Inquest into the death of John Little

CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of John Little Hearing dates: 22 March 2022 Date of findings: 22 March 2022 Place of findings: Coroner’s Court of New South Wales Findings of: Magistrate Carolyn Huntsman, Deputy State Coroner Catchwords: CORONIAL LAW – death in custody, natural cause, Pleuropulmonary Malignancy on the background of End-Stage Obstructive Pulmonary Disease File number: 2020/00343056 Representation: Sergeant Jai Kiang, Coronial Advocate Assisting the Coroner Ms Ashleigh Heritage, Commissioner for Corrective Services,

NSW Mrs Natalie Szulgit, Justice Health and Forensic Mental Health Network, NSW Findings: I make the following findings pursuant to s81 of the Coroners Act 2009 NSW: Identity: Mr John Little Date: 2 December 2020 Place: Long Bay Hospital, Long Bay Correctional Complex, 1300 Anzac Parade, Malabar, New South Wales, 2036 Cause of death: Pleuropulmonary Malignancy on the background of End-Stage Obstructive Pulmonary Disease Manner of death: Natural Cause Recommendations Nil Non-publication orders: A non-publication order was made on application of Corrective Services NSW

JUDGMENT Introduction 1 This is an Inquest into the death of Mr John Little, who was 76 years of age when he died. At the time of his death Mr Little was in the custody of Corrective Services and was housed in Cell 2, Aged and Rehabilitation Unit, Long Bay Hospital, Long Bay Correctional Complex.

2 As Coroner, I express my sincere condolences to Mr Little’s family.

Coroner’s Role 3 The purpose of an Inquest is to investigate how and why a person died, and to find ways, if possible, to stop preventable deaths.

4 It is the role of the Coroner to investigate and make findings about sudden, violent, suspicious or unnatural deaths. Findings are required to be made in relation to:

(a) the identity of the person who has died,

(b) the date and place of the person’s death,

(c) the cause of death, and

(d) the manner (or circumstances) of the person’s death.

5 Recommendations may also be made in relation to any matter connected with the person’s death where appropriate.

6 As Mr Little died whilst in custody, this is a mandatory Inquest in compliance with section 27 of the Coroner’s Act.

The evidence 7 The Police Officer in Charge of the investigation, Detective Senior Constable Sean Cummins, gave oral evidence at the inquest hearing, and the brief of evidence compiled during the investigation, was tendered. The brief indicates significant investigation of Mr Little’s death was undertaken by police.

Background 8 Mr John Little was born on 24 October 1944. He grew up in the Brunswick area in Victoria. His family members include his sister, Ms MJ, and his daughter, Ms Z.

9 After finishing high school, he worked in a foundry and later worked at United Carlton Breweries. In 1962, he competed in Greco-Wrestling in the Commonwealth Games. In a statement to police, his sister, Ms MJ, reported that Mr Little enjoyed fishing and prospecting for gold as hobbies.

10 Mr Little had a long term partner in the mid-1960s, when he was young, and this partnership saw the birth of Mr Little’s daughter, Ms Z. In about 1965 Mr Little met and married his first wife, her name was DD. They separated after a year or two. They had one daughter from this marriage but she predeceased Mr Little. In the late 1970’s, Mr Little met his second wife, SS, and moved to reside near Ballina NSW. Mr Little and his wife, SS, adopted a boy in the early 1980s but he also predeceased Mr Little. Mr Little and SS separated in the mid-1980s but Mr Little continued to live in the Ballina area and cohabitated with a female partner. Mr Little and his partner moved back to Victoria in the late 1980s. Mr Little moved to South Australia in the early 1990s, later returning to Victoria. He travelled to Thailand in around 2003, and according to Ms MJ it was around that time that he first showed psychiatric symptoms.

After community psychiatric assessments, he moved into public housing near Geelong Victoria.

11 Ms MJ told police that she last spoke to Mr Little the day before his death while he was in custody at the age care unit within the Long Bay correctional Centre.

12 On 19 March 2015, Mr Little was arrested and charged with historical child sex related offences said to have occurred in the early 1980s. In 2017, he was referred to the Mental Health Review Tribunal. On 24 June 2019, a bench warrant was issued by Lismore District Court in relation to the historical child sex offences. On 26 July 2019, Mr Little was arrested and extradited from Victoria. On 27 September 2019, he was moved from Junee Correctional Centre to the Long Bay Correctional Complex and housed in the Aged and Rehabilitation Unit due to his high daily care needs. Mr Little’s care needs included Oxygen therapy, medications, and other medical support. Mr Little was placed on palliative care pathway while in the Long Bay Hospital. On 28 October 2019, a Not for Resuscitation order was put in place. A written form evidencing Mr Little’s wishes to be not for resuscitation/CPR dated 28 October 2019 forms part of the medical records.

13 Copies of court orders in the brief of evidence indicates that on 29 November 2019, at Lismore District Court, Mr Little was found unfit to be tried and referred to the Mental Health Review Tribunal. He was also refused bail by the court on that date. A criminal history record contained in the police brief of evidence indicates that the Lismore District Court issued a bench warrant in June 2019 and in May 2020 the District Court conducted a special hearing (mental health) and made qualified findings of guilt, in relation to a number of charges. In September 2020 Mr Little received a limiting term of two years and six months commencing 24 July 2020 and concluding 23 January 2023.

The District Court issued an order for detention. Mental Health Review Tribunal documents contained within the brief indicate that the tribunal reviewed Mr Little on 30 January 2020, on that date the tribunal made no change to current order for detention and made a finding that Mr Little was not fit to be tried. The tribunal’s order states that after the review the tribunal ordered that Mr Little be detained at Long Bay Correctional Complex for care and treatment. The tribunal review and order were made under sections 46

and 47 of the Mental Health (Forensics Provisions) Act 1990 and the order was signed and dated 6 February 2020.

14 At the time of his death, Mr Little was in lawful custody in the Long Bay Hospital of the Long Bay correctional complex. He was initially in custody at Albury court cells on 26 July 2019, the Albury Local Court remanded Mr Little in custody, bail refused, to appear at the Lismore District Court on 29 July

2019. Mr Little was initially housed in Junee Correctional Centre for a short period, and from 27 September 2019 he was transferred to the Long Bay hospital within the Long Bay Correctional Centre. He was an inmate housed in Cell 2 of the Aged Rehabilitation Unit (ARU) of the Long Bay hospital within the Long Bay Correctional Complex.

Medical History 15 Mr Little reportedly suffered from significant developmental trauma due to having an alcoholic mother and an absent father. Mr Little had a long term dependency upon cannabis. Around mid-1990’s, Mr Little developed nicotine and cannabis use disorder and drug induced psychosis, with persecutory delusions and auditory hallucinations. He was treated for his mental health conditions from at least 2003. He also suffered from chronic paranoid schizophrenia (2016), depression (2017) and cognitive impairment and mild dementia secondary to vascular disease and smoking. There are no records of self-harm ideations.

16 Mr Little suffered from ill health throughout his life, including bouts of gastric cancer (underwent partial gastrectomy), bilateral hip replacements, bilateral lens implants for cataracts, laminectomy (surgical removal of portion of vertebral bone called lamina), osteoarthritis, asbestos exposure with pleural plagues which required ongoing oxygen therapy, and end stage chronic obstructive pulmonary disease (COPD). He required BiPap Ventilation and high dose intravenous antibiotics to treat his conditions. Mr Little was frail and disabled with mobility issues and his mobility was assisted with wheeled walking frame.

17 Medical records indicate that on admission to the prison system Mr Little had an existing medical diagnosis which included significant COPD related to smoking and asbestos exposure, and that he was on home oxygen prior to entry into the prison system. Whilst in custody he was supplied with oxygen as required. Other medical history noted on admission included asbestos exposure with pleural plaques; partial gastrectomy for gastric cancer, AAA repair – endoluminal; bilateral hip replacements; bilateral cataract extraction and lens implants; previous laminectomy and existing low back pain; bilateral shoulder tendinitis; schizophrenia. He was also on a significant number of medications at the time of his admission to the prison system. The police, as part of their investigation into the death of Mr Little, obtained detailed medical records. The medical records indicate ongoing treatments for health conditions whilst in custody, including due to exacerbations of his COPD. In May 2020 he had a CT scan of the chest with IV contrast, the report notes that there were pleural plaques on chest x-ray and queried an underlying mass. The impression from the CT scan was marked bilateral lung architectural distortion, with diffuse asbestos related calcified pleural plaques and diffuse emphysematous changes, and interspersed regions of pulmonary fibrosis. There was a further CT scan in June 2020 to explore potential lung cancer due to his presentation and a mass was seen (malignancy suspected).

18 During his incarceration Mr Little was subject to aged care assessments, and was given an aged care support plan. The aged care support plan noted his ongoing shortness of breath, which was impacting on his independence, and that he mobilised slowly using a four wheeled walker. He also required assistance with administration of medications, at the time of the aged care assessment this assistance was being provided by Justice Health clinic nurses on a daily basis. There was an assessment/approval for aged care residential care, noting his high support needs, and the assessment also observed that as a forensic patient there would be detainment orders or conditional release orders in the future. The support plan was provided to the Clinical Nurse Consultant with Older Persons, Justice Health Service, and Long Bay prison. The assessment is dated 2 March 2020.

19 On 2 June 2016, Mr Little was diagnosed with Chronic small vessel Ischaemic Disease, and in July 2020, he was diagnosed with suspected Small Cell Lung Carcinoma. He was deemed not suitable for surgery and chemotherapy. He was managed under palliative care services.

Events leading up to death 20 On 2 December 2020, Mr Little was given his daily medication in the morning.

Throughout the day, he was checked upon periodically by Justice Health staff.

The last check was conducted at 8pm, when his nightly medications were dispensed, being MS Contin 35mg, Lorazepam 1mg (for anxiety), Pregabalin 75mg (Neuropathic pain treatment), and Tempazepam 10mg (assist with sleeping). Mr Little was observed to have taken the medication in the presence of nursing staff and accompanying Corrective officers without issue.

He was responsive and in good spirits. Mr Little was secured in his cell and the main lights were turned out at 9pm.

21 At 9:40pm further rounds, or checks of inmates, were conducted by Justice Health staff and Mr Little was observed to be on the floor of his cell, with half of his body on a mattress from his bed and the other half on the floor. A nurse attempted to raise Mr Little through the cell door, however he did not respond and Corrective Services Officers were called who entered the cell and approached Mr Little, checking for signs of life. It was recorded that Mr Little was unresponsive at that time. The nurse went to raise assistance from other nursing staff, and while she did this, Corrective Services officers attempted CPR for approximately four minutes. This was discontinued when nursing staff returned to the cell because of the non-resuscitation directive for Mr Little which had been in place since 28 October 2019. Nursing staff commenced signs of life checks. Around 9:40pm on Wednesday 2 December 2020, Mr Little was pronounced life extinct. Nursing staff reported the death of Mr Little to the Coroner.

Investigation following the death 22 At 11:30pm on the same day, Police from Maroubra Police Station arrived and started their investigation. Crime scene officers attended shortly after and examined the scene. Corrective Services officers and Justice Health nurses were spoken to by Police. CCTV of the incident was provided and reviewed.

No issues were identified, and the content of the CCTV was consistent with reports from Corrective Services officers and Justice Health staff. An Identification statement was provided by a Justice Health nurse. All relevant files from Justice Health New South Wales, and Corrective Services, New South Wales, relating to Mr Little’s criminal, judicial and medical history, were provided to the officer in charge of the police investigation. Police also obtained audio files relating to “knock up alarms” or communications by Mr Little from his cell. It is observed that generally there were repeated requests for oxygen to his cell to assist management of his breathing. The police investigation revealed that oxygen was provided to the deceased on each occasion he asked for it and this is also supported by the medical records. Mr Little was cared for and treated appropriately whilst in custody; and in accordance with relevant policies and procedures of the Corrective Services.

Police concluded that there were no suspicious circumstances and that Mr Little died due to natural causes.

23 A postmortem examination was conducted by a forensic pathologist who found that Mr Little’s death was due to “Pleuropulmonary Malignancy on the background of End-Stage Obstructive Pulmonary Disease”.

Conclusions 24 The evidence given to the inquest and contained in the police brief of evidence indicates that there were no suspicious circumstances in the death of Mr Little. A review of medical records, including the medical records of Mr Little’s treatment in custody, indicate that his medical needs were met on an ongoing basis whilst in custody. Mr Little was 76 years of age with significant health problems which were long-standing and predate his time in custody.

He also had mental health complications but these did not contribute to his

death. Post-mortem full-bodied CT imaging showed chronic obstructive pulmonary disease, masses suspicious for malignancy, features of asbestosis, coronary artery calcification and evidence of previous gastrectomy and surgical repairs of the lower abdominal aorta, both hips and left femur. No other significant skeletal trauma was noted and there was no evidence of suspicious injuries. The autopsy report noted that Mr Little was known to be with end stage chronic obstructive pulmonary disease on a background of cigarette smoking and previous asbestos exposure and that there was a suspected pleuropulmonary malignancy noted on imaging in 2020. I have considered the forensic pathologist’s report and all of the evidence in this matter and I am satisfied on the balance of probabilities that the cause of death was Pleuropulmonary Malignancy on the background of End-Stage Obstructive Pulmonary Disease.

25 I find that Mr Little was the sole of occupant in his prison cell, and was found on the floor of his cell during checks by officers, over an hour after he was secured in the cell for the night. Nurses and Correctional Officers were unable to rouse him and he was pronounced deceased by nursing staff.

The cause of death 26 I am satisfied after review of all the evidence presented at the inquest, for reasons detailed above, that the cause of Mr Little’s death was Pleuropulmonary Malignancy on the background of End-Stage Obstructive Pulmonary Disease.

Manner of death 27 On the evidence I am satisfied that Mr Little was suffering from end stage chronic obstructive pulmonary disease and a suspected pleuropulmonary malignancy noted on imaging in 2020. The post mortem CT scans and forensic pathologist support the conclusion of the cause of death being Pleuropulmonary Malignancy on the background of End-Stage Obstructive Pulmonary Disease – this conclusion is also supported by the medical records of his health when he was in custody. Mr Little had other health conditions as

detailed in the medical evidence and autopsy report. He had poor health for many years before his entry in to the custodial environment. I am satisfied that there is no evidence of any third party involvement in his death, and the evidence supports the conclusion that Mr Little’s healthcare needs and welfare needs were being provided for whilst in custody. For all of these reasons I am satisfied the manner of death was natural cause.

FINDINGS 28 The findings I make in relation to the deceased, under section 81(1) of the Act are: Identity: Mr John Little Date: 2 December 2020 Place: Long Bay Hospital, Long Bay Correctional Complex, 1300 Anzac Parade, Malabar, New South Wales, 2036 Cause of death: Pleuropulmonary Malignancy on the background of End-Stage Obstructive Pulmonary Disease Manner of death: Natural Cause Closing 29 I acknowledge and express my gratitude to Kai Jiang, Coronial Advocate, for his assistance both before and during the inquest. I also thank the Police officer in charge, Detective Senior Constable Sean Cummins, for his work in the Police investigation and compiling the evidence for the inquest.

30 On behalf of the Coroners Court of New South Wales, I offer my sincere and respectful condolences to Mr Little’s family.

31 I close this inquest.

Magistrate Carolyn Huntsman Deputy State Coroner Coroners Court of New South Wales