Watson, Eric Handley

OFFICE OF THE STATE CORONER FINDINGS OF INQUEST CITATION: Inquest into the death of Eric Handley WATSON TITLE OF COURT: Coroner’s Court JURISDICTION: Brisbane FILE NO(s): COR 2011/247/0001 DELIVERED ON: 31 May 2012 DELIVERED AT: Rockhampton HEARING DATE(s): 31 May 2012 FINDINGS OF: Mr Michael Barnes, State Coroner CATCHWORDS: CORONERS: Death in custody, natural causes

REPRESENTATION: Counsel Assisting: Mr Peter Johns Department of Community Safety: Ms Melinda Zerner Queensland Health: Ms Amanda Hickey

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 Eric Handley Watson. 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 Eric Watson was 75 years of age when he died at Rockhampton Base Hospital late on the evening of 17 January 2011. At the time of his death, and for the preceding 17 months, Mr Watson was a prisoner in the custody of Queensland Corrective Services. After presenting to medical staff at Capricornia Correctional Centre (CCC) with deteriorating respiratory symptoms in the second half of 2010, he was diagnosed in November of that year with advanced terminal lung cancer.

These findings:  confirm the identity of the deceased person, 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 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 Uniformed police attended the Rockhampton Base Hospital in the early hours of 18 January 2011 and made preliminary investigations into the circumstances of the death of Mr Watson. They arranged for formal identification of the body and notified the QPS Corrective Services Investigation Unit (CSIU). Detective Sergeant Myke Anderson and Detective Senior Constable Rudy Knaggs from that unit travelled to Rockhampton later in the morning to commence their investigations. The latter compiled a report of the investigation which was submitted to my office and tendered at the inquest.

The detectives attended CCC and conducted interviews with each of the inmates who had been in contact with the deceased. All relevant records from CCC and Rockhampton Base Hospital were seized. A detailed statement was taken from the prisoner who had been assigned to care for Mr Watson in the months prior to his death.

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A QPS scenes of crime officer was deployed to Rockhampton Base Hospital and a series of photographs was taken of the body in situ at the hospital and during the course of the autopsy examination which took place in the hospital morgue. Detective Senior Constable Knaggs examined the medical and correctional history of the deceased and liaised with staff in my office with regard to the need for further investigation.

Detective Knaggs produced a comprehensive report summarising the results of his investigation. That investigation and report were of a commendable standard.

The Inquest An inquest was held in Rockhampton on 31 May 2012. All of the statements, records of interview, medical records, photographs and materials gathered during the investigation were tendered at the inquest.

The investigating officer gave evidence and Mr Johns proposed no further oral evidence be heard subject to contrary submissions from any other party. Mr Johns had earlier written to Mr Watson’s wife, enclosing a copy of the police investigation report and explaining that he would make this submission. No objection was received to the proposed course from any party and I agreed that the evidence tendered was sufficient for me to make the requisite findings.

The evidence Personal circumstances Mr Watson was born on 26 November 1936 in Birmingham, England. A 1963 conviction for disorderly behaviour was all that appeared on his criminal record until his conviction on 30 April 2010 on 20 counts of indecent treatment of children. These counts related to offences that took place between 1979 and 1998 and Mr Watson was sentenced to a period of six years imprisonment with a parole eligibility date of the 16 May 2011.

Mr Watson was remanded in custody shortly after being arrested in relation to these offences. He was placed in the protection unit at CCC where he stayed from his reception on 9 May 2009 until his death. Mr Watson is survived by his wife Nola.

Medical history At his reception medical at CCC on 9 May 2009 Mr Watson presented with a history of asthma, though he denied suffering current symptoms. Medical records obtained by the nursing staff at CCC confirmed he had previously been diagnosed with bronchial asthma. In August 2010 he was prescribed Ventolin 5mg as nebuliser as required. The medical records also revealed a series of presentations by Mr Watson in early 2009 relating to pain in his shoulder. An ultrasound at that time suggested a tear in the rotator cuff/biceps and Mr Watson underwent physiotherapy treatment.

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At the reception medical at CCC Mr Watson also disclosed he had recently attempted suicide as a result of the investigation into the offences with which he was ultimately charged. By the time he arrived at CCC he denied any suicidal ideation and this remained the case for the duration of his stay.

Treatment prior to death On 9 September 2010 Nola Watson rang the nursing staff at CCC to inform them Mr Watson had told her in a telephone call that he was suffering from shortness of breath. When nursing staff spoke to Mr Watson he told them he felt fine and was only suffering from shortness of breath when he became anxious. He was placed on the “daily blood pressure” list due to his high reading on that day.

On 11 October 2010 Mr Watson was seen by a visiting medical officer, Dr Christie. He complained of increasing shortness of breath to Dr Christie and of coughing at night. Mr Watson told Dr Christie he had been a smoker in the past but not for 25 years. The impression of Dr Christie was that the symptoms related to Mr Watson's diagnosed asthma and he formulated a treatment plan involving an increase in medication and frequent monitoring of Mr Watson's condition.

During medical consultations on 19 October 2010 and 5 November 2010 Mr Watson continued to complain of increasing shortness of breath and by the latter date his blood pressure had increased significantly. Mr Watson had daily contact with the medical staff at CCC thereafter until 8 November 2010. After staying overnight in the CCC medical centre on 7 November 2010 in order to ensure constant access to a nebuliser, Mr Watson's shortness of breath reached critical levels early the following morning. Nursing staff noted him to have a blue periphery and he was transferred to the Rockhampton Base Hospital for treatment.

Dr Matthew Burge, a visiting medical oncologist at Rockhampton Base Hospital summarised Mr Watson's presentation and the subsequent findings as follows: “He presented to hospital with a several week history of some weight loss, dry cough and shortness of breath and was found to have a collapsed left lung with large left pleural effusion. He had an intercostal catheter and the pleural effusion drained, but the left lung did not reinflate. Cytology from this pleural fluid has confirmed adinocarcinoma consistent with a lung primary. CT scanning did not reveal any clear evidence of a primary lung cancer or metastases elsewhere, although of course the left lung is collapsed” On 8 December 2010 Dr Burge had a long discussion with Mr Watson in which he said the condition was incurable and if left to its own devices Mr Watson would likely die within months. Dr Burge explained the availability of palliative chemotherapy which had the potential to improve survival time and maintain quality of life, at least more than would otherwise be the case. After some thought, Mr Watson advised his doctor he did not wish to undergo Findings of the inquest into the death of Eric Handley Watson 3

chemotherapy treatment and had decided to leave the carcinoma to take its natural course.

Mr Watson returned to CCC on 24 November 2010 after his condition was diagnosed at Rockhampton Base Hospital and a palliative care plan had been formulated. He had by that time been transferred to the oncology department at the Rockhampton Base Hospital and they later liaised with nursing staff at CCC in order to ensure Mr Watson received the appropriate level of palliative care and medication. Another prisoner, David Hines, was assigned to Mr Watson as his carer in order to assist him with maintaining hygiene and basic daily tasks which were becoming increasingly difficult.

On 17 January 2011 Mr Watson's condition had deteriorated such that he could no longer be cared for by staff at CCC. He was transferred to Rockhampton Base Hospital and over the course of that afternoon and evening was given pain relief. A non-resuscitation directive was already in place. During the course of the afternoon and evening Mr Watson remained under guard by corrective service officers (CSO’s) although his friends and family were able to freely visit him.

At 11:25pm it was noted Mr Watson was no longer breathing and a short time later he was pronounced deceased and a life extinct certificate issued by Dr Alegbe Oladapo.

The CSO’s in attendance maintained a log of events and a record of all people attending the scene in the hours prior to and subsequent to the death.

Autopsy results After considering the views of Mr Watson's family and the circumstances of his death, I ordered an autopsy by way of external examination only. This was carried out on 20 January 2011 by an experienced forensic pathologist, Dr Nigel Buxton. Dr Buxton issued a report in which he stated: “Death in this patient is the result of metastatic lung cancer of adenocarcinoma type. Examination of the body shows no evidence of physical trauma that would have contributed to death or shortened the gentleman's life. Examination of the medical record shows no evidence of over prescription of opiates. I believe death to be natural.” As a result of his findings, Dr Buxton issued a certificate listing the cause of death as: 1(a) Carcinomatosis, due to, or as a consequence of 1(b) Carcinoma of the left lung.

Investigation findings None of the other inmates at CCC provided information to the investigating officers suggestive of foul play or of any deficiency or inappropriateness with regard to the treatment received by Mr Watson while in custody.

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Detective Senior Constable Knaggs told the inquest that after examining the scene of Mr Watson's death, interviewing eyewitnesses and examining contemporaneous documents, he holds no suspicions the death of Mr Watson was anything but natural.

Conclusions I conclude Mr Watson died from natural causes. I find none of the correctional officers or inmates at CCC caused or contributed to his death.

I am satisfied he was given adequate medical treatment at CCC during the latter part of 2010. Although he presented a number of times with increasing shortness of breath before he was hospitalised, examinations were undertaken on each occasion and adequate monitoring by nursing staff followed. It is relevant Mr Watson's symptoms were consistent with his longterm diagnosis of asthma and even after he was transferred to Rockhampton Base Hospital on 8 November 2011 his carcinoma was not diagnosed until three days later. It is sadly clear by the time he presented with symptoms which are now known to be related to his cancer, it had grown and spread to an extent that meant it was untreatable.

I am also satisfied the care afforded to Mr Watson by staff at the Rockhampton Base Hospital in the months prior to his death was adequate and appropriate.

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 Eric Handley Watson How he died - While in custody Mr Watson died from natural causes despite receiving appropriate medical care.

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

Date of death – He died on 17 January 2011.

Cause of death – Mr Watson died from carcinomatosis.

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.

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I have found that Mr Watson died from natural causes and that no third party was involved in his death. I have also found that he received appropriate health care in the months before his death. In the circumstances of this case there is no basis on which I could make any useful preventative recommendations.

I close the Inquest.

Michael Barnes State Coroner Rockhampton 31 May 2012 Findings of the inquest into the death of Eric Handley Watson 6