Inquest into the death of David Grahame Jones

CORONERS COURT OF NEW SOUTH WALES Inquest: Into the death of David Grahame Jones File number: 2020/103425 Hearing dates: 23 June 2021 Date of findings: 23 June 2021 Place of findings: Coroners Court, Lidcombe Findings of: Deputy State Coroner E. Truscott Catchwords: Coronial Law-Cause and manner of death- natural- death in lawful custody Representation: Coronial Advocate: Ms K Mackay Corrective Services NSW Ms V Markovina of Department of Community and Justice, Legal Justice Health and Forensic Mental Health Network Ms N Szylgit Findings: Identity David Grahame Jones Date 2 April 2020 Place Kevin Waller Aged Care Rehabilitation Unit, Long Bay Correctional Centre NSW Cause General frailty and inanition; antecedent conditions: Chronic cardiac and renal failure and diabetes.

Manner Natural causes whilst in lawful custody of Corrective Services NSW

Non-publication Orders

1. That the following information contained in the brief of evidence tendered in the proceedings not be published under section 74(1)(b) of the Coroners Act 2009 (NSW): a. The names, contact numbers and addresses and any other personal information that might identify: i. Any member of David Jones’ family; and ii. Any person who visited David Jones while in custody (other than legal representative or visitors acting in a professional capacity); iii. Any child victim of an offence committed by David Jones.

b. The residential address of David Jones prior to entering into custody; c. The names, personal information and Master Index Numbers (MIN) of any persons in the custody of Corrective Services New South Wales (‘CSNSW’), other than David Jones; d. The direct contact details and personal addresses of CSNSW Officers not otherwise publicly available; e. Portions of the ‘Inmate Accommodation Area Journals’ (C Watch and A Watch) that describe the security checks performed by CSNSW staff; f. Portions of the ‘Transfer to Hospital Order’ and accompanying documents concerning security practices when escorting inmates; g. The closed-circuit television (CCTV) and CCTV still images captured at the Long Bag Hospital ARCU;

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 David Grahame Jones aged 88 years.

2. At the time of his death, Mr Jones was imprisoned in Long Bay Correctional Centre, Sydney, NSW. An inquest into his death is required pursuant to sections 23 and 27 of the Coroners Act NSW 2009 (the Act).

Section 81 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 coronial recommendations.

Background

3. David Grahame Jones was born on the 24 July 1932 to parents . He was the youngest of children to his parents.

4. Following his graduation from Newington High School, Mr Jones lived in England for two years working for a Rover Company. Upon his return to Australia he worked with Granville Motors, and in the 1960’s developed his own motor repair company, until his retirement in 2002.

5. Mr Jones met his wife in 1962, the couple married in and . Following retirement, the couple settled in , in the .

6. Mr Jones had an extensive medical history; he suffered several complex and serious medical conditions. He’d had several surgeries during his lifetime, including an appendectomy in 1942, a right shoulder surgery in 1978, a mitral valve replacement in in 2003, knee replacements to his right knee in 2010 and left knee in 2014 and a cardiac bifascicular block in 2019.

7. He suffered several serious health conditions including, atrial fibrillation, type 2 diabetes, heart valve disorder, mitral valve replacement, heart failure, burdle branch block, hypercholesterolemia, renal failure, vitamin D deficiency and gastroesophageal reflux disease.

8. On the 30 September 2019, Mr Jones was arrested and charged with several child sexual assaults and was subject to strict bail conditions. On the 14 October 2019, his bail was revoked, and he was remanded into Corrective Services custody.

9. Mr Jones was initially housed at the Goulburn Correctional Centre, until being transferred to Parklea Correctional Centre on the 4 November 2019.

10. While housed at Parklea, Mr Jones was transferred to Blacktown Hospital on two occasions, following unwitnessed falls in his cell. On the 6 February 2020, he was admitted to the hospital again and remained there until a placement at the Kevin Waller Aged Care and Rehabilitation Unit Long Bay Hospital.

11. On the 11 February 2020, he was transferred to Kevin Waller Aged Care and Rehabilitation Unit, Long Bay Hospital with an “Advanced Care Directive”.

12. A “Not for CPR” order was completed on the 13 February 2020.

13. On 19 February 2020 Mr Jones was transferred to the Prince of Wales Hospital for investigations and treatment into a decline of overall heath and weight loss. He was diagnosed with sigmoid diverticulitis, acute on chronic kidney injury and oesophageal candidiasis.

14. On the 10 March 2020, he was returned to Kevin Waller Aged Care and Rehabilitation Unit for palliative care.

15. On the 2 April 2020 Mr Jones Mr Jones died in his bed in his cell. CPR was not administered in accordance with the directive dated 13 February 2020.

16. The investigation into Mr Jones’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 accommodated by CSNSW.

Findings: Identity David Grahame Jones Date 2 April 2020 Place Kevin Waller Aged care and Rehabilitation Unit Long Bay Correctional Centre, NSW Cause General frailty and inanition; antecedent causes- chronic cardiac and renal failure and diabetes.

Manner Mr Jones died due to natural causes whilst in the lawful custody of Corrective Services NSW.

Magistrate E Truscott Deputy State Coroner 23 June 2021