Lahrs, Brendon John

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Brendon John Lahrs TITLE OF COURT: Coroners Court JURISDICTION: Brisbane FILE NO(s): 2017/1083 DELIVERED ON: 6 December 2019 DELIVERED AT: Brisbane HEARING DATE(s): 6 December 2019 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: CORONERS: Death in custody, natural causes.

REPRESENTATION: Counsel Assisting: Ms Sarah Lio-Willie Queensland Corrective Services: Ms Taylor Mobbs Princess Alexandra Hospital: Ms Fiona Banwell

Contents

Introduction

1. At the time of his death, Brendon Lahrs was 27 years of age. He was a prisoner receiving treatment in the Princess Alexandra Hospital Oncology Unit. Prior to his admission to hospital he had been in custody at the Southern Queensland Correctional Centre (SQCC). On 2 September 2013, Mr Lahrs was convicted of manslaughter and sentenced to 10 years imprisonment.

2. In May 2016, while Mr Lahrs was in custody, he was diagnosed with a rare terminal cancer, referred to as Ewing’s sarcoma. He immediately commenced chemotherapy which involved being transported to the Princess Alexandra Hospital Secure Unit (PAHSU) for review and treatment at least twice a month. The frequency of these visits increased as his disease progressed.

3. Further scans in November 2016 revealed that Mr Lahrs’ cancer was refractory to treatment. Consequently chemotherapy was ceased, and treatment instead was changed to palliative radiotherapy. That therapy was completed by 28 December 2016; however, subsequent scans confirmed the ongoing spread of the disease.

4. On 4 March 2017, Mr Lahrs was admitted to the PAHSU with worsening shortness of breath, increasing lower limb fluid retention, abdominal distension and lower back pain, which was aggravated by a burn caused by use of a hot pack following application of a heat rub. The following day he was moved from the PAHSU to the Oncology Unit for palliative care.

5. On 12 March 2017, Mr Lahrs’ family attended the Oncology Unit to celebrate his 27th birthday with him, which was on 13 March. Shortly before midnight nursing staff were called to Mr Lahrs’ room as he appeared to be nearing the end of his life. Mr Lahrs was declared deceased at 12.14am.

The investigation

6. Police officers from the Corrective Services Investigation Unit (CSIU) attended the hospital and subsequently examined the scene.

7. A targeted investigation into the circumstances surrounding Mr Lahrs’ death was conducted byPlain Clothes Senior Constable Penelope McEwen from the CSIU. A Coronial Report was subsequently provided with various annexures, includi ng witness statements and medical records. The report arrived at the following conclusions:

• Mr Lahrs died of natural causes as a result of Metastatic Sarcoma;

• He was provided with adequate medical care while a prisoner in the care of Queensland Corrective Services; Findings of inquest into the death of Brendon John Lahrs 1

• The death was unavoidable and there is no act or omission by any person which resulted in the death; and

• There are no suspicious circumstances surrounding this death.

8. Mr Lahrs’ mother informed Senior Constable McEwen that she had no concerns about the treatment he received while in custody.

9. The Head of Health Services at the SQCC, Karen Sacco, noted that she had conversations with Mr Lahrs about how he was coping in the prison, his pain levels and general health. She said that he was always pleasant and respectful and he managed his disease with grace and few complaints. She said that he had good support from his family, and she endeavoured to reassure his mother that he was receiving appropriate care.

10. Records from the PAH also indicate that Mr Lahrs’ mother was actively supporting him while he was undergoing treatment at the hospital. I extend my condolences to her and to other family members.

The inquest

11. As Mr Lahrs died while in custody an inquest was required by s 27 of the Coroners Act 2003. Ms Lio-Willie appeared as counsel assisting. All of the statements, records of interview, medical records, photographs and materials gathered during the investigation were tendered at the inquest. I was satisfied I had sufficient materials to make the findings required under the Coroners Act 2003.

The evidence Criminal History

12. Mr Lahrs’ criminal history commenced in 2010, and related to wilful damage, unlawful use of a motor vehicle and minor nuisance type offences. He had not previously been sentenced to a term of imprisonment until his conviction on 2 September 2013, when he was sentenced to 10 years imprisonment for the manslaughter of his half-brother when Mr Lahrs was aged 20.

13. Mr Lahrs was first remanded on 11 February 2011, thus having served over two and a half years in presentence custody. This was his first period of incarceration.

Medical and treatment history

14. On 27 April 2016, Mr Lahrs first complained of a constant non-productive cough with occasional episodes of breathlessness over the preceding two Findings of inquest into the death of Brendon John Lahrs 2

(2) weeks. He was initially given a Ventolin (asthma reliever) puffer by the nurse and advised to return in a couple of days if his cough did not improve.1

15. Prior to this date Mr Lahrs had no significant medical history other than asthma as a child.

16. Mr Lahrs used the entire Ventolin canister, containing 200 doses, in five days. He was not reviewed again until 20 May 2016, when he reported ongoing symptoms. He was assessed by a doctor who prescribed antibiotics for possible bronchitis with a plan for review in two days.

17. On the evening of 21 May 2016, a Code Blue medical emergency was called as Mr Lahrs was having difficulty breathing. He improved with additional Ventolin and was transferred to the medical holding bay for observation. The following morning he was transferred to the Princess Alexandra Hospital (PAH) with suspected pneumonia.

18. On 22 May 2016, Mr Lahrs was initially admitted under the respiratory team with complete whiteout due to the collapse of his right lung caused by fluid in the space between the chest and the lung (pleural effusion). Tumour lesions involving the lining of the chest cavity (pleura) were also seen on the CT scan.

19. On 24 May 2016, a biopsy was taken of his pleural malignancy and revealed an aggressive round cell malignant tumour resembling Ewing’s sarcoma, involving the right chest. As the typical DNA abnormalities associated with Ewing’s sarcoma were not detected the biopsy was sent to the Royal Prince Alfred Hospital in Sydney for further testing.

20. In June 2016, DNA rearrangement in the region referred to as CIC-DUX4 was confirmed. Dr Warren Joubert, Medical Oncologist at the PAH, is type of rare malignancy carries a poor prognosis with only a slight chance of cure.2

21. On 2 June 2016, Mr Lahrs commenced first-line chemotherapy with repeat imaging in August 2016 showing a partial response. However, further scans performed on 17 November 2016, after eight of the planned 17 cycles of chemotherapy revealed significant disease progression. Consequently, chemotherapy was ceased, and treatment changed to five cycles of palliative radiotherapy that were completed by 28 December 2016.

Subsequent scans on 4 January 2017 confirmed ongoing spread of disease.

22. Mr Lahrs was taken to the PAHSU for treatment at least twice a month to receive chemotherapy and radiotherapy respectively. In December 2016, given the progression of his disease Mr Lahrs’ attendance at the PAHSU for treatment increased.

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23. On 31 January 2017, Mr Lahrs was admitted to the PAH with increasing shortness of breath on a background of one week of persistent coughing and daily vomiting. He was given a course of oral antibiotics for a possible chest infection and the Palliative Care team were consulted to assist in pain management.

24. Staging scans performed on 22 February 2017 showed further progression with pressure on the heart, liver and vascular structures.

Events leading up to the death

25. On 4 March 2017, Mr Lahrs was suffering from worsening shortness of breath, increasing lower limb fluid retention, abdominal distension and lower back pain, which was aggravated by a burn caused by use of a hot pack following application of a heat rub. Registered Nurse (RN) Melinda Evans at SQCC advised the prison that Mr Lahrs required further medical treatment offsite. On the same date he was admitted to the PAHSU.

26. By this time, Mr Lahrs’ disease had significantly progressed and he was in the terminal phase. On 5 March 2017 the decision was made to transfer Mr Lahrs to the Oncology Unit for palliative care and pain management.3

27. On 12 March 2017, Mr Lahrs was visited by his family to celebrate his 27th birthday which was to occur on 13 March 2017.

28. At approximately 11.55pm, Custodial Correctional Officer (CCO) Rachel Strick Van Linschoten, who was one of the escorting officers for Mr Lahrs, alerted nursing staff to tend to Mr Lahrs. Nursing staff arrived to assess Mr Lahrs and called for a doctor.

29. Dr James Latchford attended Mr Lahrs’ room and pronounced his death at 12.14am. Dr Latchford signed a life extinct form and Mr Lahrs’ room was cleared and secured.

Autopsy

30. An external autopsy examination was performed by Dr Christopher Day on 15 March 2017 at Queensland Health Forensic and Scientific Services at Coopers Plains.4 A CT scan was also undertaken.

31. The external examination noted moderate abdominal swelling. There was an area of blistering and superficial ulceration to the lower back, consistent with a previous burn. No other recent injuries were identified.

32. The CT scan identified a large tumour mass within the right side of the chest with metastatic deposits within the lungs and liver and fluid within the left 3 Ex B1 4 E x A 4 Findings of inquest into the death of Brendon John Lahrs 4

chest cavity. Dr Day found that the cause of Mr Lahrs’ death was metastatic sarcoma.5 Medical Review

33. Dr Ian Home of the Clinical Forensic Medicine Unit conducted a review of the medical treatment provided to Mr Lahrs while he was in custody.

34. Dr Home provided a report detailing his conclusions.6 His observations can be summarised as follows:

• Mr Lahrs first reported a two week persistent cough on 27 April 2016 for which he was given a trial of Ventolin for suspected asthma;

• Despite being advised to return in a couple of days if his symptoms did not improve, he did not return for further medical review until 20 May 2016. This delay would not have altered the outcome in this case;

• Mr Lahrs suffered from CIC-DUX4 translocation sarcoma which is a rare and aggressive form of cancer with a poor prognosis; and

• Despite use of recommended first-line chemotherapy agents, Mr Lahrs’ cancer was refractory to treatment with significant disease progression.

35. Dr Home saw no reason to be critical of the care provided to Mr Lahrs by Offender Health Services or the PAH, nor did he find any areas of concern.

Conclusions

36. Mr Lahrs’ death was the subject of a thorough police investigation. That investigation has been considered by me and I accept that the death was from natural causes with no suspicious circumstances associated with it.

37. None of the correctional officers involved at SQCC contributed to his death.

I am satisfied that Mr Lahrs was given appropriate medical care by staff at SQCC and the PAH while he was admitted there. His death could not have reasonably been prevented.

38. It is an accepted 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, including Dr Home’s review, established the adequacy of the medical care provided to Mr Lahrs when measured against this benchmark.

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Findings Required by s. 45

39. 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 the evidence, I am able to make the following findings: Identity of the deceased– Brendon John Lahrs How he died - Mr Lahrs died as a result of a rare terminal cancer which was diagnosed in May 2016 while he was serving a term of imprisonment for manslaughter. Despite receiving chemotherapy immediately, the disease was found to be refractory and he received palliative treatment up until his death.

Place of death – Princess Alexandra Hospital, Woolloongabba in the State of Queensland.

Date of death – 13 March 2017 Cause of death – Metastatic sarcoma.

40. The circumstance of Mr Lahrs’ death do not call for any comment relating to issues of public health and safety or the administration of justice or ways to prevent deaths from happening in similar circumstances.

41. I close the inquest.

Terry Ryan State Coroner Brisbane 6 December 2019 Findings of inquest into the death of Brendon John Lahrs 6