Inquest into the death of Manuel Katsaros

CORONERS COURT OF NEW SOUTH WALES

Inquest: —— “Inquest into the death of Manuel Katsaros Hearing date: 413 September 20: 2023 SO

Date of findings: 13September 2028 Place of findings: _ Nsw Coroners Court - Lidcombe. 7 7: Findings of "Magistrate Elizabeth Ryan, Deputy State Coroner

catchwords: ~ CORONIAL Law - death of inmate at the Prince of Wales Hospital Annex — natural causes death.

File number: 2019/181202 Representation: Coronial Advocate assisting the inquest: K Jiang,

| ‘Coronial Advocate

Justice Health and Forensic Mental Health Network: M Sterry. the JH Network.

‘The Commissioner, Corrective Services NSW: V Wei,

Department of Communities and Justice.

Findings in the Inquest into the death of Manuel Katsaros

Findings: Identity \ [The person who died is Manuel Katsaros.

Date of death: Manuel Katsaros died on 27 February 2021

Place of death:

Manuel Katsaros died at the Prince of Wales Hospital)

‘Annex.

‘Cause of death: ‘The cause of Manuel Katsaros’ death is metastatic ‘small cell lung cancer.

(Manner of death: Manuel Katsaros died from natural causes while he was in lawful custody.

Non publication orders

Orders prohibiting publication of certain evidence pursuant to section 74(1)(b) of the Coroners Act 2009 [the Act] have been made in this inquest. A copy of these orders, and corresponding ones pursuant to section 65(4) of the Act, can be found on the Registry file.

Section 81(1) of the Act requires that when an inquest is held, the Coroner must record in writing his or her findings as to various aspects of the death.

These are the findings of an inquest into the death of Manuel Katsaros.

Introduction

1. On 27 February 2021 Manuel Katsaros aged 54 years died in his hospital bed at the Prince of Wales Hospital Annex, where he was receiving palliative care for terminal lung cancer. At about 1.30pm that afternoon Mr Katsaros had been administered with medication. When the nurse entered his room again at 2.20pm she found him unresponsive, lying in his bed. Resuscitation was not attempted, as Mr Katsaros had in place a ‘no resuscitation’ direction. He was pronounced deceased at 2.26pm.

2. Since Mr Katsaros was in lawful custody at the time of his death, an inquest

into the circumstances of his death is mandatory pursuant to sections 23 and 27 of the Coroner’s Act 2009.

Findings in the Inquest into the death of Manuel Katsaros

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The role of the Coroner

3. The Coroner must make findings as to the date and place of a person’s death, and the cause and manner of death.

4. In addition, pursuant to section 82 of the Act the Coroner may make recommendations in relation to matters which have the capacity to improve public health and safety in the future, arising out of the death in question.

Mr Katsaros’ medical treatment

Manuel Katsaros was born on 8 April 1966. He had a history of asthma and chronic obstructive pulmonary disease. He had been a smoker for many years, but he stopped smoking in 2018.

On 5 May 2018 Mr Katsaros was arrested and charged with a number of serious offences. He was convicted and sentenced to imprisonment for a period of seven years. He would not have been eligible for parole until 7 November 2022.

Mr Katsaros was received into the Metropolitan Remand and Reception Centre with a recommendation for normal placement. Health conditions of anxiety, substance abuse and mental health issues were recorded. On 28 May 2018 he was transferred to Hunter Correctional Centre in Newcastle.

Shortly afterwards Mr Katsaros started experiencing shortness of breath and a fast heart rate. Medical testing revealed that he had developed extensive stage 3 small cell lung cancer. He commenced chemotherapy followed by courses of radiotherapy.

This treatment continued until 2021.

On 3 March 2020 Mr Katsaros was transferred from the Hunter Correctional Centre to Long Bay Correctional Centre. This was to facilitate his cancer treatment at the Prince of Wales Hospital, Randwick. It was noted that he had a life expectancy of approximately two years.

CT scans performed in July 2020 showed that despite treatment Mr Katsaros’ cancer was progressing, and a course of a second line chemotherapy commenced. Six months later, further scanning revealed progression of disease to sites in Mr Katsaros’ bones and in his brain. He received further radiotherapy, and regular reviews to manage his pain levels.

Mr Katsaros’ disease continued to spread, and with his consent a decision was made to cease active treatment for his cancer and instead to focus only on supportive care.

On 10 December 2020, Mr Katsaros moved into the Medical Sub-Acute Unit at the Hospital in the Long Bay Correctional Centre for supportive care. A resuscitation plan was made whereby he chose not to be resuscitated in the event of a cardiac arrest.

As Mr Katsaros’ condition deteriorated, on 22 February 2021 he was admitted to Prince of Wales Hospital Annex for continued palliative and comfort-focused terminal

Findings in the Inquest into the death of Manuel Katsaros

care. On 27 February 2021 Mr Katsaros’ parents and sister were present at his bedside. He died that afternoon.

The post mortem report

A limited autopsy was performed by Dr Jack Garland. Dr Garland concluded that Mr Katsaros had died as a result of metastatic small cell lung cancer. CT scans revealed a mass within his right lung which was in keeping with his history of lung cancer. The scans also showed areas of metastasis in his lymph nodes and bones. He had no significant injuries.

The coronial brief of evidence included details of the medical treatment Mr Katsaros received for his cancer while he was in custody. | am satisfied that the care and treatment which he received was appropriate. His family has not expressed any concerns about his care.

The time, place, cause and manner of Mr Katsaros’ death are able to be established on the evidence. There is no evidence of systemic deficiencies which might form the basis of any recommendations.

| thank Coronial Advocate Kai Jiang for his assistance in the preparation and conduct of this inquest.

| convey to Mr Katsaros’ family my sincere condolences for his death.

Findings required by s81(1)

As a result of considering all of the documentary evidence and the oral evidence heard at the inquest, | am able to confirm that the death occurred and make the following findings in relation to it.

Identity The person who died is Manuel Katsaros.

Date of death: Manuel Katsaros died on 27 February 2021

Place of death: Manuel Katsaros died at the Prince of Wales Hospital Annex.

Cause of death: The cause of Manuel Katsaros’ death is metastatic small cell lung cancer.

Manner of death: Manuel Katsaros died from natural causes while he was in lawful custody.

Findings in the Inquest into the death of Manuel Katsaros

| close this inquest.

efe—*

Magistrate E Ryan Deputy State Coroner, Lidcombe

Date 13 September 2023

Findings in the Inquest into the death of Manuel Katsaros