Inquest into the death of Stephen Pitty

CORONERS COURT OF NEW SOUTH WALES Inquest: Into the death of Stephen Pitty File number: 2019/261510 Hearing dates: 4 September 2020 Date of findings: 4 September 2020 Place of findings: Coroners Court, Lidcombe Findings of: Deputy State Coroner E.Truscott Catchwords: Coronial Law-Cause and manner of death- natural- death in custody Representation: Coronial Advocate : Ms K Mackay Corrective Services NSW Ms K McKinlay of Department of Community and Justice, Legal Justice Health and Forensic Mental Health Network Mr H Norris Findings: Identity Stephen Pitty Date 21 August 2019 Place Prince of Wales Hospital, Randwick, NSW Cause Complications of Ischaemic cardiomyopathy and Chronic Obstructive Pulmonary Disease Manner Mr Pitty died whilst in the lawful custody of Corrective Services NSW, housed in the Kevin Waller Unit at the Metropolitan Special Purpose Centre, Long Bay NSW

Non Publication Orders

1. Pursuant to section 74(1)(b) of the Coroners Act 2009 (NSW), the following information contained in the brief of evidence tendered in the proceedings not be published: a. The names, Visitor Index Numbers, contact numbers and addresses of any member of Stephen Pitty’s family, friends and visitors other than legal or professional visitors; b. The names, personal information and Master Index Numbers (MIN) of any persons in the custody of Corrective Services NSW (CSNSW) other than Stephen Pitty; c. The direct contact details of CSNSW staff and staff from external service providers not otherwise available to the public; and d. The closed-circuit television (CCTV) footage obtained from the Kevin Waller Unit and any stills of that footage.

2. Pursuant to section 65(4) of the Coroners Act 2009 (NSW), a notation be placed on the Court file that if an application is made under section 65(2) of that Act for access to Corrective Services NSW documents on the Court file, that material shall not be provided until Corrective Services NSW has had an opportunity to make submissions in respect of that application.

IN THE CORONERS COURT LIDCOMBE NSW Section 81 Coroners Act 2009

REASONS FOR DECISION Introduction

1. This is an inquest into the death of Stephen Edward Pitty aged 70 years.

2. At the time of his death, Mr Pitty was serving a term of imprisonment at Long Bay Correctional Centre, an inquest is mandatory pursuant to Sections 23 and 27 of the Coroners Act NSW 2009 (the Act). Section 21 of the Act 2009 provides jurisdiction to a Coroner to hold an inquest into the death, or suspected death of a person, and to make findings as to the date, place, cause and manner or circumstances of death. Section 82 of the Act provides for a coronial recommendations.

Background

3. Stephen Pitty was born on the 16 April 1949 in Sydney, he was one of six children who grew up in the Sydney suburb of Rozelle. He was the father to four children, however has apparently not had contact with them or his siblings since about 2006.

4. Mr Pitty met his partner Kathleen Rollan in 2012 and they resided together at a property in Birdwood on the mid-north coast of New South Wales up until his incarceration.

5. Mr Pitty had a lengthy medical history and was a long-term user of methylamphetamine and cannabis. He had ischaemic heart disease and between 2003 and 2015 he received seven cardiac stents. Additionally he

suffered angina, post-traumatic stress disorder, type 2 diabetes, chronic pulmonary disease and chronic lung disease, for which he took several prescribed medications.

6. On the 10 July 2015, Mr Pitty was arrested and charged with several historical sexual offences, he was bail refused and was sentenced on the 12 February 2016, he was sentenced to a term of imprisonment of seven years and six months, with an earliest release date of the 9 January 2023.

7. Mr Pitty was accommodated in a number of correctional facilities including Cessnock, Parklea, the Metropolitan Special Purpose Centre, Long Bay Correctional Centre.

8. During his incarceration Mr Pitty was regularly attended to by Justice Health and Forensic Mental Health Network (Justice Health) medical and nursing staff for the management of his health conditions.

9. On the 8 February 2019, Mr Pitty attended a planned admission to the Prince of Wales Hospital for a coronary angiogram. On the 12 February 2019 he was discharged to the Long Bay Hospital Medical Sub-Acute Unit. His discharge summary noted he was suffering chronic obstructive pulmonary disease, Type 3 pulmonary failure, pulmonary hypertension, progressive profound dyspnoea on exertion, dyslipidaemia, type 2 diabetes and coronary artery disease, it was recommended he receive constant oxygen.

10. On the 5 July 2019, Mr Pitty was placed in the Kevin Waller Unit, a unit which specifically accommodates aged and frail inmates in the Metropolitan Special Purpose Centre where he received ongoing medical care.

11. At 4:45pm on 21 August 2019, Mr Pitty was observed sitting on the toilet in his cell suffering shortness of breath, he was assisted to his bed where he utilised his oxygen tank.

12. At 5pm on 21 August 2019, Correctional officers were called to Mr Pitty’s cell, he was seated on his bed and when spoken to he did not respond, his eyes rolled back, and he collapsed, slumping backwards towards the wall.

13. Justice Health nursing staff were called who observed that Mr Pitty’s breathing was very shallow with a respiration rate of eight.

14. The nurses commenced CPR until the arrival of the NSW Ambulance service personnel at 5:11pm. They took over care and transferred Mr Pitty to the Prince of Wales Hospital, Accident and Emergency Department.

15. CPR and medical intervention continued en route to the Prince of Wales Hospital arriving at 6:05pm. Mr Pitty was unresponsive to medical treatment and pronounced deceased at 6:15pm by the treating accident and emergency practitioner.

16. The investigation into Mr Pitty’s death establishes that he suffered multiple serious complex and chronic illnesses, for which he was provided appropriate care and treatment from Justice Health and was appropriately accommodation by CSNSW.

Findings: Identity Stephen Pitty Date 21 August 2019 Place Prince of Wales Hospital, Randwick, NSW Cause Complications of Ischaemic cardiomyopathy and Chronic Obstructive Pulmonary Disease Manner Mr Pitty died whilst in the lawful custody of Corrective Services NSW, housed in the Kevin Waller Unit at the Metropolitan Special Purpose Centre, Long Bay NSW Magistrate E Truscott Deputy State Coroner 4 September 2020