Skilton, Robert Douglas

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Robert Douglas Skilton TITLE OF COURT: Coroners Court

JURISDICTION: BRISBANE FILE NO(s): 2018/1888 DELIVERED ON: 5 December 2019 DELIVERED AT: Brisbane HEARING DATE(s): 5 December 2019 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, death in custody, natural causes

REPRESENTATION: Counsel Assisting: Ms Rene Jurkov Metro South Hospital And Health Service: Ms Fiona Banwell Queensland Corrective Services: Ms Nikola Core

Contents

Introduction

1. At the time of his death Robert Skilton was aged 73 years. He was in the custody of Queensland Corrective Services at the Wolston Correctional Centre (WCC). He had been convicted of murder on 3 October 1975 and sentenced to life imprisonment. After being transferred to the Princess Alexandra Hospital (PAH) Secure Unit on 19 April 2018, he died on 29 April 2018.

2. Mr Skilton had a 59 year smoking habit beginning at age 14 years and ending when tobacco was banned in correctional centres in 2015. He consistently declined medical attention throughout his time in custody, with records indicating up to five years between medical appointments1 and a regular refusal of medical tests and check-ups.2 The investigation

3. An investigation into the circumstances leading to Mr Skilton’s death was conducted by Detective Senior Constable Marcelle Sannazzaro from the Queensland Police Service (QPS) Corrective Services Investigation Unit

(CSIU).

4. Upon being notified of Mr Skilton’s death, members of the CSIU attended at the PAH. Mr Skilton’s correctional records and his medical files from WCC and PAH were obtained.

5. The investigation was informed by statements from the relevant custodial correctional officers, nursing staff and custodial staff at WCC, fellow prisoners, and a medical officer at the PAH. These statements were tendered at the inquest.

6. At the request of the Coroners Court, Dr Ian Home from the Clinical Forensic Medicine Unit (CFMU) examined Mr Skilton’s medical records from WCC and the PAH and reported on them.

7. The CSIU investigation concluded that Mr Skilton died as a result of natural causes, and that he was provided with opportunities for medical care at WCC. It also found that there were no suspicious circumstances associated with the death. I am satisfied that the CSIU investigation was thoroughly and professionally conducted and that all relevant material was accessed.

1 Exhibit C2, pages 5 and 38 2 Exhibit C2, pages 38 and 65.

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The inquest

8. As Mr Skilton died while in custody an inquest was required by s 27 of the Coroners Act 2003. All of the statements, records of interview, medical records, photographs and materials gathered during the investigations were tendered at the inquest.

The evidence Incarceration history

9. Mr Skilton was sentenced to life imprisonment on 3 October 1975. In 1988, 13 years into his sentence, he was assessed as being not suitable for release on parole. The reviewing psychiatrist, Dr Edwards, noted that Mr Skilton showed “no sign of remorse and no guilt feelings”.3 His records do not indicate that he applied for parole again.

10. One of his fellow inmates commented that he believed Mr Skilton knew he was not getting parole and allowed his health to deteriorate to assist his chances.4 Mr Skilton’s history displays extensive avoidance of medical treatment since his incarceration of over 43 years began.

11. Mr Skilton was said to be active for his age5 and worked within trade ind ustries at WCC. Mr Skilton had worked at ‘SNAPS’ (Fire Safety Systems) from 2013 up until his admission to hospital in 2018. His health had begun deteriorating in the six months leading up to his death, with other prisoners noting a loss of weight, chesty, chronic cough and frailty. A trade instructor from ‘SNAPS’ eventually persuaded Mr Skilton to see a doctor after becoming concerned about his cough and shortness of breath at work.

Personal history

12. Mr Skilton was married at age 19 to his first wife with whom he had a daughter. He had not seen this daughter since she was five years of age.6 He remarried and had three more children before being imprisoned, and subsequently divorced in 1976. Mr Skilton’s father died when he was aged 19 years, and Mr Skilton had not been in contact with his mother in the decade prior to his death.

13. One of Mr Skilton’s daughters was contacted by the PAH on 24 April 2018 regarding his diagnosis.7 She had not been in contact with him for six years8, but was happy to receive updates and a phone call from him.

3 Exhibit C2.1, page 31.

4 Exhibit A5, page 9.

5 Exhibit A6, page 9.

6 Exhibit C2.1, page 29.

7 Exhibit C1, page 49.

8 Ibid, page 74.

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Medical history

14. Mr Skilton started smoking at age 14, only ceasing with the correctional centre tobacco ban in 2015. The only record of Mr Skilton self-referring to a doctor while in custody was his first appointment with Dr Janssens on 10 April 2018.

15. Mr Skilton had immunisations yearly, saw a dentist in 1989 and 20099 and saw an optometrist for prescription glasses in 2013.10 Apart from those instances, he did not have any medical appointments. During his check-up on 1 May 2007, his progress notes state that he “prefers no tests”.11 This was similar to his previous check-up on 25 June 2002 where he preferred not to have colonoscopy for cancer screening or Statin medication.12 In 2009, he had refused his influenza vaccination,13 and in 2015 expressed disinterest in bowel cancer screening.14

16. On 10 April 2018, Mr Skilton saw Dr Michael Janssens, a locum medical officer at WCC. He observed that Mr Skilton appeared emaciated with a weight of 44kgs, and with a wheeze on the left side of his chest.15 Dr Janssens’ primary diagnosis was of lung malignancy with a differential diagnosis of chronic obstructive lung disease. Dr Janssens arranged blood tests, a chest x-ray and CT scan, and commenced a course of antibiotics.

A review of Mr Skilton was scheduled in a week.

17. Upon review on 17 April 2018, Mr Skilton stated that he was feeling a little less short of breath and his cough had improved, however he had lost weight and was now 42.6kgs.16 Mr Skilton had not undergone imaging, and Dr Janssens found that the radiological tests had not been carried out due to the referral not being signed by him. It was signed and resubmitted, with a review scheduled in two days.

18. On 19 April 2018, Mr Skilton had still not had his imaging carried out. To expedite this, Dr Janssens referred Mr Skilton to the Princess Alexandra Hospital Emergency Department. Mr Skilton was transported to the hospital via ambulance later that day.

19. Mr Skilton was admitted to PAH on the afternoon of 19 April 2018 and underwent a CT scan that same day. The scan confirmed a large right lung mass compressing vital structures.17 9 Exhibit C2, page 31, 29 respectively.

10 Ibid, page 20, 21.

11 Ibid, page 38.

12 Ibid.

13 Exhibit C2, page 65.

14 Exhibit C2.1, page 9.

15 Exhibit B2, para 10.

16 Ibid, para 15.

17 Exhibit C1, page 25.

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20. The likely diagnosis of advanced pulmonary malignancy was discussed with Mr Skilton on 20 April 2018 with Dr Geoffrey Eather, his treating physician at the PAH.18 Mr Skilton understood that this was likely to be incurable.19 It was determined that a definitive diagnosis could be obtained via a bronchoscopy biopsy, which Mr Skilton agreed to do the following week.

21. On 24 April 2018, the bronchoscopy was performed, providing a tissue diagnosis of squamous cell carcinoma (non-small cell lung cancer) with advanced staging. During the recovery period of the biopsy, Mr Skilton incurred complications including tachyarrhythmia, tachypnea and hypoxaemia.20 He was stabilised promptly with oxygen, ventilation and digoxin and transferred to the Respiratory High Dependency Unit for further stabilisation before being moved back to the Secure Unit.

22. The results from biopsy were discussed at a Multidisciplinary Lung Malignancy Conference on 26 April 2018, with the outcome being that Mr Skilton was assessed as having terminal advanced cancer. Mr Skilton was made aware that this was incurable with poor survival chances. He was referred to the Palliative Care Service and discussed his wishes regarding resuscitation at the end of his life. Mr Skilton completed an Acute Resuscitation Plan21 stating that he did not wish to be resuscitated, including measures such as CPR, defibrillation and non-invasive ventilation.22

23. The Radiation Oncology team reviewed Mr Skilton on 27 April 2018, and he agreed to palliative radiotherapy for comfort/symptom control. This was scheduled to commence on the following week.

24. On the morning of 28 April 2018, Mr Skilton was assessed as being stable, symptomatically well and comfortable. That evening, at approximately 8:02pm, a rapid response call was made due to the onset of acute respiratory distress with tachycardia and tachypnea. Comfort measures were taken in accordance with Mr Skilton’s Acute Resuscitation Plan, and he was administered an appropriate dose of morphine, midazolam and metoclopramide (via infusion) at 20:29. This was effective in alleviating his distress.

25. Mr Skilton was visually confirmed to be deceased at 10:16pm by nursing staff with a formal death certification being made at 00:30am.

18 Exhibit B1.

19 Exhibit B1, page 2, para 6.

20 Ibid, page 2.

21 Exhibit C1, page 2.

22 Exhibit B1, page 3, para 1.

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Autopsy report

26. On 29 April 2018 Dr Andrzej Kedziora conducted an autopsy consisting of an external examination of the body, toxicology, a full body CT scan and a review of medical records from the PAH and West Moreton Health Service.23

27. The external examination showed no external injuries and the CT scan revealed no internal injuries. Toxicology revealed therapeutic levels of medications used at the PAH (morphine and midazolam) with no alcohol or illicit drugs detected. These results are consistent with the PAH records of the comfort-based treatment used at the end of Mr Skilton’s life.

28. The CT scan confirmed a “right parahilar/posterior mediastinal mass consistent with right lung carcinoma”.24 With the medical records indicating his history of chronic smoking, weight loss, increased exertional dyspnoea and pre-death diagnosis of squamous cell carcinoma, Dr Kedziora found the cause of death to be lung cancer.

29. The cause of death was given as lung cancer (squamous cell carcinoma).25 CFMU report

30. Dr Ian Home from the Clinical Forensic Medicine Unit provided advice regarding Mr Skilton’s treatment at the WCC and PAH.

31. Dr Home agreed with the cause of death given at autopsy, and considered the response from Dr Janssens at WCC on 10 April 2018 to be appropriate.

He noted that the medical examination on that date was comprehensive and of a high standard.26

32. Mr Skilton had died 18 days after his first appointment with Dr Janssens, and there was a delay of nine days in arranging imaging following an administrative oversight. Dr Home commented that while Mr Skilton’s x-ray requests were not processed in a timely way, it did not cause significant or outcome-changing delays in his management. This was largely due to Dr Janssens’ subsequent direct referral to the emergency department at the

PAH.27

33. Dr Home considered the PAH’s response to Mr Skilton’s admission to be swift and appropriate, with medical staff keeping Mr Skilton apprised of their findings and prognosis. He noted that Mr Skilton was involved in his treatment and chose to follow a non-interventional path with palliative radiotherapy. As his lung disease was incurable and presented with compression of major structures, rapid deterioration was expected. When 23 Exhibit A4.

24 Exhibit A4, page 4.

25 Exhibit A4, page 7.

26 Exhibit D1, CFMU Report, page 9.

27 Ibid.

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this occurred, Dr Home noted that the PAH management was in accordance with his wishes of palliative analgesia and sedation. 28

34. Dr Home explored the toxicology results of Mr Skilton, providing an explanation of the dosages of morphine and midazolam that were administered during his respiratory distress on 28 April 2018. Neither drug was found to have contributed to Mr Skilton’s death.29 Conclusions

35. Mr Skilton’s death was caused by natural causes. He was diagnosed with lung cancer that was at a very advanced stage in the weeks before his death. There were no missed opportunities for intervention.

36. I am satisfied that the medical care provided to Mr Skilton while he was in custody at WCC was adequate. As Dr Home noted, he rarely attended the medical clinics at WCC. The only record of him self-referring to a doctor was the first meeting with Dr Janssens shortly before his death. Dr Home noted that Dr Janssens’ diagnosis was accurate and his management plan was reasonable.

37. Although there was an administrative delay of just over a week in Mr Skilton receiving chest imaging, I am satisfied that this delay had no effect on Mr Skilton’s treatment or management.

38. I am also satisfied that the treatment provided by the PAH was appropriate.

Palliative care services were engaged at the terminal phase of his illness and supervised the institution of appropriate comfort measures when an acute deterioration occurred in the final stages. This was in keeping with Mr Skilton’s wishes, which were well documented.

39. I consider that the treatment provided to Mr Skilton was of the same sta ndard that an ordinary member of the community would receive.

28 Ibid.

29 Exhibit D1, page 6, 7.

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Findings required by s. 45

40. 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 evidence I am able to make the following findings: Identity of the deceased – Robert Douglas Skilton How he died – Mr Skilton had been imprisoned for over 43 years. He declined to have routine medical check-ups while in prison. In the six months leading up to his death he had lost 10kg in weight with a productive cough, progressive exertional dyspnea and intermittent, dull chest discomfort. After being persuaded to see a prison doctor in April 2018 he was diagnosed with end stage lung cancer.

Place of death – Princess Alexandra Hospital Secure Unit Woolloongabba in the State of Queensland Date of death– 29 April 2018 Cause of death – Lung cancer (squamous cell carcinoma)

41. I close the inquest.

Terry Ryan State Coroner

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