Inquest into the death of Donald GREENAWAY

CORONERS COURT NEW SOUTH WALES Inquest: Inquest into the death of Mr Donald Victor GREENAWAY Hearing dates: 12 October 2021 Date of findings: 12 October 2021 Place of findings: NSW State Coroner’s Court, Lidcombe Findings of: Magistrate C Forbes, Deputy State Coroner Catchwords: CORONIAL LAW-death in custody, mandatory inquest, cause and manner of death, natural causes File number: 2020/241740 Representation: Mr J Herrington, Advocate Assisting, Crown Solicitors Office Ms J de Castro Lopo for the Commissioner of Corrective Services New South Wales Findings: Donald Victor Greenaway died on 17 August 2020 in the Aged Care Ward at Long Bay Correctional Centre. The cause of Mr Greenaway’s death was the effects of metastatic prostate carcinoma. He died from natural causes, whilst in lawful custody serving a sentence of imprisonment.

Non-publication order On 12 October 2021, orders were made pursuant to section 74 of the Coroners Act 2009 (NSW) (“the Act”), prohibiting the publication of certain material contained within the brief of evidence.

Orders were also made pursuant to section 65 of the Act. Copies of the orders have been placed on the Registry file.

IN THE NSW STATE CORONER’S COURT LIDCOMBE SECTION 81 CORONERS ACT 2009 REASONS FOR DECISION Introduction

1. This is an inquest into the death of Donald Victor Greenaway who died on 17 August 2020 while he was being held in lawful custody at Long Bay Correctional Centre. He was serving a 21-year prison sentence.

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 The Act requires a Senior Coroner to conduct an inquest where the death occurred whilst a person is in lawful custody. In such cases the community has an expectation that the death will be properly and independently investigated.

4 This Inquest has been a close examination of the circumstances surrounding Mr Greenaway’s death and pursuant to s.37 of the Act a summary of the details of this case will be reported to Parliament.

Mr Greenaway

1. Mr Greenaway was born on 21 October 1931. He was 88 years old when he died in cell 9 of the Aged Care Ward at Long Bay Correctional Centre. He was serving a 21-year prison sentence for child sex offences committed over a 30 year period. He had a non-parole period of 15 years and 9 months. Some of the offences were committed when Mr Greenaway was a volunteer teacher at the Woodlands Boys Home at Wallsend, an institution which was the subject of examination by the recent Royal Commission into Institutional Responses to Child Sex Abuse.

2. Mr Greenaway entered into custody on 3 December 2013. His earliest possible release date was to be in September 2029.

3. Mr Greenaway appears to have had no known close friends or associates. His closest surviving relative is a first cousin. The cousin has informed this court that Mr Greenaway was an only child and his parents have now both passed away. His father died in 1976 and he continued a close relationship with his mother until her death in 1994.

4. He was raised in the small town of Craven in New South Wales and attended Newcastle Boys High School. After leaving high school, he worked in various retail positions and at a sawmill, before moving onto an apparently successful career as an accountant and/or auditor.

5. Mr Greenaway’s paternal grandmother was Aboriginal and Mr Greenaway identified as an Aboriginal man. Mr Greenaway spoke to the prison Chaplain early upon his incarceration about his Aboriginality and cultural tradition. He stated that his father took him to the Aboriginal community in the Newcastle area as a child, but he did not have any further contact with that community.

6. Mr Greenaway’s one surviving cousin stayed in contact with him whilst he was in custody by way of the occasional exchange of letters. The cousin has informed this court that, as far as he was aware, there were no issues with the medical treatment Mr Greenaway received whilst he was in custody.

Medical Background

7. Mr Greenaway was diagnosed with an enlarged prostate in around 2007, having had urological problems for about 15 years.

8. Mr Greenaway was diagnosed with prostate cancer in March 2009 when a biopsy showed a stage IV adenocarcinoma. He underwent external beam radiotherapy, under the care of oncologists at the Calvary Mater Hospital in Newcastle, which was completed in July 2009.

After that, Mr Greenaway received follow-up assessments by specialists at the hospital and no evidence of recurrence of the cancer was detected over a three-year period.

9. Prior to going into custody he was last seen by an oncologist at Calvary Mater Hospital on 7 December 2012, when his PSA was noted to have risen slightly although not so much to suggest a recurrence of the cancer. Mr Greenaway was advised to monitor his PSA score at 6-monthly intervals and he was to be reviewed in one year Care and treatment in custody

10. At the time of his arrest and entry into custody on 3 December 2013 ‘prostate cancer’ was recorded on Mr Greenaway’s New South Wales Police Force Custody Management Record as a current medical problem for which he was receiving ‘radiation treatment’. In addition, Mr Greenaway’s other conditions included peripheral neuropathy, radiation enteritis and proctisis, osteopenia and hypertension

11. Mr Greenaway’s complex medical conditions soon saw him frequently transferred to Prince of Wales Hospital for treatment during the course of his period in custody. For most of the 6 years he was in custody before his death he was housed within the Kevin Waller Unit or the Aged Care and Rehabilitation Unit of Long Bay Hospital. In both those settings the records indicate that he was seen by nursing staff on a daily basis and was also under the care of a

geriatrician and general practitioner, among the other clinical staff. A detailed chronology of his medical care in custody is Exhibit 2 in these proceedings.

12. Mr Greenaway’s PSA was tested on various occasions throughout 2014 in 2015 while he was in custody.

13. From December 2015, he began to receive frequent treatment at the Royal Prince of Wales Hospital for urinary symptoms including haematuria, cystitis, kidney stone removal and cystoscopy.

14. On 14 February 2016, Mr Greenaway underwent a CT scan at the Prince of Wales Hospital.

The CT noted a mild to moderately enlarged prostate and noted that there were no lesions suspicious for metastases.

15. Diagnostic tests on 4 March 2016 revealed moderately large prostate lateral lobes with no obvious malignant lesions. Abdominal pelvic CT on 8 March 2016 showed no suspicious osteolysis lesions.

16. There followed a series of further, relatively frequent admissions to Prince of Wales Hospital in 2016 and 2017 for urinary symptoms.

17. On 13 October 2016 Mr Greenaway underwent a further CT of the upper abdomen and pelvis. That examination noted that there were no suspicious lesions.

18. In April 2017 a suspicious nodule was detected on Mr Greenaway’s bladder, which was suspected to be a transitional cell-carcinoma.

19. He was reviewed 15 June 2017.

20. On 9 September 2017, sclerotic lesions were found upon CT scanning on the right proximal femur and right inferior pubis, which suggested bony metastasis from either the bladder lesion that was detected, and/or the prostate. It is noted that those bony lesions had not been present on CT’s performed in March and October 2016. Mr Greenaway did not wish for there to be further investigation of the lesions.

21. The bony lesions appeared unchanged upon examination on 25 October 2017.

22. A non-resuscitation order was put in place on 30 December 2017 by the treating geriatrician upon Mr Greenaway’s wishes.

23. Mr Greenaway began to receive palliative care from the Nelune Comprehensive Cancer Centre at the Prince of Wales Hospital on 5 April 2018.

24. On 26 April 2018, a bone scan was arranged, with clinicians noting that there was no hard evidence that prostate cancer had recurred, and that radiotherapy for the bony lesions was not indicated as it did not appear that Mr Greenaway was being caused significant pain or was at risk of fracture.

25. The results of a further bone scan on 3 May 2018 showed widespread osteoblastic metastases. On 14 May 2018 Mr Greenaway was commenced on androgen deprivation therapy for prostate cancer, and it was thought that palliative radiotherapy to symptomatic bony lesions may be beneficial. That therapy was carried out on 25 June 2018. Regular evaluation of Mr Greenaway’s PSA in that time showed that it was kept in low level.

26. On 24 May 2018, Mr Greenaway was seen by a psychiatrist. He was noted to have accepted his cancer diagnosis and treatment and declined any further psychiatric review. He was noted as having presented as settled.

27. On 11 July 2018, a further CT scan of the upper abdomen and pelvis showed an increase in the size and density of the bony metastases.

28. On 7 November 2018, Mr Greenaway saw Dr Ingham at Prince of Wales Hospital Radiation Oncology. A diagnosis of high risk prostate adenocarcinoma was noted, with progressive disease and widespread bony metastases.

29. It appears throughout 2019 Mr Greenaway received regular review by Prince of Wales Hospital Radiation Oncology and remained largely symptom-free. A palliative care review was conducted by Dr O’Keefe on 1 April 2019, when it was noted that Mr Greenaway’s back pain with being well-controlled, particularly following the palliative radiotherapy to his right pelvis. It was noted that Mr Greenaway was continuing to be treated with androgen deprivation therapy and a plan was made for the community palliative team to continuously monitor Mr Greenaway’s progress

30. On 6 November 2019, a review was conducted by Dr Chen at Prince of Wales Hospital. It noted that Mr Greenaway was reasonably well with no symptoms or signs to suggest prostate cancer progression and no bone pain. Mr Greenaway’s PSA is noted to have risen to 3.6, with the suspicion that he developed castrate-resistant prostate cancer.

31. On 13 March 2020 a CT showed that Mr Greenaway’s sclerotic lesions had significantly increased in size, with additional and large lymph nodes and nodules in the lung bases.

32. By 5 May 2020, Mr Greenaway’s PSA had risen to 15.2. He was referred to Professor Goldstein for consideration of enzalutamide for management of castrate resistant prostate cancer.

33. On 10 May 2020, Mr Greenaway stated to nurses that he no longer wanted to be sent to hospital, but wanted to be kept comfortable at Long Bay.

34. On 28 May 2020 Mr Greenaway was admitted to Prince of Wales Hospital for removal of skin lesions on his cheeks, back and legs. This was the last time he received treatment in hospital.

35. From 5 June 2020, and consistent with his apparent wish for no further investigations or treatment, Mr Greenaway remained in custody at Longbow Hospital, receiving palliative care until his death on 17 August 2020.

Conclusion

36. The cause of Mr Greenaway’s death is well documented.

37. An autopsy performed by Dr Elsie Berger on 26 August 2020 confirmed that the direct cause of Mr Greenaway’s death to be the effects of metastatic prostate carcinoma. The postmortem CT scan revealed widespread metastatic lesions in Mr Greenaway’s body.

38. Having regard to the relevant records from Corrective Services New South Wales and Justice Health regarding Mr Greenaway’s period in custody and the findings from the post mortem examination, it is evident that Mr Greenaway died as a result of a significant pre-existing

natural disease process Dr Colin Chen, Staff Specialist in the Department of Radiation Oncology at Prince of Wales Hospital was involved in his treatment since 2018 and expressed the opinion that Mr Greenaway was managed with the best supportive care.

39. The medical records indicate that Mr Greenaway’s illness was continually assessed and investigated. The re-emergence of his cancer was detected and though he initially refused further assessment and treatment in late 2017 he reconsidered that view and from early 2018 he received regular treatment in the form of hormone therapy and palliative radiation for his cancer by oncology specialists at Prince of Wales Hospital. His cancer had become castrate resistant by May 2020. It is evident that Mr Greenaway wished to receive only palliative care towards the end of his life and refused further admission to Prince of Wales Hospital, wishing to be made comfortable in Long Bay Hospital.

40. Dr Chen, radiation oncologists Prince of Wales Hospital provided a letter to this court noting that Mr Greenaway developed castrate resistant metastatic prostate cancer complicated by bladder outlet obstruction, which was a terminal condition. There is no evidence that his level of medical care during his period in custody was not adequate and appropriate. There is no evidence to suggest that any aspect of the care provided by Corrective Services New South Wales and Justice Health staff contributed in any way to his death Findings: s 81 Coroners Act 2009 Identity The person who died was Donald Victor Greenaway Date of death Mr Greenaway died on 17 August 2020 Place of death Mr Greenaway died in Cell 9 of the Aged Care Ward at Long Bay Correctional Centre.

Cause of death The cause of Mr Greenaway’s death was metastatic prostate carcinoma Manner of death

Mr Greenaway died from natural causes, whilst in lawful custody serving a sentence of imprisonment Magistrate C Forbes Deputy State Coroner 12 October 2021