McLaughlin, Mark Ian

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Mark Ian McLaughlin TITLE OF COURT: Coroners Court JURISDICTION: Brisbane FILE NO(s): COR 2016/2491 DELIVERED ON: 24 January 2018 DELIVERED AT: Brisbane HEARING DATE(s): 24 January 2018 FINDINGS OF: Mr Terry Ryan, State Coroner CATCHWORDS: CORONERS: Death in custody, natural causes

REPRESENTATION: Counsel Assisting: Daniel Bartlett Queensland Corrective Services: Dominic Robinson, Dept. of Justice and AttorneyGeneral Townsville Hospital and Health Service: Stephanie Gallagher

Introduction

1. On 24 April 2016, Mark Ian McLaughlin, aged 55 years, presented to the Cairns Base Hospital (CBH) with gross haematuria, headaches, sweats vertigo and difficulties mobilising. A CT scan revealed a ring-enhancing right parietal lobe lesion with oedema and midline shift. It was initially thought to be a metastatic lesion from an unknown primary source.

2. Mr McLaughlin was transferred from CBH to the Townsville Hospital (TTH).

There he underwent surgery, and a further MRI scan occurred on 2 May

2016. The findings were ominously suggestive of a glioblastoma multiforme.

3. On 3 May 2016, a right temporoparietal craniotomy and debulking of the tumour was performed. Histopathology confirmed the diagnosis of a Grade 4 multifocal glioblastoma multiforme - an extremely aggressive brain tumour. It was concluded that the tumour was aggressive and incurable.

4. Mr McLaughlin was referred to palliative care, for end of life management, and continued to deteriorate quickly. On 18 June 2016 he was found to be unrousable, and considered to be in the terminal phase. He died two days later on 20 June 2016.

The investigation

5. An investigation into the circumstances leading to the death of Mr McLaughlin was conducted by Detective Sergeant Andy Seery from the Queensland Police Service (QPS) Corrective Services Investigation Unit

(CSIU).

6. Upon being notified of Mr McLaughlin’s death, the CSIU attended the TTH.

Mr McLaughlin’s correctional records and his medical files from the CBH and TTH were obtained. The investigation was informed by statements from the relevant custodial correctional officers, clinical staff and treating doctors at CBH and TTH, and a statement from his son, Jacob McLaughlin. These statements were tendered at the inquest.

7. An external and partial internal autopsy examination with associated CT scans and toxicology testing was conducted by forensic pathologist, Dr David Williams. At the request of the Coroners Court of Queensland, Dr Natalie MacCormick from the Queensland Health Clinical Forensic Medicine Unit (CFMU) examined the statements as well as the medical records for Mr McLaughlin from the CBH and TTH and reported on them.

8. I am satisfied that the investigation was thoroughly and professionally conducted and that all relevant material was accessed.

The Inquest Mr McLaughlin’s death was clearly from natural causes, and his family had no concerns about the treatment he received while in custody. However, an 9.

inquest into his death was mandated by the Coroners Act 2003 because he was in custody at the time of his death.

The inquest was held on 24 January 2018. After the statements, medical records and material gathered during the investigation was tendered, 10.

Counsel Assisting proceeded to submissions in lieu of any oral testimony.

Circumstances of the death

11. Mr McLaughlin was aged 55 years at the time of his death. On 22 April 2016, he was convicted in Cairns of Commonwealth and State offences relating to possessing child exploitation material and using a carriage service to distribute child pornography. He had no criminal history prior to this conviction. He was sentenced to two years imprisonment, suspended after a period of five months for the State offences. He was sentenced to 12 months imprisonment, also to be released after five months, for the Commonwealth offences.

12. On 24 April 2016, while Mr McLaughlin was at the Cairns watch house awaiting transfer to a correctional centre, it was noticed that he was not able to mobilise properly. At 5:24pm, he presented to the CBH emergency department with ambulance officers, guarded by the Queensland Police Service. The reasons for his presentation were two-fold. First, he was suffering gross haematuria (blood in the urine). Second, he was suffering from vertigo and an inability to walk while he was at the watch house.

Paramedics confirmed that he had otherwise normal observations, a GCS of 15 and his pupils were equal and reactive.

13. Mr McLaughlin was seen initially by the emergency department registrar, and his history was noted to include two days of immobility along with recent onset of haematuria. He denied fevers or dysuria. His haematuria was noted to be significant, on the background of a recent robotic prostatectomy performed on 14 March 2016 for prostate cancer. The outpatient urology notes for Mr McLaughlin’s post-operative review confirmed that he had made a good recovery with no major issues. His medical history was also noted to include supraventricular tachycardia, hypertension, hypothyroidism, osteoarthritis, stage 3 chronic kidney disease and an open appendicectomy.

Findings of the inquest into the death of Mark Ian McLaughlin 1

14. Blood tests at the CBH revealed an elevated white cell count. A CT scan of Mr McLaughlin’s head revealed a ring-enhancing right parietal lobe lesion with oedema and midline shift. This finding was consistent with a brain metastases. The case was discussed with the Neurosurgical Registrar at TTH, and he was admitted to the surgical ward at CBH for an MRI of the brain and CT scanning of his chest and abdomen.

15. The Neurosurgical Registrar at TTH was consulted again, and Mr McLaughlin was accepted for transfer to the care of a neurosurgeon at TTH.

On 26 April 2016 Mr McLaughlin was transferred via Retrieval Services Queensland to TTH for surgery. A statement was tendered at the inquest from Dr Richard Corkill, who was Mr McLaughlin’s palliative care specialist.1 Dr Corkill also provided information concerning Mr McLaughlin’s surgical care while at TTH.

16. On 2 May 2016, Mr McLaughlin underwent a further MRI of the brain, the results of which reported that there was multifocal enhancing intracerebral lesions in the right temporoparietal region. On 3 May 2016, a right temparietal craniotomy and debulking of the tumour was performed by neurosurgeon Dr David Anderson. Histopathology confirmed the diagnosis of a Grade 4 multifocal glioblastoma multiforme. It was concluded that the tumour was aggressive and incurable. Mr McLaughlin was referred to the oncology team. He was assisted by a social worker and end of life measures were put in place, including an Advanced Health Directive. Mr McLaughlin’s son, Jacob, was contacted and the diagnosis, prognosis and treatment options were discussed with him.

17. On 25 May 2016, the hospital contacted Jacob McLaughlin to inform him of his father’s current status, and that it was no longer appropriate for radiation to be administered. It was recommended that Mr McLaughlin be referred to palliative care services for ongoing management.

18. Jacob McLaughlin agreed with this course. Mr McLaughlin’s GCS fell to 8, and a further CT head scan was conducted. He was thus assessed as being suitable for palliative care measures, and he was transferred. Palliative care family meetings took place on 27 May 2016, and again on 12 June 2016.

Mr McLaughlin’s symptoms were managed with pain relief, including opioids. His function continued to deteriorate with him becoming drowsier.

19. On 18 June 2016, Mr McLaughlin was unable to be roused, and was no longer alert enough so as to swallow medications. It was noted at this time that he now appeared to be in phase 4, which is the terminal phase. On 20 June 2016, with Mr McLaughlin’s family present, he passed away at 2:32pm.

1 Exhibit B2.

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20. In his statement to the inquest, Jacob McLaughlin confirmed that he had no criticisms or concerns regarding the treatment of his father. He was satisfied with the medical care and treatment provided by TTH and the way he was managed by Queensland Corrective Services. He noted that his father had reported headaches from April 2016, only a few weeks before the diagnosis of his brain cancer.

21. Dr MacCormick assisted the inquest by reviewing the available medical records, witness statements, and the autopsy report completed by Dr Williams. She provided a detailed report which was tendered at the inquest.2

22. Dr MacCormick considered that the decision to transfer Mr McLaughlin from the watch house to the hospital on 24 April 2016 occurred within a reasonable timeframe. He was promptly assessed, diagnosed and investigated at CBH, with input from the Townsville neurosurgical team, and then appropriately transferred to TTH. All appropriate palliative treatment options were explored with an attempt at surgical debulking and consideration of radiotherapy. Dr MacCormick explained that it was unfortunate that Mr McLaughlin’s condition was complicated by an intraparenchymal bleed, causing him to deteriorate rapidly. Having exhausted all options, the goals of treatment appropriately changed to comfort cares.

23. Dr MacCormick could not identify omissions in Mr McLaughlin’s clinical management at any stage which may have altered the outcome. There was no earlier opportunity at which to diagnose the glioblastoma multiforme. His care in hospital was very thorough, and the diagnosis was sensitively managed. The level of health care was equivalent to what would be expected within the general community.

Conclusions

24. Mr McLaughlin’s death was the subject of a police investigation by the CSIU.

That investigation has been considered by me together with Dr MacCormick’s review. I accept that the death was from natural causes with no suspicious circumstances associated with it.

25. I conclude that Mr McLaughlin died from natural causes. I find that none of the correctional officers involved in supervising Mr McLaughlin, or any other person, caused or contributed to his death. I am satisfied that Mr McLaughlin was given appropriate medical care by staff at Cairns watch house and also at the CBH and TTH while he was admitted there. His death could not have reasonably been prevented.

2 Exhibit B6.

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26. It is a recognised principle that the health care provided to prisoners should not be of a lesser standard than that provided to other members of the community. The evidence tendered at the inquest established the adequacy of the medical care provided to Mr McLaughlin when measured against this benchmark.

Findings required

27. 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.

After considering all of the evidence I am able to make the following findings: Identity of the deceased – The deceased person was Mark Ian McLaughlin.

How he died - Mr McLaughlin died after he was diagnosed with a ring-enhancing right parietal lobe lesion with oedema and midline shift. Upon histological examination, it was identified to be a Grade 4 multifocal glioblastoma multiforme - an extremely aggressive brain tumour. The progression of the tumour was rapid, and it was not amenable to curative surgical treatment.

Place of death – He died at the Townsville Hospital, Townsville in the State of Queensland.

Date of death – He died on 20 June 2016.

Cause of death – Mr McLaughlin died from Glioblastoma multiforme.

Comments and recommendations

28. The Coroners Act 2003 enables a coroner to 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.

29. While I accept that there are no comments or recommendations to be made that would assist in preventing similar deaths in future, I note the statement from Dr Corkill recorded that several unsuccessful attempts were made to prevent Mr McLaughlin’s death becoming a death in custody by contacting Queensland Corrective Services to seek his release on exceptional circumstances parole, in view of his rapidly deteriorating condition and expected death from glioblastoma multiforme.

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30. While this issue was not examined in any detail as part of the coronial investigation, it appears that Mr McLaughlin may not have been considered eligible for exceptional circumstances parole because he was also serving a period of imprisonment for Commonwealth offences.3 Detective Sergeant Seery recommended in his report that there be some clarification as to when exceptional circumstances parole should be granted.

31. Under s 19AP of the Crimes Act 1914 (Cth), the Commonwealth AttorneyGeneral or delegate may grant a licence for a person serving a federal sentence to be released from prison. Section 19AP(4) provides that the Attorney-General must not grant a licence under this section unless satisfied that exceptional circumstances exist which justify the grant of the licence.

The Attorney-General may have regard to any serious medical condition the person has that cannot adequately be treated or managed within the prison system.

32. While these provisions clearly require parallel applications for exceptional circumstances parole to the Attorney-General and the Queensland Parole Board where a prisoner is sentenced for Commonwealth and State offences, there is no legal impediment to the early release from custody to palliative care of persons suffering terminal medical conditions on compassionate grounds. However, from a practical perspective it appears that such applications are often not considered until the prisoner is in the final stages of life.

33. In appropriate cases such early release would clearly be of significant benefit to the family of the dying person, who are otherwise left to endure the decline of their next of kin, who is likely to be restrained, in the presence of custodial officers in circumstances where the person poses no risk to community safety.

34. I close the inquest. I extend my condolences to Mr McLaughlin’s family, including his six adult children.

Terry Ryan State Coroner Brisbane 24 January 2018 Exhibit A7, page 6.

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