Deceased
Ray Jabaltjari Gibson
Demographics
41y, male
Date of death
2016-04-05
Finding date
2017-01-13
Cause of death
respiratory arrest secondary to advanced metastatic breast cancer
AI-generated summary
Ray Jabaltjari Gibson was a 41-year-old Aboriginal man with advanced metastatic breast cancer who died of respiratory arrest while in prison custody. He had been diagnosed with breast cancer in 2013 while imprisoned and received surgical, chemotherapy and endocrine treatment. His health gradually deteriorated over the following years with multiple hospital admissions for sepsis, electrolyte disturbance and pleural effusion. At end of life, he transitioned to palliative care at Alice Springs Hospital with comfort-focused management aligned to his wishes. The coroner found his care, supervision and treatment were appropriate and conducted in accordance with his stated preferences. His medical care appears to have been reasonable given the advanced and incurable nature of his disease. No clinical failures were identified.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
CITATION: Inquest into the death of Ray Jabaltjari Gibson
[2017] NTLC 003 TITLE OF COURT: Coroners Court JURISDICTION: Alice Springs FILE NO(s): A0009/2016 DELIVERED ON: 13 January 2017 DELIVERED AT: Alice Springs HEARING DATE(s): 14 December 2016 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Death in Custody, natural causes
REPRESENTATION: Counsel Assisting: Kelvin Currie Judgment category classification: A Judgement ID number: [2017] NTLC 003 Number of paragraphs: 32 Number of pages: 6
IN THE CORONERS COURT AT ALICE SPRINGS IN THE NORTHERN TERRITORY OF AUSTRALIA No. A0009/2016 In the matter of an Inquest into the death of
RAY JABALTJARI GIBSON ON 5 APRIL 2015 AT ALICE SPRINGS HOSPITAL FINDINGS Judge Greg Cavanagh Introduction
Ray Jabaltjari Gibson (the deceased) was a 41 year old Aboriginal man at the time of his death. He was born on 13 April 1974 at Yayayi (a settlement 40 kilometres west of Papunya) to his mother, Yinarupa Nangala and father, Yala Yala Jungarai.
Much of his life he spent in the Kiwirrkurra Community in the Gibson Desert in Western Australia as well as the Communities of Kintore and Papunya.
He is recorded by Births Deaths and Marriages as having a daughter, Caseyanna Gibson in 1997 to Janet Brown in Kintore. He indicated that he also had a son by the name of Darryl.
He was an obese man and suffered a number of chronic diseases including Type II diabetes and hypertension.
The deceased had an extensive criminal history dating back to the mid nineteen-nineties. Much of it was for driving offences. For instance he is recorded as driving unlicensed on 20 occasions. On occasions when intoxicated he was also known to become violent. He had a number of
convictions for assault and in 2013 he was recorded as sexually assaulting a young woman in Western Australia. He was added to the Australian National Child Offender Register (ANCOR) and was required to report annually.
In his last few years there was little time when he was out of prison. For instance on 24 January 2013 he was imprisoned for eight months in Western Australia. However after his release in September 2013 he was only at liberty for a couple of months.
He was taken into custody again on 16 November 2013. On 19 November 2013 while in Alice Springs Correctional Centre he was diagnosed with advanced breast cancer. It was considered incurable but he underwent surgery, chemotherapy and endocrine treatment with the intent of slowing its progress. He was released on 15 February 2014.
However he was soon returned to prison and spent from 19 February 2014 to 16 February 2015 in Alice Springs Correctional Centre for aggravated assault. He spent the next nine months out of prison. During that time he was largely non-compliant with his endocrine treatment.
On 30 November 2015 and again on 2 December 2015 he was detected by Police driving unlicensed, unregistered and uninsured. On the first occasion he had 0.016% blood alcohol reading (being unlicensed he committed an offence if the reading was above zero) and a passenger in the vehicle not wearing a seatbelt. On 4 December 2015 he was sentenced to four months and 14 days imprisonment, fined $6950.00 (or 48 days in default of payment) along with a victims levies totalling $1650.00.
It was the twelfth time he had been to prison in the Northern Territory. He had been imprisoned in Western Australia on another five occasions. He was due for release on 16 April 2016.
Due to the ANCOR reporting conditions the deceased did not meet the criteria for an open security classification (where he could have left the gaol
on work schemes) however he was suitable for and was provided a low security rating.
During his incarceration he received regular health assessment and hospitalisation.
On 5 December 2015 (the day after his sentencing) he was taken to Alice Springs Hospital due to concerns of the admitting prison nurse. He had cellulitis to his left leg, for which he had been in hospital a month before.
The CT scans showed progressive metastatic disease. He was seen by Alcohol and other Drugs, the dietician, the wound care nurse, oncology and palliative care. His endocrine treatment was restarted as was chemotherapy.
He was discharged five days later on 10 December 2015 back to the Correctional Centre. Throughout his stay in hospital he denied being in any pain.
He was taken once more to hospital on 7 January 2016 to attend the chemotherapy unit for injections and two units of blood.
On 11 January 2016 the deceased was admitted to Alice Springs Hospital for sepsis secondary to fungating metastatic breast cancer. He was noted to be in “pain crisis”. He had shoulder pain, back pain and femur pain. He was provided antibiotics and analgesia. The pain was brought under control.
On his second day in hospital he told the discharge planner that when he was released he would like to see his children, Caseyanne and Darryl who he said were both in foster care in Western Australia. He said that he would be released from prison between 14 and 16 April 2016 if he lived that long. He wished to return to the Kiwirrkurra Community to die. He said his uncle Ray James would care for him there. He was referred to the social worker for the arrangements to be made.
During his stay at the hospital the prison provided blanket approval for all visitors who wished to see him. He was discharged back to the prison on 16 January 2016.
On his return it was recognised that his health was deteriorating and he was rehoused in the John Bens Unit to facilitate heightened observations. He was granted unrestricted access to other family members in the prison.
He spent a lot of the time sleeping in his cell but when he was able he spent time in the management area watching the sport and interacting with other prisoners. He also used the telephone on a regular (often daily) basis contacting members of his family.
On 2 February 2016 he was admitted to Alice Springs Hospital due to electrolyte disturbance. The disturbance was said to be caused by a combination of his cancer and the chemotherapy. The deceased said he was feeling weak but denied any pain. He was given magnesium, calcium and potassium. There are many entries that suggest that the deceased just wanted to sleep. He was stabilised and discharged back to the prison on 10 February 2016.
On 1 March 2016 the deceased said he had right sided pain, especially in the right shoulder that had kept him awake overnight. He was given pain killers and sent to Alice Springs Hospital. A chest X-ray showed new pleural effusion on the right side of his lungs. With the analgesia he was no longer in any pain and said he wished to go back to the prison. He was discharged that same day with a plan to drain the effusion if it worsened.
of care than was available at the prison. However he did not wish to be admitted to Alice Springs Hospital.
On 30 March 2016 he was having significant difficulty with self-care and toileting. Dr Oliver Hosking discussed the issues with the deceased and he agreed to the transfer to Alice Springs Hospital “for better nursing care in preparation for his repatriation to Kintore and Kiwirrkurra at the end of his sentence”.
He was transferred to Alice Springs Hospital where he was palliated and provided with comfort care until he took his last breath at 6.15am on 5 April
An application had been made on 30 March 2016 for his early release on 9 April 2016 (a week early). That had been approved on 4 April 2016.
The medical consultant Doctor Graeme Maguire provided the opinion that the deceased died of respiratory arrest secondary to advanced metastatic breast cancer. Doctor Fariba Nadimi, the palliative medicine specialist and palliative care consultant at Alice Springs Hospital was of the same opinion.
He noted that his death was expected.
However by reason of the deceased being held in custody at the time his death was a reportable death. By reason of section 15 of the Coroners Act (the Act) an inquest must be held for the same reason.
Where there has been a death in custody, pursuant to section 26 (1) of the Act a coroner:
I find that the care, supervision and treatment of the deceased was of an appropriate standard and his medical care was undertaken in accordance with his declared wishes.
Pursuant to section 34 of the Coroner’s Act, I find as follows:
(i) The identity of the deceased was Ray Jabaltjari Gibson, born on 13 April 1974, in Yayayi, Northern Territory, Australia.
(ii) The time of death was 6.35am on 5 April 2016. The place of death was Alice Springs Hospital in the Northern Territory.
(iii) The cause of death was respiratory arrest secondary to advanced metastatic cancer.
(iv) The particulars required to register the death:
The death was reported to the coroner by the Alice Springs Correctional Centre.
The cause of death was confirmed by Medical Consultant, Professor Graeme Maguire.
The deceased’s mother was Yinarupa Nungala and his father was Yala Yala Jungarai.
Dated this 13th day of January 2017.
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