Inquest into the death of Michael Quinn

CORONERS COURT NEW SOUTH WALES Inquest: Inquest into the death of Michael Quinn Hearing dates: 17 August 2022 Date of findings: 17 August 2022 Place of findings: NSW State Coroner’s Court, Lidcombe Findings of: Magistrate C Forbes, Deputy State Coroner Catchwords: CORONIAL LAW-natural causes death in custody-care and treatment of quadriplegic inmate in custody File number: 2020/100722 Representation: Mr H Mullen, Coronial Advocate Assisting the Coroner Ms Szulgit for Justice Health and Forensic Mental Health Network Ms C Moore for the Commissioner of Corrective Services NSW Findings: Michael Quinn died on 1 April 2020 at the Prince of Wales Hospital, Randwick, NSW. The cause of Mr Quinn's death was sepsis due to urosepsis and pneumonia on a background of C3 incomplete tetraplegia. Mr Quinn died from natural causes, whilst in lawful custody serving a sentence of imprisonment Non-publication orders: See Annexure A

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 Mr Michael Quinn who died on 1 April 2020 whilst he was in custody serving a sentence of imprisonment

2. Section 23 of the Coroners Act 2009 requires a senior coroner to conduct an inquest 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.

3. 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: i. the identity of the deceased; ii. the date and place of the person’s death; iii. the physical or medical cause of death; and iv. the manner of death, in other words, the circumstances surrounding the death.

4. This Inquest has been a close examination of the care and treatment Mr Quinn received whilst he was in custody prior to his death and pursuant to s.37 of the Coroners Act 2009 a summary of the details of this case will be reported to Parliament.

Mr Quinn

5. Mr Quinn was born on 30 September 1988 at Wollongong Hospital to parents Anthony and Joanne Quinn and was the older brother to Thomas Quinn.

6. He had medical issues that confronted him during his life. At the age of 20, he was diagnosed with obsessive compulsive disorder. At the age of 25, he was diagnosed with personality trait disorder.

7. In 2007 while he was studying a Bachelor of Creative Arts at the University of Wollongong he was counselled for intimidating another student. He did not return to Wollongong University, but enrolled at Sydney University where he undertook a Bachelor of Visual Arts, Fine Art, and Painting

8. While he was studying, Mr Quinn worked for Illawarra Home Tuition, tutoring students in Mathematics, English and Modern/Ancient History. He also worked as a Night Filler at Woolworths.

9. In 2010 Mr Quinn commenced a relationship with Ms. Cherie Vize. The relationship lasted for a period of approximately 3 years.

10. The details of the incident which led to Mr Quinn’s imprisonment are both tragic and traumatic. However, for context in relation to Mr Quinn’s medical history, in custody, it is important that they are briefly touched on.

11. On 22 July 2013, Mr Quinn fatally stabbed Ms. Vize. Almost immediately after stabbing Ms. Vize, Mr Quinn attempted to take his own life by stabbing himself. Mr Quinn stabbed himself in the neck which caused traumatic and catastrophic injuries including quadriplegia.

12. Mr Quinn was subsequently charged and found guilty of murder, and was sentenced to 20 years imprisonment, commencing 9 September 2015, concluding 9 September 2035, with a non-parole period of 15 years.

Custodial History

13. On 9 September 2015 Mr Quinn entered custody and he was predominately housed at the Long Bay Correctional Centre Hospital, in the Medical Subacute Ward. During his time in custody, he was transferred, as required, to the Prince of Wales Hospital

for specialist appointments, investigation, and treatments. The Prince of Wales Hospital has a secure annexure wing for patients in the custody of Corrective Services.

14. Upon his admission into custody, Mr Quinn was suffering from the following conditions: i. Cervical 3 ASIA C incomplete quadriplegia ii. Obesity iii. Anxiety iv. Obsessive Compulsive Disorder

15. Whilst in custody, he was further diagnosed with: i. Obstructive Sleep Apnoea ii. Osteoporosis iii. Right distal humerus fracture iv. Sever spasticity v. Autonomic dysreflexia vi. Neurogenic bladder vii. Recurrent urinary tract infections requiring supra pubic catheter viii. Bladder treatment with intravesical botox ix. Laparascopic colostomy

16. In February 2020 there had been a family meeting regarding the management of his care. It was agreed at that time that extreme measures such as intubation and cardio pulmonary resuscitation would not be used if an overwhelming infection occured.

17. On 13 February 2020, Mr Quinn was admitted to the Prince of Wales Hospital with symptoms of reduced consciousness and delirium, bradycardia, hypothermia, pneumonia, hypoxic and hypercapnic respiratory failure which required intubation and ventilation.

18. Mr Quinn was subsequently discharged back into the care of the Long Bay Hospital Medical Subacute Ward.

19. On 27 March 2020, Mr Quinn was found by nursing staff at the Long Bay Hospital, in a less-responsive state. He was assessed and provisionally diagnosed with hypoactive delirium caused by infection/sepsis. He was taken to the Prince of Wales.

20. Upon his admission to the Prince of Wales, he was accompanied with a Not for Resuscitation order.

21. Over the next three days, Mr Quinn was cared for and treated by hospital staff at the Prince of Wales Hospital. He was ultimately diagnosed with urosepsis and declining respiratory function.

22. Mr Quinn was given various medication to control all aspects of the diagnosis. An end of life plan was discussed and enacted. Hospital staff ensured that continued comfort was maintained, non-essential medication was ceased, and oxygen supply was continued.

23. On 31 March 2020, records reflect that Mr Quinn was less distressed and more settled.

24. On 1:20pm on 1 April 2020, Mr Quinn was observed as being alert and orientated. At 9:45pm on that day a Registered Nurse conducted a routine check on Mr Quinn. He was described as pale with his lips showing signs of cyanosis. His breathing was laboured. The Nurse tells investigating police that she took the hand of Mr Quinn and told him that she was here with him. She tells police that Mr Quinn took 2 or 3 gasping short breaths before he stopped breathing completely.

25. Shortly thereafter, the Doctor attended and declared Mr Quinn’s life extinct.

Cause of death

26. On 6 April 2020, a post-mortem was conducted by Dr Kendall Bailey. The cause of death was determined to be sepsis with the antecedent causes being listed as urosepsis and pneumonia and C3 incomplete tetraplegia.

Investigation into Mr Quinn’s death

27. As part of the coronial investigation, Mr Quinn’s extensive Justice Health medical records and history were independently reviewed by Professor Anthony Costello, Emeritus Professor Urology (Honarary), Royal Melbourne Hospital. Professor Costello

was asked to review the appropriateness of the care and treatment that Mr Quinn received whilst he was in custody prior to his death.

28. Professor Costello explained that the sepsis suffered by Mr Quinn was related to his indwelling bladder catheter, which was used for urinary drainage management and control of incontinence subsequent to his quadriplegia. He said that indwelling catheters strongly impact on survival of patients with spinal cord injury. That patients with a neurogenic bladder, that is a bladder, which is non-functional secondary to a spinal cord injury, the utilisation of a chronic indwelling catheter is associated with reduced survival. He informed this court that this has been quantified in a recent article in the journal: Urology which reported on patients who are quadriplegic where longterm indwelling bladder managed with indwelling catheters were found to have a significantly higher risk of death. Mortality is most often related to sepsis. Professor Costello clarified that here had been no relevant prior medical or surgical intervention related to this patient’s demise.

29. Professor Costello concluded that Mr Quinn died as a quadriplegic patient with multiple comorbidities following long term indwelling bladder catheter management.

30. Professor Costello was of the opinion that Mr Quinn was appropriately treated for his septicaemia and organ failure with relevant antibiotics. He further stated that he would commend the doctors and nurses at Prince of Wales Hospital for their excellent care of a terminally ill patient

31. The available evidence indicates that Mr Quinn was provided with appropriate medical care to address and treat his medical condition whilst in custody. There is no evidence to suggest that any aspect of his medical care provided by Corrective Services and Justice Health staff contributed to his death in any way.

32. Before turning to the findings, I am required to make pursuant to section 81 of the Coroners Act 2009 I would like to acknowledge, and express my gratitude to Mr Howard Mullen, Coronial Advocate for his assistance in this inquest. I also thank Detective Senior Constable Matt Perry for the coronial investigation he conducted into Mr Quinn's death and for the brief of evidence that he prepared.

33. On behalf of the Corners Court of NSW, I offer my sincere and respectful condolences to Mr Quinn's family. Mr and Mrs Quinn attended this inquest and it is evident that they feel his lost most deeply.

Findings: s 81 Coroners Act 2009 Identity The person who died was Michael James Quinn Date of death Mr Quinn died on 1 April 2020 place of death Mr Quinn died at the Prince of Wales Hospital, Randwick NSW Cause of death The cause of Mr Quinn's death was sepsis due to urosepsis and pneumonia on a background of C3 incomplete tetraplegia Manner of death Mr Quinn died from natural causes, whilst in lawful custody serving a sentence of imprisonment.

Magistrate C Forbes Deputy State Coroner 17 August 2022 Coroners Court of New South Wales