Inquest into the death of Denis Ives

STATE CORONER’S COURT

OF NEW SOUTH WALES oa dates: pes September 2024 |

Place of findings: Coroner's: s Court of New South Wales, Lidcombe |

Magistrate Kasey | Pearce, Deputy State Coroner | rennet et a on ne see mint see iCORONIAL LAW — death in Corrective Services NSW V custody >

whether care and treatment concerns

i t H i { H i H i i |

File number: - 2022/00047320

iAlison Storm, Advocate Assisting the Coroner

Natalie Szulgit on behalf of the Justice Health Forensic Mental i Health Network

Rossana Gonzalez, Department of Communities and Justice, on;

behalf of the Acting C Commissioner of Community Services NSW

'Non-publication order ‘A non- publication order has been made pursuant to sections 74(1),

f lof the Coroners Act 2009 (NSW) in relation to certain material contained within the brief of evidence. A copy of this order is on the @ Registry file.

:

i

Findings: IDenis Ives died on 16 February 2022 at Prince of Wales 1s Hospital, i ‘Barker Street, Randwick Ihe cause of Mr Ives’ death was COVID-19 pneumonitis on a background of ANCA nephropathy, hypertension, and diabetes mellitus (type 1).

lMr ves died of natural causes while in the lawful custody of Corrective Services New South Wales |

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Table of Contents

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8 Conclusions

9 Consideration...

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The Coroners Act in s81 (1) 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 Denis Ives.

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1.2

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Introduction

On 1 October 2021 Denis Ives was sentenced at Parramatta Local Court to a term of imprisonment of 30 months commencing 20 November 2021 with a non-parole period of 15 months for sexual offences against a child. His earliest release date was 19 February

On 28 January 2022 while an inmate at Long Bay Correctional Centre Mr Ives tested positive to COVID 19. He was put into isolation and monitored regularly. However, on 7 February 2022, after several unwitnessed falls overnight, he was transferred to Prince of Wales Hospital for assessment and further treatment. Mr Ives’ condition was complicated by pneumonitis and difficulties with his kidney functioning, and he continued to deteriorate while in hospital. A Do Not Resuscitate Order was put in place, and he received only noninvasive treatment. Sadly, Mr Ives was pronounced life extinct at 7:13 pm on 16 February

2022. He was 78 years old at the time of his death.

Why was an inquest held?

Under the Coroners Act 2009 (‘the Act’) a Coroner is responsible for investigating all reportable deaths. This investigation is conducted primarily so that a Coroner can answer questions that are required to be answered pursuant to section 81 of the Act, namely, the identity of the person who died, when and where they died, and the cause and the manner

of that person’s death.

When a person is sentenced to a term of imprisonment, they are lawfully detained in the custody of Corrective Services NSW (CSNSW) until their sentence has been served. By depriving that person of their liberty, CSNSW assumes responsibility for the care of that person as the person is unable to independently take steps to seek medical assistance or other care. The combined effect of sections 23 and 27 of the Act is that it is mandatory for a Senior Coroner to hold an inquest where a person dies while in lawful custody. In such cases the community has an expectation that the death will be properly and independently investigated to ensure that CSNSW has cared for a person in its custody in a reasonable and

appropriate way. In this case, there is no suggestion that CSNSW cared for Mr Ives in

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anything other than a reasonable and appropriate away.

Mr Ives’ wife, Carolyn, did not wish for an inquest to be held into her husband’s death. The coronial process represents an intrusion by the State into what is usually one of the most traumatic events in the tives of those who have lost someone close to them. An inquest by its very nature unfortunately compels the family and friends of a deceased person to re-live events often several years after their loved one’s death, and to do so ina public forum. This is an entirely foreign, and sometimes distressing, experience for those who have lost

someone close to them.

Mr Ives’ life

Before moving to a consideration of the circumstances of Mr lves’ death, it is important to

acknowledge the facts of his life.

Mr Ives was born in Kogarah on 29 January 1944. He was the third of four children born to his parents’ relationship. During Mr Ives’ childhood, his family moved from Kogarah to Grafton and back again to Sydney for reasons related to Mr Ives’ father’s work with Dairy

Farmers.

Mr Ives went to high school in Sydney and then attended Granville Technical College. He met his wife, Carolyn, when he was 19 and she was 17, when Mr Ives did some plumbing work for Carolyn’s father. They were in a relationship for about two years before separating. A year or so later they rekindled their relationship and lived together as de facto partners. They had two children together, Bradley and Gregory, born in 1969 and 1971 respectively. They married in 1975.

Mr Ives worked as a plumber, drainer gasfitter, window furnishings installer and truck driver

until he retired in January 2010 at the age of 66.

Mr Ives and Carolyn lived together in Wentworthville and later purchased a property together in Fairfield in which they brought up their family. Mr Ives and his wife were still

living in the Fairfield property at the time he went into custody.

In the family statement Carolyn provided to the court at the close of the inquest she acknowledged that despite her inability to forgive Mr Ives for the crimes he had committed

there were many good things about her husband.

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5.1

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Mr Ives’ medical history

Mr Ives had been diagnosed with numerous medical conditions and had suffered various

medical episodes prior to him going into custody including:

« Type 1 diabetes

e Diabetic neuropathy

« Chronic kidney disease (stage 4)

e = Anti-neutrophilic Cytoplasmic Autoantibody (‘ANCA’) e Bell's palsy (2014)

e = Dyslipidaemia

e Transient cerebral ischaemic attack (2009)

e Meningioma (2003)

¢ Back injuries and 2 jumbar spine surgeries

e Bilateral hearing loss

He took a variety of medications to manage these conditions.

Mr Ives’ time in CSNSW custody

On 20 November 2020 Mr Ives was arrested by Fairfield Police in relation to alleged child sex offences. This was the first time Carolyn became aware of any police investigation into

her husband.

Mr Ives was received into CSNSW custody on 21 November 2020 at Amber Laurel Correctional Centre and then transferred to Parklea Correctional Centre the same day after he was refused bail at Fairfield Local Court. He was initially held at the Medical Support Unit (‘MSU’) for observation and management of his health issues. The same day Mr Ives applied to be placed on Special Management Area Protection (‘SMAP’) because of his fear of

harassment due to the nature of his charges.

When initially assessed, Mr Ives could not recall the names of all the medication he was taking, however, after consultation with his General Practitioner, within four days of being in CSNSW custody, Mr !ves began receiving the totality of his prescribed medications. He was vaccinated against COVID-19 on 2 September 2021, 29 September 2021, and 21 January 2022.

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5.6

On 8 November 2021, after he was sentenced at Parramatta Local Court on 1 October 2021, Mr Ives was transferred to Long Bay Correctional Centre (‘LBCC’). Although Carolyn was unable to visit Mr Ives due to COVID restrictions, she was able to speak to him often by

phone.

On 24 December 2021 Mr Ives was assaulted by his cell mate. He suffered serious injuries consisting of multiple rib fractures, two broken bones in his right hand, a fracture of the left neck of femur, intra-cranial haemorrhage, pulmonary contusion, scalp laceration and numerous wounds on his upper extremities. He received treatment at Prince of Wales Hospital, including a partial hip replacement, before being returned on 3 January 2022 to the MSU at the Metropolitan Special Programs Centre (‘MSPC’) at Long Bay Correctional

Centre. He was semi-mobile, required a walking frame and was not able to use his left arm.

Despite ongoing support, Mr ives struggled both physically and mentally with his recovery.

He sometimes refused to complete physiotherapy as he felt too tired and often declined to

take his medication as prescribed.

Medical issues - Long Bay Correctional Centre 23 January 2022 — 7 February 2022

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On 23 January 2022 Mr Ives called Carolyn to wish her a happy birthday, which was in two days’ time. He was concerned that he may not be well enough to call her on her actual

birthday.

On 24 January, Mr Ives told CSNSW staff that he felt that the assault had taken its toll as he

felt tired all the time.

The following day, being 25 January 2022, Mr Ives called his wife to wish her a happy

birthday. According to Carolyn he sounded breathless and unwell.

On 27 January 2022, Mr Ives complained to medical staff that he was feeling unwell. He subsequently tested positive for COVID-19 and was placed in isolation at Long Bay. Despite being recorded as being asymptomatic, Mr Ives was assessed as a ‘category 2 patient’ and was treated in accordance with the COVID medium risk protocol, which meant that twice

daily his welfare was checked, and his vital signs taken.

Over the following days little change was noted to Mr Ives’ condition, although he seems to have developed a cough and ongoing diarrhoea for which he was prescribed medication.

it was noted in his medical records on 6 February ‘unsure how to please patient,

argumentative with staff challenging all actions.’ On the morning of 7 February Mr Ives’ reported two falls overnight. Nursing staff observed blood on the bathroom floor, cell floor and bed sheet and injuries to Mr Ives’ head, calves, and arms. He was reported not to be oriented to time and date and over the course of the day his confusion did not improve. At about 2:30 pm on 7 February Mr Ives was taken to Prince of Wales Hospital by ambulance,

escorted by CSNSW officers.

Medical issues — Prince of Wale Hospital 7 February 2022 — 16 February 2022

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6.1

Mr Ives tested positive to COVID-19 on a rapid antigen test conducted in the Emergency Department of Prince of Wales Hospital. He was noted to have a head injury, slight confusion and lethargy and multiple upper and lower limb lacerations. He was subsequently diagnosed with pneumonitis. Over the following days he was observed to not be eating well against a background of malnourishment and although he was provided with oxygen via a mask, he de-saturated when his oxygen mask was removed. Mr Ives renal function

deteriorated despite treatment.

On the evening of 14 February Mr Ives suffered a significant episode of respiratory distress.

Carolyn made clear to medical staff that Mr Ives would not want to be placed on a ventilator with a breathing tube. He was given high flow oxygen to assist with his breathing. Mr Ives

agreed that he did not wish for CPR to be performed if required.

On 16 February it was noted that Mr Ives’ condition was deteriorating, and a decision was made that he be shifted to palliative care. By the afternoon of 16 February Mr Ives had become non-responsive. At Carolyn’s request he was taken off high flow oxygen. By 7:00 pm Mr Ives was noted to be breathing shallowly. With Carolyn at his bedside, Mr Ives was

declared deceased at 7:13 pm.

The post-mortem examination

Mr Ives was subsequently taken to the Department of Forensic Medicine where, on 18 February 2022, Dr Sairita Maistry performed an external autopsy examination. This

examination identified the following relevant findings:

e features consistent with COVID-19 pneumonitis; e valvular and coronary artery calcification; and

® no acute skeletal trauma.

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8.2

In the autopsy report dated 31 March 2023 Dr Maistry concluded that the cause of Mr ives’ death was COVID-19 pneumonitis on a background of ANCA nephropathy, hypertension and diabetes mellitus (type 1).

Investigations after Mr Ives’ death

CSNSW Senior Investigator, Martin Kiernan, investigated Mr Ives death. This involved a review of Mr Ives’ Case Management File, Case Notes, Warrant File, and associated

correspondence. He concluded as follows:

e Mr Ives was lawfully detained, appropriately classified and placed prior to, and at the

time of, his death;

• there was no issue or concern regarding the management of Mr Ives whilst at Prince of

Wales Hospital, LBH (Long Bay Hospital) or MSPC prior to his death; e there are no suspicious circumstances surrounding his death;

® there are no issues arising in respect of the management of Mr Ives prior to his death

in custody or the response to his death in custody.

Conclusions

After considering all the evidence gathered from the coronial investigation, no organisation or individual was identified as having a sufficient interest in the subject matter of the coronial proceedings in accordance with section 57(1) of the Act, although Carolyn Ives, CSNSW, the Justice Health and Forensic Mental Health Network, and St Vincent’s Health

Care were advised of the inquest.

An inquest is mandatory because Mr Ives died whilst in the custody of CSNSW. However, unlike most other inquests, no issues apart from the statutory requirements pursuant to section 81 of the Act were identified from the coronial investigation which required discrete

examination during the inquest.

Consideration Having regard to the above, the available evidence establishes the following:

e¢ at the time he went into the custody of CSNSW Mr Ives was an elderly man with numerous

significant medical issues;

on his acceptance into custody, inquiries were made of Mr Ives as to his medical conditions and medication he was taking to treat those conditions;

a request for medical records was made of Mr Ives’ General Practitioner within 24 hours of him going into custody;

within four days of his going into custody Mr ives was prescribed and received all relevant medication;

Mr tves received three vaccinations for COVID-19 while in custody;

Mr Ives was regularly monitored and treated for his numerous medical conditions, including his diabetes, for the duration of his time in custody

Mr Ives was transferred to, and treated in, Prince of Wales Hospital in a timely manner after suffering an assault in December 2021;

Mr ves was monitored regularly and treated appropriately for the injuries he suffered as a result the assault and subsequently for the effects of COVID-19.

All the care and treatment Mr Ives received while in custody is recorded in notes kept by

Justice Health staff and staff at Prince of Wales Hospital.

9.2 The evidence establishes that there was no issue or concern regarding the management of Mr Ives while at Prince of Wales Hospital or LBCC prior to his death.

10 Findings

10.1 | would like to express my thanks to the officer in Charge, Detective Senior Constable Mark Franklin, and Advocate, Alison Storm, for all the work they have done in investigating this matter and preparing it for inquest.

10.2 The findings 1 make under section 81(1) of the Act are:

Identity

The person who died was Denis Ives.

Date of death

Mr Ives died on 16 February 2022.

Place of death

Mr Ives died at Prince of Wales Hospital, Barker Street, Randwick NSW 2031.

Cause of death

The cause of Mr Ives’ death was COVID-19 pneumonitis on a background of ANCA

nephropathy, hypertension and diabetes mellitus (type 1).

Manner of death Mr Ives died of natural causes whilst in the lawful custody of Corrective Services NSW.

10.3 On behalf of the Coroner’s Court of New South Wales | offer my sincere and respectful

condolences to Mr Ives’ family, in particular his wife, Carolyn.

10.4 [close thig/inquest.

My, Le.

Magistrate Kasey Pearce

Deputy State Coroner

19 September 2024

Coroners Court of New South Wales