Inquest into the death of David HALL

CORONERS COURT

NEW SOUTH WALES Inquest: Inquest into the death of David HALL | Hearing dates: 117 March 2022

Date of findings:

17 March 2022

i

Place of findings: NSW State Coroner’s Court, Lidcombe

Findings of: Magistrate C Forbes, Deputy State Coroner

Catchwords: CORONIAL LAW-Death in custody-natural causes File number: 2021/00018276 Representation: Counsel Assisting

Ms K Jiang, Coronial Advocates Unit

Corrective Services

ms Heritage, DC) legal

ustice Health

Ms Szulgit, Justice Health

REASONS FOR DECISION

Introduction

1. This is an Inquest into the death of Mr David Hall who was 55 years of age when he died in Cell 30 of the Medical Subacute Unit at the Long Bay Hospital within the Long Bay Correctional Facility at 5:15pm on Wednesday 20" of January 2021.

inquest

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. This Inquest has been a close examination of the circumstances surrounding Mr Hall’s death and

pursuant to s.37 of the Act a summary of the details of this case will be reported to Parliament.

Background

4. Mr David Hall was born on 26" of May 1965. He was married and is survived by three adult children, two sons and one daughter. The family resided at their family home in Erskine Park. Mr Hall had three siblings, two brothers and a sister. Mr Halls father passed away at a young age of 46 due to

myocardial infarction, and his mother died at the age of 80 with bladder cancer.

5. Mr Hall worked for Linfox for over 20 years, started as a truck driver and was eventually promoted to

a fleet manager.

6. On 9" of July 2019, Mr Hail was arrested and charged with child sex related offences. On 26" of June 2020, Mr Hall was convicted of the charged offences and was sentenced to imprisonment of 5 years

and 3 months, with the earliest release date being 8" of October 2022. Mr Hall had no other criminal

history apart from these offences. He was housed in Cell 30 of the Medical Subacute Unit at the Long Bay Forensic Hospital within the Long Bay Correctional Facility at the time of his death due to

worsening health conditions.

Medical History

11,

Asa child, Mr Hall was diagnosed with epilepsy, however, has never experienced any seizures.

Mr Hall was also tested positive for Tuberculosis.

In January 2017, he was diagnosed with relapsing and remitting Multiple Sclerosis, and received multiple lesions to the brain causing constant fatigue and lethargy. Prior to his incarceration, Mr Hall received intravenous Tysabri infusions once every five weeks at St Vincent’s Hospital under the care of

Dr. lan SUTTON to treat the Multiple Sclerosis, with the last infusion in June 2019.

In August 2017, Mr Hall was diagnosed with Bladder Cancer and was treated at Nepean Hospital under the care of Dr Mohammed KHADRA. He underwent chemotherapy first, which was not successful. In April 2018, his bladder and prostate were removed after a Cystoprostatectomy and he was required to wear an ileostomy bag at all times after the operation. Mr Hail recovered well post operation with no symptoms of concern, however, reportedly began suffering from depression which

was not treated.

On 11" of July 2019, Mr Hail entered into custody with his existing health conditions noted in Justice Health records; Bladder Cancer and Multiple Sclerosis. He received treatment from the Department of Oncology and the Department of Urology at the Prince of Wales Hospital whilst serving his

imprisonment sentence.

In August 2020, whilst in custody at Long Bay Correctional Facility, a bone scan was conducted and he was diagnosed with Metastatic Urothelial Cancer. He underwent a left femoral prophylactic

intramedullary nailing insertion and palliative radiation for his malignant neoplasm of bladder.

On 20" of September 2020, Mr Hall was admitted to the Prince of Wales Hospital due to large bowel obstruction and spinal cord compression. On 30" of September 2020, Mr Hall commenced radiotherapy for the Metastatic Urothelial Cancer. From this point onwards, he continued to receive

various forms of palliative care for his cancer at the Prince of Wales Hospital.

14. On 16" of November 2020, Mr Hall elected not to be resuscitated, On 19" November 2020, an Advanced Care Directive was signed by Mr Hall and he was discharged and transferred to the Medical

Subacute Unit at the Long Bay Forensic Hospital.

15. On 30" November 2020, Mr Hall stated to Justice Health that he wished to die in prison, and declined any futile medical treatment; al! he wanted was to be kept comfortable while he was dying and did not wish to return to Prince of Wales Hospital even if it meant that there would be better

management of his symptoms.

16. In December 2020, Mr Hall declined any further chemotherapy and his health conditions continued to

deteriorate. He was provided with treatment focused on reducing and managing his pain.

Events leading up to death

17. On 18" January 2021, Mr Hall suffered a fall whilst using the toilet and was moved to Cell 30 for closer monitoring by Justice Health nursing staff. This was recommended numerous times over the weeks

prior. However, Mr Hall had declined these recommendations until the fall.

18. On 19" January 2021, Mr Hall’s conditions continued to deteriorate, and was managed by an increase administration of Morphine and sedation. He was observed by nursing staff to be “very breathless, pallor and presenting with increased weakness” but was described to be in “reasonable spirits and

was laughing at jokes during his consult.”

19. On 20" January 2021, Mr Hall stated to a social worker that he does not wish to be transferred to the hospital. His condition deteriorated significantly and was unable to take any oral medications. At 9:30am on the same day, it was noted by nursing staff that he had entered the Terminal Phase and

was only able to respond coherently with one or two-word answers with pain at a scale of three out of

ten. He understood that he was dying and was granted open door and radio privileges. By 1:30pm, Mr

Hall became non-verbal and was not responsive. At 4:30pm, Mr Hall's family said their goodbyes over

the phone. He showed no signs of distress or agitation.

20. At 5:15pm on 20" January 2021, Mr Hall was pronounced life extinct.

investigation following the death

24,

After the Mr Hall’s passing, Cell 30 was secured, the death was reported to corresponding managers

at Corrective Services and Maroubra Police was notified.

At 6:50pm on 20" January 2021, Police attended. Photographs of the scene were taken. Statements were obtained from Justice Health nurses and Corrective Officers. Relevant records and casefiles were

also obtained from Justice Health and Corrective Services.

CCTV footage at the Medical Subacute Unit was obtained and reviewed by Police. The footage commences from 4:30pm on 20 January 2021 and covers the nurse station and doors to cells 30 to 32 (from right to left). The CCTV does not however show the inside of the cells nor is the bed occupied by

Mr Hall visible. No suspicious activities could be identified after a review of the CCTV footage.

A statement was obtained from the Senior Next of Kin, who was overall satisfied with the treatment and care the deceased received in custody. Mrs Hall was provided with regular updates regarding Mr

Hall’s conditions.

The Officer in Charge has conducted a comprehensive investigation and he concluded that all of Mr Hall’s requests were addressed and granted by Justice Health in an efficient manner. There were no

suspicious circumstances, or any care and treatment issues identified.

On 25 January 2021, an external post mortem examination was conducted; the forensic pathologist

determined the cause of Mr Hall’s death to be due to “Consequences of Urothelial Cancer”.

| am satisfied that Mr Hall’s death was due to natural causes and that he was provided with appropriate care for his pre-existing conditions whilst in custody. No care.and treatment concerns

have been identified or raised.

Findings: s 81 Coroners Act 2009

| find that David HALL died on 20 January 2021, in Cell 30 of the Medical Subacute Unit at the Long Bay

Hospital within the Long Bay Correctional Facility in the State of NSW. The cause of his death was the

consequences of urothelial cancer. The manner of his death was natural causes.

Magistrate C Forbes Co

Deputy State Coroner

17 March 2022