Tiers, Matthew Maurice

OFFICE OF THE STATE CORONER FINDINGS OF INQUEST CITATION: Inquest into the death of Matthew Maurice TIERS TITLE OF COURT: Coroner’s Court JURISDICTION: Rockhampton FILE NO(s): COR 2010/1611 DELIVERED ON: 29 September 2011 DELIVERED AT: Rockhampton HEARING DATE(s): 21 July 2011; 28 - 29 September 2011 FINDINGS OF: Mr Michael Barnes, State Coroner CATCHWORDS: CORONERS: Death in custody, natural causes

REPRESENTATION: Counsel Assisting: Mr Peter Johns Ms Susan Walker: Mr Jeff Clarke (instructed by

ATSILS) Queensland Health: Mr Kevin Parrot (Crown Law) Sergeant Ian Williams: Mr Craig Pratt (Gilshenan and Luton) QPS Commissioner: Ms Christina Heffner (QPS Solicitors Office)

TABLE OF CONTENTS

The Coroners Act 2003 provides in s47 that when an inquest is held into a death in custody, the coroner’s written findings must be given to the family of the person who died, each of the persons or organisations granted leave to appear at the inquest and to various officials with responsibility for the justice system. These are my findings in relation to the death of Matthew Maurice Tiers. They will be distributed in accordance with the requirements of the Act and posted on the web site of the Office of State Coroner.

Introduction Matthew Tiers was 53 years of age when he died at Rockhampton Hospital on 14 May 2011. He had undergone four days of intensive treatment to reverse the effects of a bacterial illness that ultimately overwhelmed him. Mr Tiers’ condition was first noticed on 10 May 2011 while he was in custody at the Capricornia Correctional Centre (CCC). He had been received by that institution three days earlier at which time he was examined and medicated for alcohol withdrawal, but was otherwise considered well enough to be accommodated amongst the general prison population. When it was realized he was generally unwell he was immediately transferred to the Rockhampton Hospital where he subsequently died.

These findings

• confirm the identity of the deceased person, how he died, the time, place and medical cause of his death;

• consider whether any third party contributed to his death;

• determine whether the authorities charged with providing for the prisoner’s health care needs prior to his transfer to Rockhampton Hospital adequately discharged those responsibilities; and

• consider whether any changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice.

The investigation Staff at Rockhampton Hospital made contact with the Office of the State Coroner prior to the death of Mr Tiers and when he died on the afternoon of 14 May 2010 local police promptly attended. The QPS Corrective Services Investigation Unit was notified and Detective Sergeant Myke Anderson assigned to conduct the investigation. Arrangements were made for Rockhampton scenes of crime officers to attend the hospital and a number of photographs were taken of the body of Mr Tiers in situ.

No signs of violence were noted on the body of Mr Tiers. Arrangements were made to obtain the most recent of Mr Tiers’ seven volumes of medical records stored at the Rockhampton Hospital. Mr Tiers’ body was identified, secured Findings of the inquest into the death of Matthew Maurice Tiers 1

and later transferred to Brisbane where an autopsy examination was conducted.

Investigations then focused on the movements of Mr Tiers in the days leading to his death. Statements were obtained from all QPS personnel who dealt with Mr Tiers during the course of his arrest and being held in custody on 6 and 7 May 2010. Statements were obtained from all relevant custodial and Queensland Health staff located at CCC. Interviews were conducted with all prisoners in section S5 at CCC where Mr Tiers had been housed prior to his transfer to Rockhampton Hospital.

Further statements were obtained from Queensland Ambulance Service (QAS) officers and from the sister of Mr Tiers, Ms Susan Walker.

Those assisting me had the quality of his health care critiqued by a doctor from the Clinical Forensic Medicine Unit (CFMU).

I am satisfied that all relevant exhibits have been identified and collected and that the investigation was thorough and professionally conducted.

The Inquest An inquest was held in Rockhampton on 28 and 29 September 2011. Mr Johns was appointed as counsel to assist me with the inquest. Leave to appear was granted to the sister of Mr Tiers, Susan Walker; Queensland Health, the Commissioner of the QPS, and Sergeant Williams.

All of the statements, records of interview, medical records, photographs and materials gathered during the investigation were tendered at the inquest.

The evidence I turn now to the evidence. Of course, I cannot even summarise all of the information contained in the exhibits but I consider it appropriate to record in these reasons, the evidence I believe is necessary to understand the findings I have made.

Social and medical history Matthew Tiers was born in Rockhampton, the third eldest of eight children born to Jack and Dorothy Tiers (formerly Collins). He was a descendant through his father of the Birrigubba people, the traditional owners of the land to the north and west of Rockhampton. He was brought up in accordance with tribal customs; his chest exhibiting markings from a tribal initiation ceremony as a young man.

Mr Tiers’ sister, Susan Walker, described him to the court as a tribal elder. He was formerly married and is the father of five children.

In the years leading up to his death Mr Tiers had been living an itinerant lifestyle in and around Rockhampton.

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Mr Tiers’ extensive medical history included alcoholic liver disease with derangement of the liver function at the time of death; hypertension, hepatitis B, macrocytic anaemia, epilepsy, atrial fibrillation and syphilis. He had also undergone surgery for a stab wound inflicted during a previous period of imprisonment. It does not appear that in the lead up to his death he was taking medication previously prescribed for some of these problems.

I suspect many people who came into contact with Mr Tiers dismissed him as a hopeless alcoholic who was largely to blame for his unfortunate circumstances. Such a superficial assessment of the complex contributory causes of the social dislocation of Indigenous people such as Mr Tiers is largely worthless.

Although he usually slept in public areas or in a local diversionary centre, Mr Tiers often stayed with Ms Walker with whom he was very close. He had attempted to maintain a link with his Indigenous cultural heritage and was respected as an elder by Indigenous people in this area, and his traditional country. He was loved and is missed by his siblings and his extended family. I offer them my sincere condolences.

Custody Mr Tiers had a lengthy criminal history. In recent years it consisted almost entirely of public drunkenness and street offences not uncommonly associated with an itinerant lifestyle. Police regularly took him to an Indigenous alcohol diversionary centre or to his sister’s house, but when these options were not available or appropriate he was dealt with at the Rockhampton Watchhouse.

On 1 March 2010 he was imprisoned for four months with a court ordered parole eligibility date of 1 April 2010. Mr Tiers was transported to CCC on 3 March 2010 and released from custody on 7 April 2010. He was directed, as a condition of his parole, to report to the Rockhampton Probation and Parole District Office by 13 April 2010. He failed to comply with this direction and so on 30 April 2010 his parole was suspended pursuant to section 201 of the Corrective Services Act 2006 and a warrant for his arrest issued by the Chief Executive of Queensland Corrective Service pursuant to powers conferred under the same legislation.

At 5:40pm on 6 May 2010 police located Mr Tiers near Quay Street in Rockhampton. He was arrested as a result of the outstanding warrant and taken to Rockhampton watchhouse.

Rockhampton watchhouse Mr Tiers was received at the watchhouse by the shift supervisor Sergeant Ian Williams. He told the inquest he had been working in Rockhampton for approximately 20 years at this time and he had had a “vast” number of dealings with Mr Tiers. He says on this occasion Mr Tiers was able to speak clearly and support himself unaided at the charge counter. This is supported by CCTV recorded vision. Indeed the officer said he had never seen Mr Tiers looking better.

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According to Sergeant Williams Mr Tiers refused to answer the standard health related questions and his refusal was noted in the risk assessment questionnaire on the QPS computer system. Those parts of the risk assessment that could be filled out through observation of Mr Tiers were completed. This included answers in the negative to questions as to whether Mr Tiers required medical attention and whether he showed signs of being under the influence or signs of withdrawal from alcohol or drugs.

The QPS computer system records warning notes made by officers involved in previous dealings with a prisoner. In the case of Mr Tiers there were warning notes regarding his health, the most significant of which was recorded on 9 February 2007 and read: Tiers has been received at the Rockhampton watch-house in recent times and staff have noted a significant decline in his health. Client is unable to control body functions and concerns are held that Tiers may be seriously ill. Medical clearance is strongly advised prior to acceptance at the watch-house.

In his previous dealings with Mr Tiers (predominantly in relation to his being drunk and disorderly) Sergeant Williams had attempted to make arrangements for him to be taken by his sister, Ms Walker or by a local diversionary centre. Those options were not open on this occasion as Mr Tiers had been arrested on a “return to prison” warrant. Sergeant Williams told the inquest that despite the warnings relating to Mr Tiers’ health he was satisfied he appeared well enough to be housed at the watch-house until transfer to CCC the following morning. In recognition of the need to take extra care with Mr Tiers due to his parlous health Sergeant Williams said he placed him in holding cell 2 which allowed constant physical observation by staff working at the charge counter. He reasoned that if Mr Tiers deteriorated this would be noticed by the officers working there and medical assistance could be summoned.

The evening was uneventful and shortly after 10.00am on the next day Mr Tiers was transported by police to the CCC. On arrival he was noted to have lost control of his bowels.

Capricornia Correctional Centre On arrival at the CCC Mr Tiers was instructed to shower and provided with clothing for admission. He was seen by Nurse Paul Baker who filled in a reception medical history. This document is in the form of a questionnaire and the answers to all questions, with only one exception, appear to have been replicated from the same form completed when Mr Tiers was imprisoned in early March 2010. There is no indication that answers which should have prompted follow up questions – such as “yes” when asked about shortness of breath – prompted such follow up. The last page of the form contains a checklist apparently designed to assist with a physical examination of the prisoner. However, the inquest was told by another nurse from the centre that the checklist was only completed when a prisoner was reviewed by a doctor.

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Mr Tiers’ pulse and sitting blood pressure are recorded as 102 and 136/98 respectively. This compares to readings of 97 and 130/88 when Mr Tiers was examined on 3 March 2010. On both occasions “NAD” (no abnormality detected) is recorded next to the section for urine screening. On the occasion of both examinations no other part of the form is filled out.

No blood tests were conducted on 7 May 2010. When he was received on 3 March 2010 the medical record indicates that Mr Tiers refused to consent to blood testing but no such notation was made on 7 May 2010.

Dr Alexandra Moore, a visiting medical officer to CCC, was present while Mr Tiers was being assessed by Nurse Baker. She said in her statement that she was made aware that Mr Tiers was being placed onto the alcohol withdrawal regime in place at CCC. This involved a continuation of the multi-vitamin and thiamine supplements previously prescribed and an additional prescription of Diazepam at a low dosage of 5mg, twice per day. Dr Moore says that although this was low she considered it sufficient to control withdrawal symptoms given Mr Tiers’ poor nutrition and general physical condition. The need for Diazepam was to be re-assessed on 15 May 2010. There was seemingly no requirement for ongoing examination of Mr Tiers’ withdrawal symptoms prior to that time although he was being seen twice daily by nursing staff during the dispensing of medications.

There are no other notes recording any of the observations made by Nurse Baker during his initial assessment. Nurse Thistlethwaite said that in accordance with usual practice, Mr Tiers would have been reviewed by a medical practitioner within 7 days at one of the clinics conducted at the CCC four times per week.

Mr Tiers was housed in cell 4 of secure unit 5 which contains thirty one-man cells. Also housed in that unit was a nephew of Mr Tiers.

On the morning of 8 May 2010 it was discovered that Mr Tiers had defecated on his cell floor. The following day his cell was observed to have urine covering the floor. At around 5.00pm on that day, Sunday 9 May 2010, while nursing staff were dispensing medication in the cell block it was again discovered that Mr Tiers had apparently lost control of his bladder.

Correctional Supervisor Keith Johnson approached the nurses and organized through them to have Mr Tiers seen by a doctor the following day in relation to his inability to control his bodily functions. During his handover to the Correctional Supervisor on duty the following day Mr Johnson stressed the need for Mr Tiers to be seen by a doctor.

On the morning of 10 May 2010 it was discovered that Mr Tiers had again been incontinent of faeces. He was taken to the medical unit but refused to be seen by nursing staff. He was returned to his cell, however, a short time later corrections staff received a complaint from prisoners that Mr Tiers had defecated in a mop bucket. Custodial Corrections Officer (CCO) Chizzoni approached Mr Tiers and tried to convince him to return to the medical unit for Findings of the inquest into the death of Matthew Maurice Tiers 5

examination. He initially refused, however, was finally persuaded after CCO engaged the assistance of Mr Tiers’ nephew.

On return to the medical unit Mr Tiers was seen by Nurse Karen Thistlethwaite. She noted him to be drowsy and breathing rapidly. When she asked him how he was feeling he told her he was “feeling crook”. Routine medical observations showed blood pressure of 153/90, pulse of 136, respiration rate of 44 per minute, oxygen saturation of 94% and temperature of 38.7 degrees. Nurse Thistlethwaite says that she suspected Mr Tiers had a chest infection. During the examination she says that Mr Tiers thrashed out at one stage with his arm and said “Just leave me alone. I want to go back to the block”.

Nurse Thistlethwaite telephoned Dr Moore and advised her of the observations she had taken. Dr Moore recalls being contacted on the morning of 10 May 2010 and on hearing the details of Mr Tiers’ condition was sufficiently concerned that she decided it was necessary for him to be transported to Rockhampton Hospital.

A Health Referral form filled out by Nurse Thistlethwaite authorising transfer to Rockhampton Hospital includes the observations referred to earlier as well as reference to Mr Tiers coughing up a large amount of sputum. Also noted in the context of a chest examination are “crackles in both bases”. A further note indicates Panadol was given at 1540 hours.

QAS records show that an ambulance was dispatched at 15:29pm, arriving at CCC at 15:42pm and, after a delay making their way through security, arriving at the patient at 15:53pm. Paramedic Geoffrey Thompson provided a statement in which he noted that only partial vital signs could be recorded by he and his partner due to Mr Tiers being uncooperative and verbally abusive.

They were able to administer oxygen through a mask during the journey to Rockhampton Hospital accident and emergency section where they arrived at 4:32pm.

Rockhampton Hospital On arrival at the Rockhampton base Hospital Mr Tiers underwent a chest xray which showed haziness of the lung fields. There was a provisional diagnosis of pneumonia with a differential diagnosis of acute respiratory distress syndrome. He was transferred to the intensive care ward where he was sedated.

Dr David Austin provided a report to the inquest in his capacity as Director of Intensive Care at Rockhampton Hospital. He stated that Mr Tiers was in intensive care for four days with worsening septic shock. He did not respond to treatment. He had a coagulopathy despite continued platelet transfusion and daily volumes of fresh frozen plasma. Mr Tiers developed acute renal and hepatic failure and on withdrawal of sedating medication he remained at a low level of consciousness.

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Extensive discussion about Mr Tiers’ condition took place and by 14 May 2010 it was agreed that further treatment of his condition would be futile.

Therapy was withdrawn and Mr Tiers passed away a very short time later. He was declared deceased at 2:18pm on that date.

Mr Tiers was formally identified by his sister, Ms Walker at Rockhampton Hospital later on 14 May 2010.

Autopsy results An autopsy examination was carried out on the body of Mr Tiers by Dr Beng Ong, an experienced forensic pathologist, on 18 May 2010. At the request of the family of Mr Tiers and in accordance with their traditional beliefs, the examination was external only so as to exclude the involvement of violent trauma.

A CT scan of the body showed prominent symmetrical opacities bilaterally and a collection of fluid in the pleural and pericardial cavities.

Dr Ong noted Mr Tier’s extensive medical and surgical history and after considering the contents of the Rockhampton Hospital records he drew the following conclusions: From the interpretation of the hospital notes, it was clearly documented that he had multi-organ failure arising from sepsis. The underlying cause was not known but could arise from the lungs (pneumonia) and exacerbated by suboptimal immunity as he had been suffering from chronic liver disease and possible malnutrition.

Dr Ong issued a certificate listing the cause of death as:

1. (a) Multi-organ failure, due to or as a consequence of

(b) Sepsis Other significant conditions:

2. Chronic liver disease, epilepsy Conclusions I am satisfied that the decision to hold Mr Tiers in the Rockhampton Watchhouse on the evening of 6 May 2010 without first obtaining a medical review of his condition was not unreasonable, having regard to the absence of any signs of significant ill health and his being detained in a cell in full view of the charge counter.

Having regard to the numerous co-morbidities from which Mr Tiers was suffering when he arrived that the CCC, I am concerned that the cursory records of the medical assessment undertaken on reception suggests it was perfunctory.

Further, it would have been preferable for Mr Tiers to have been seen by a medical practitioner when he was received at the prison. However, I Findings of the inquest into the death of Matthew Maurice Tiers 7

acknowledge that he was not exhibiting signs of acute illness at that stage and he was treatment resistant.

Dr Moore goes so far as to suggest that even if Mr Tiers had been admitted to hospital on the day before his reception at the CCC the outcome would have been the same. I agree with Dr Griffin that she is mistaken. Blood tests taken in the days before Mr Tiers was admitted to hospital on Monday 10 May may have made it clear that he had an infection and the sooner antibiotics were started the greater chance that Mr Tiers would have survived. It is impossible to say whether a review by a medical practitioner at the CCC on 7, 8, or 9 May would have caused such tests to be undertaken, but it may have.

I am also concerned the plan for managing his alcohol withdrawal was not devised with reference to a symptom triggered protocol that involved the use of a standardised alcohol withdrawal scale to direct the administration of medication and that it did not include a daily review by a medical practitioner.

Notwithstanding these concerns, I accept that the health care Mr Tiers received in the three days he was at the CCC was adequate and the shortcomings I have referred to did not contribute to his demise.

Despite the best efforts of the treating team at the Rockhampton Hospital, Mr Tiers was unable to be saved because of parlous state of his general health due to his long term alcohol abuse and his refusal to allow any health care regime to run its course. It is likely he was immunocompromised. By the time it was realized he had contracted an infection, death was almost inevitable.

No third party played any part in the death.

Findings required by s45 I am required to find, as far as is possible, the medical cause of death, who the deceased person was and when, where and how he came by his death. As a result of considering all of the material contained in the exhibits, I am able to make the following findings.

Identity of the deceased – The deceased person was Matthew Maurice Tiers How he died - Mr Tiers died while a prisoner in the Capricornia Correctional Centre from the combined effects of years of alcohol abuse, numerous untreated chronic diseases and an acute infection. No third party caused or contributed to the death. He received adequate health care while in custody.

Place of death – He died at the Rockhampton Hospital in Queensland.

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Date of death – Mr Tiers died on 14 May 2010.

Cause of death – He died from multi-organ failure caused by sepsis.

Comments and recommendations Section 46, insofar as it is relevant to this matter, provides that a coroner may comment on anything connected with a death that relates to public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in the future. Only one issue warranted consideration for that perspective in this case.

Recommendation 1 - Alcohol withdrawal protocol As detailed earlier, the management of Mr Tiers’ withdrawal from alcohol was somewhat ad hoc. The literature is replete with studies indicating that symptom triggered protocols that involve the use of a standardised alcohol withdrawal scale to direct the administration of medication have superior outcomes. Accordingly, I recommend Offender Health Services review its policies to ensure they are most appropriate for dealing with such a prevalent problem among its patient population.

I close the Inquest.

Michael Barnes State Coroner Rockhampton 29 September 2011 Findings of the inquest into the death of Matthew Maurice Tiers 9