Inquest into the death of Kingsley EAGER

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Kingsley Eager Hearing dates: 23 June 2020 Date of findings: 23 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: 2019/323357 Representation: Sergeant A Chytra, Coronial Advocate Assisting the Coroner Ms K McKinlay, instructed by Legal, Department of Communities and Justice New South Wales, representing Corrective Services Ms N Szulgit representing Justice Health and Forensic Mental Health Network

Findings: Identity of deceased: The deceased person was Kingsley Eager Date of death: He died on 15 October 2019 Place of death: He died in the Medical Sub-Acute Unit of Long Bay Hospital, Long Bay Correctional Complex, Malabar, New South Wales Cause of death: The death was caused by Hodgkin lymphoma and the consequences.

Manner of death: natural causes

INQUEST INTO THE DEATH OF KINGSLEY EAGER

1. This is an inquest into the death of Kingsley Eager. He died on 15 October 2019. At the time of his death he was 80 years of age and he was serving a term of imprisonment at Long Bay Correctional Centre.

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.

Kingsley Eager

4. Kingsley Eager was born on 14 October 1939 in Geelong, Victoria. He had one sibling, a younger brother. Mr Eager moved to Sydney in 1959 where he began training as a nurse. It was during this time that he met his future wife. They went on to have two daughters and adopted three children.

5. On 22 December 2016, Mr Eager was arrested and charged with 26 offences. He pleaded guilty to twenty of these offences on 20 April 2018 and he was sentenced at the Newcastle District Court on 6 August 2018. He was sentenced to a term of imprisonment of nine years and three months. His earliest release date was to be 5 February 2023, and his latest release date was to be 5 November 2027.

6. Mr Eager was received into custody at Newcastle Court Cells on 6 August 2018. The New Inmate Lodgement sheet noted that he had a heart condition and hearing impairment. Mr Eager was transferred to Parklea Correctional Centre and the Justice Health Problem Notification Form (HPNF) requested “two out” cell placement due to Mr Eager’s cardiac issues. In his Reception Screening Assessment, he reported an extensive medical history that Findings in the Inquest into the death of Kingsley Eager

was confirmed by information received from his General Practitioner. His medical history included hypertension, benign prostatic hyperplasic, preventative treatment of blood clotting with Cartia, hearing impairment and chronic kidney disease. He also reported that he had been undergoing investigations for Hodgkin Lymphoma.

7. On 25 September 2018, he was transferred to the Metropolitan Special Program Centre before being transferred to the Long Bay Hospital for his health conditions.

8. Mr Eager was classified as a C1 Minimum Security inmate and was initially placed in Protection Limited Association Area for three months before his status was changed to Special Management Area Placement. He was granted protective custody due to the nature of his offending and because it was his first time in custody. He had no breaches of discipline charges during his time in custody.

Medical Treatment whilst in Custody

9. Between entering custody and November 2018, Mr Eager attended numerous consultations with nurses and doctors for treatment of his various medical conditions. On 23 November 2018, he attended an outpatient Ear Nose and Throat specialist appointment at the Prince of Wales Hospital for continued investigation for Hodgkin Lymphoma. On the 13 December 2018, a core biopsy of Mr Eager’s right-sided cervical lymphadenopathy was performed which led to a diagnosis of an early stage classical Hodgkin lymphoma with good treatment prognosis.

10. On the 11 February 2019, Mr Eager attended an outpatient haematology appointment at the Prince Of Wales Hospital Haematology Department where he expressed reluctance to undertake any treatment for his lymphoma. Medical staff continued to offer Mr Eager treatment for his Hodgkin lymphoma, but he declined. Mr Eager’s daughter told police that her father was against any cancer treatment due to his upbringing as his own father had been an herbalist. Mr Eager had wanted to try a raw diet with juices to combat the cancer, but this was not possible in the custodial setting.

11. On the 21 August 2019, Mr Eager attended a consultation with a doctor for recent confusion, lethargy and falls. He was subsequently admitted to the Prince Of Wales Hospital Emergency Department where he was assessed and admitted. He was prescribed intravenous Ceftriaxone and Clindamycin and two units of packed blood cells. On the 27 August 2019, he was discharged and transferred back to the Medical Special Programs Centre. Whilst there he attended regular consultations with nurses and doctors for ongoing treatment of health concerns, mainly related to Hodgkin lymphoma.

12. Mr Eager’s health continued to deteriorate and on 28 of August 2019, he was admitted to the Long Bay Hospital Medical Sub -Acute Unit where he discussed a palliative care plan with Findings in the Inquest into the death of Kingsley Eager

a doctor. On 30 August, he completed an advanced care directive stating that he did not wish for intensive or resuscitation measures to be applied.

13. On the 16 September 2019, Mr Eager was taken back to Prince Of Wales Hospital as his condition had deteriorated. A CT scan showed that his Hodgkin lymphoma had progressed and following a discussion between Mr Eager, his next of kin and the Prince Of Wales Hospital specialist doctor, it was agreed to commence palliative care and cease active treatment. An additional advanced care directive was completed on this date. Mr Eager was transferred back to the Medical Sub-acute Unit on 18 September 2019 where he received palliative care and comfort measures. He was administered Sodium Bi-Carbinate Mouthwash, Nilstat and 5ml of Morphine every six hours prior to his death.

14. About 6pm on the 15 October 2019, Mr Eager was administered his medication. At that time, he appeared comfortable and responded briefly to medical staff, though his interactions were minimal due to his deteriorating condition. Throughout the evening he was checked on hourly by medical staff and complained of pain if they tried to move or adjust him.

15. About 9.30pm that night, Registered Nurse Maher attended his room and observed Mr Eager to be unresponsive. She requested Corrective Officers Garratt and Pradhan to attend as she assessed Mr Eager for cardiac output, signs of breathing and neurological response.

Corrective Officer Garratt commenced a Critical Incident Time Log and Senior McFarlane was informed of Mr Kingsley’s death.

Investigation following Mr Eager’s death

16. About 10.35pm on the 15 October 2019, police from the Eastern Beaches Police Area Command attended the Long Bay Hospital. The Officer in Charge, Plain Clothes Senior Constable Steven Cigana, took photographs and completed the P79A notification to the Coroner. There were no suspicious circumstances detected.

18. A limited autopsy was conducted by pathologist Dr Van Vuuren on 23 October 2019. Dr Van Vuuren concluded that the cause of death was Hodgkin lymphoma and the consequences.

Findings in the Inquest into the death of Kingsley Eager

19. The available evidence establishes that Mr Eager’s care and treatment while he was in custody was appropriate. No family member or associate of Mr Eager have raised any care and treatment issues.

Findings required by s 81 (1) Coroner’s Act 2009 The identity of the deceased The deceased person was Kingsley Eager Date of death Died on 15 October 2019 Place of death Died at Medical Sub-Acute Unit of Long Bay Hospital, Long Bay Correctional Complex, Malabar, New South Wales.

Cause of death The death was caused by Hodgkin lymphoma and the consequences.

Manner of death Natural causes Deputy State Coroner Carmel Forbes Lidcombe Coroners Court Date 23 June 2020 Findings in the Inquest into the death of Kingsley Eager