Morphine for dyspnoea and comfort.

18. About 11.20am, nursing staff who were present with Mr Kedwell noted that he displayed no vital signs. About 11.30am, Doctor Khor issued a ‘Verification of Death’ certificate.

19. An autopsy was performed by Doctor Kendall Bailey on 21 February 2019. Doctor Bailey concluded that the direct cause of death was respiratory infection with the antecedent cause being complications of metastatic carcinoma.

20. The gaol and health records reveal Mr Kedwall’s care and treatment were appropriate. No family member or associates have raised any care and treatment issues whilst he was in custody.

Findings required by s 81 (1) The identity of the deceased The deceased person was Thomas John Kedwell Date of death Died on 15 February 2019 Place of death Died at Prince of Wales Hospital, Randwick, NSW Cause of death The death was caused by respiratory infection on a background of metastic carcinoma Manner of death Natural causes Findings in the Inquest into the death of Thomas Kedwell

Deputy State Coroner Carmel Forbes Lidcombe Coroners Court Date 12 June 2020 Findings in the Inquest into the death of Thomas Kedwell