Inquest into the death of Sebastian Barry Davis

CITATION: Inquest into the death of Sebastian Barry Davis [2001] NTMC 27 TITLE OF COURT: Coroner’s Court JURISDICTION: Alice Springs FILE NO(s): A44/00 DELIVERED ON: 9 March 2001 DELIVERED AT: Alice Springs HEARING DATE(s): 9 March 2001 FINDING OF: Mr Greg Cavanagh

CATCHWORDS: Coroners – Inquest Child in Care

REPRESENTATION: Counsel: Assisting: Elizabeth Morris Judgment category classification: B Judgment ID Number: [2001] NTMC 27 Number of paragraphs: Number of pages: 7

N.B. Copyright in this transcript is the property of the Crown. If this transcript is copied without the authority of the Attorney-General of the Northern Territory, proceedings for infringement will be taken.

---

NORTHERN TERRITORY OF AUSTRALIA CORONER’S COURT No A 0044 of 2000

AN INQUEST INTO THE DEATH OF SEBASTIAN BARRY DAVIS ON 29 JULY 2000 AT NELSON TERRACE, ALICE SPRINGS MR G. CAVANAGH, Coroner

TRANSCRIPT OF PROCEEDINGS AT ALICE SPRINGS ON FRIDAY 9 MARCH 2001 Certified true transcript of a record produced out of the custody of the Clerk of Courts Transcribed by: Court Recording Services (NT) Pty Ltd C3/m3/gw 2 Davis

MS MORRIS: Your Worship, the next matter we have listed this morning is the matter of Sebastian Davis. There are a couple of people outside who have an interest in this matter, who may wish to be present.

THE CORONER: Okay.

Good morning, everyone. Take a seat, come in, relax.

This is an inquest into the death of Sebastian Barry Davis.

MS MORRIS: Yes, Your Worship. It’s an inquest pursuant to section 15(1)(a). At the time that the deceased passed away, he was held in care. ‘In care’ under our definition of the Coroner’s Act, section 12(1)(a), and so an inquest is a mandatory procedure under the Coroner’s Act for anybody who is in care who passes away, no matter what the reason for their passing.

How I intend to present the evidence before you, Your Worship, is in written form, and I’ll be calling the investigating officer in relation to this death. Senior Constable Allan Duncan, I’ll be calling him to tender the evidence that he’s gathered.

THE CORONER: The investigation brief?

MS MORRIS: Yes. I do have an opening, Your Worship.

THE CORONER: Yes.

MS MORRIS: The deceased was born at the Alice Springs Hospital on 8 September 1989 to the parents of Vrena Davis and Michael Drover. He was born with a very rare condition called congenital sensory neuropathy, with an hydrosis.

The main effects of this condition were that he didn’t sweat and he lacked the sensation of pain. He was at continual risk of overheating when exposed to high ambient temperatures.

Originally when he was born and when the condition was discovered, he was only given a fairly short expected life span of some three years. Due to his lack of pain sensation, his risk of accident or injury was quite high and constant vigilance was required on behalf of his carers.

Over the years he has had a number of admissions to Alice Springs and Adelaide hospitals. I won’t be tendering all of his medical records, Your Worship, only the last one.

THE CORONER: How old was he when he died?

MS MORRIS: He was 10, yearly 11. But the records are lengthy and numerous.

Both of his legs were amputated above the knee and he’d lost most of the tips of his fingers.

C3/m3/gw 3 MS MORRIS Davis 9/3/2001

Family, Youth & Children’s Services first became involved with the deceased in April 1990 when his parents were unable to care for him. He was then cared for by his maternal grandparents, Barry and Elva Cook, at Endartnama(?) Outstation - which, as Your Worship is aware, is outside of Hermannsburg - for the next two years.

During this time he had regular admissions to the Alice Springs Hospital and his family were unable to meet his ever-increasingly complex needs. Family, Youth & Children’s Services were approached to arrange a foster placement for him.

In 1993 he was placed in the sole guardianship of the Minister. He was placed in a group home initially and a short period of foster placement was arranged in early 1995, and then he went back to the group home until 29 March ’95 when he was placed with Ms Barbara Geraghty, who is present in court, Your Worship, at 68 Nelson Terrace, Alice Springs.

Ms Geraghty remained the deceased’s carer until his death. Doctor George Clothier, who is a paediatrician at the Alice Springs Hospital, had been the deceased’s attending doctor since birth. He has informed the coronial investigating officer that the deceased, during his short life, suffered from bilateral amputation of his lower limbs, dilated cardio-myopathy, osteomyelitis, femoral remnants, scapula both humeri, right radius and ulna, unhealed fracture of his right radius and ulna, and a septic arthritis left shoulder with sinus.

During the last few weeks of his life, the deceased lost 7.2 kilograms and was increasingly reluctant to eat and became more and more lethargic. Doctor Clothier’s opinion was that this was due to the poorly controlled osteomyelitis in a number of sites; in particular, both his residual femora, his left and right humeri, right forearm and both scapula.

THE CORONER: I take it from reading the investigation brief that all of these conditions, and the way he was in the last few weeks of his life, were all to do from his congenital condition and had nothing to do with the quality of the care that he was receiving.

MS MORRIS: That is the evidence that we’ve discovered as a result of this investigation, Your Worship. Letters and reports by Doctor Clothier will be in the brief.

In a report by the program manager for Child & Family Support Services, by Ms Flaherty, the program manager, she states in her report: In addition to caring for Sebastian, Ms Geraghty has cared for a number of children placed in short or medium term care. She has particular skills in caring for children with disabilities. In particular, her intuitive understanding of the principles of normalisation and her clear belief in the rights of all children, especially those with disabilities, enabled C3/m3/gw 4 MS MORRIS Davis 9/3/2001

Sebastian to enjoy all the activities that he was physically able to manage. Ms Geraghty’s willingness to develop a relationship with Sebastian’s birth family allowed him frequent and spontaneous access.

On Saturday 29 July 2000 the deceased became increasingly lethargic. At around 1210 hours Ms Geraghty became concerned for his health and contacted Doctor Clothier. The doctor had already been with the deceased at about 8 o’clock that morning and had stated that things did not auger well for the deceased.

After making the telephone call to Doctor Clothier, she returned to the deceased’s bedroom at around 1215 hours and was with him as he passed away.

Doctor Clothier attended and certified that the deceased had in fact passed away.

Your Worship, there are no suspicious circumstances surrounding this death that we have uncovered in this investigation. I’d like to call Senior Constable Allan Duncan in order to tender the evidence.

ALLAN JEFFERY DUNCAN, sworn: MS MORRIS: Senior Constable, please give your full name, rank and station?

---My full name is Allan Jeffery Duncan. I’m a Senior Constable of Police and I’m a Coroner’s Constable in Alice Springs.

How long have you been the coroner’s constable for?---Eight years.

Does that work involve investigating many coronial deaths that come within the Coroner’s Act?---Yes, it does.

Over that eight years any idea how many deaths you would’ve investigated?---I’m sorry, I don’t.

Many?---Yes, there were – there are several.

Several or - - -?---Yeah, more than several.

And you’re basically the sole coronial investigator for the Alice Springs Police District?---That is correct, yes.

You became aware of the death of the deceased?---Yes.

And you prepared a coronial brief in relation to that death?---I did.

I’ll hand you the original of that document. That’s the coronial brief you prepared?

---That is the brief, yes.

I tender that record, Your Worship.

C3/m3/gw 5 A.J. DUNCAN Davis 9/3/2001

EXHIBIT 1 Coronial brief.

MS MORRIS: You also arranged for the deceased’s medical records to be obtained?---I did, yes.

I don’t think I need to tender that through the officer, but I’ll just tender – I think it’s file number 3 of the medical records from Alice Springs Hospital of Sebastian Davis.

EXHIBIT 2 File 3 of medical records.

MS MORRIS: Now, senior constable, as a result of your investigation did you speak to medical staff?---Yes, I did.

At the Alice Springs Hospital. Did you speak to the deceased’s carers?---Yes.

And friends of the deceased’s carer?---I did, yes.

And other persons who had dealings with the deceased?---Yes.

And did you form an opinion in relation to the care he received from his foster placement?---I did. After speaking with all these people, I was of the – I believe that he had very good care by Mrs Geraghty and it definitely prolonged the deceased’s life with the illness that he did have.

Your Worship, I don’t have any further questions of the constable.

THE CORONER: Thank you, constable. You can stand down.

WITNESS WITHDREW MS MORRIS: Your Worship, two further details that I wish to tender. One is a certified copy of the deceased’s birth certificate and the other is the original of the autopsy report which was performed by forensic pathologist Doctor Michael Anthony Zillman on 2 August 2000 at the Alice Springs Hospital.

The cause of death in that report, which was sworn on 5 December 2000, was septic arthritis of the left shoulder. For the court’s information, the comments that the pathologist made was that (1) the cause of death was septic arthritis, ie a severe joint infection involving the left shoulder joint; (2) the mode of death was acute heart failure resulting from the toxic effects of this infection; (3) the deceased neurological condition predisposed his joints to severe degenerative changes and recurrent infections.

EXHIBIT 3 Certified copy of birth certificate.

EXHIBIT 4 Autopsy report.

C3/m3/gw 6 A.J. DUNCAN Davis 9/3/2001

MS MORRIS: Your Worship, that is the evidence that I wish to present in relation to the death of the deceased.

THE CORONER: Thank you, Ms Morris.

The Coroner’s Act makes mandatory having a public inquest for those people who died when they’re in the care – and that is to say the responsibility – of the Minister, the Government. A lot of times when people die, the reportable deaths to the coroner, we have an investigation but we don’t necessarily go on to have a public inquest, because we’re quite confident that through the investigation we know all there is to know.

But, as I say, when people are in the responsibility or in the care of Government, as a way of just keeping an eye on the bureaucracy doing the right thing, we have this mandatory public inquest. It’s noteworthy that this young man received all the care, and indeed love, that anyone could expect and that happened through the institutions of the State.

So from time to time we hear of the department – what is it? Family, Youth and?

MS MORRIS: Children’s Services.

THE CORONER: Family, Youth & Children’s Services getting a caning for not being particularly responsible, but they should, so far as I’m concerned, in respect of this matter, receive all the plaudits that are available and so should his carers, being initially early on in his life Barry and Elva Cook, and later on, and especially, Miss Barbara Geraghty.

I’ll go on now to make my formal findings. These will be typed up in due course, but I think we don’t have to adjourn awaiting formal findings.

I find that the identity of the deceased was Sebastian Barry Davis, an Aboriginal male born on 8 September 1989 at Alice Springs Hospital. The time and place of death was 1215 hours on Saturday 29 July 2000 at 68 Nelson Terrace, Alice Springs. The cause of death was natural causes, being septic arthritis of the left shoulder.

In order to register the death, the particulars are the deceased was a male.

He was of Aboriginal Australian origin. The death was reported to the Coroner. I have already confirmed the cause of death was confirmed by post-mortem examination. The pathologist viewed the body after death. The pathologist was Doctor Michael Anthony Zillman of the Royal Darwin Hospital.

The father of the deceased was Michael Drover; the mother was Vrena Carol Davis. The usual address of the deceased was 68 Nelson Terrace, Alice Springs, and the deceased was not employed.

C3/m3/gw 7 Davis 9/3/2001

In relation to the circumstances surrounding the death, I adopt all of the opening summary of counsel assisting, Ms Elizabeth Morris. I specifically go on to make the commendations that I have already made in respect of the carers of that young boy.

I close the inquest. Thank you all for coming. That you for all your interest.

ADJOURNED C3/m3/gw 8 Davis 9/3/2001