Taylor, Darren Rodney

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Darren Rodney TAYLOR TITLE OF COURT: Coroners Court JURISDICTION: Brisbane FILE NO(s): 2017/3043 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. Darren Rodney Taylor was an Indigenous man aged 52 years when he died in the Princess Alexandra Hospital Secure Unit (‘PAHSU’). Before admission to hospital he was an inmate at the Wolston Correctional Centre (‘WCC’) from 13 December 2012.

2. On 14 November 2012, Mr Taylor was convicted and sentenced to seven years imprisonment for charges of rape, indecent treatment of a child under 12 years and possession of child exploitation material.

3. On 24 March 2017, Mr Taylor was diagnosed with high grade neuroendocrine cell carcinoma with metastasis to the liver, abdomen and lymph nodes. His condition was not amenable to surgery and Mr Taylor completed an Acute Resuscitation Plan (‘ARP’) indicating he wanted comfort cares along with antibiotics.

4. Mr Taylor initially commenced chemotherapy but did not respond to this treatment. On two occasions he suffered from biliary sepsis and biliary duct stents were inserted to relieve his symptoms. His condition did not improve and he underwent palliative radiotherapy to liver lesions in June 2017, after which he was returned to WCC.

5. On 12 July 2017, Mr Taylor was found in a confused state with low oxygen saturations and a non-recordable blood pressure. He was transferred to the PAHSU where he was diagnosed with multi-organ failure due to recurrent biliary sepsis that was likely terminal. The following day Mr Taylor was in clear distress due to abdominal pain and a decision was made to cease active treatment and transition to comfort cares. His condition deteriorated and he was subsequently declared deceased at 7:16am on 14 July 2017.

The investigation

6. An investigation into the circumstances surrounding Mr Taylor’s death was conducted by Senior Constable Kelly Burbank of the Corrective Services Investigation Unit (CSIU).

7. Senior Constable Burbank provided a report, along with information about the circumstances of the death and statements and medical records. Senior Constable Burbank did not identify any issues or concerns indicating the death was suspicious. She concluded the death was the result of longstanding medical conditions that had been treated appropriately.1

8. An external autopsy examination with associated CT scans and toxicology testing was conducted by Forensic Pathologist, Dr Beng Ong. The cause of death, based on a review of the medical records, external post-mortem 1 Exhibit A5 – QPS Report Findings of the inquest into the death of Darren Rodney Taylor 1

examination and associated testing including CT scanning, was found to be metastatic neuroendocrine carcinoma.

9. At the request of the Coroners Court, Dr Ian Home from the Queensland Health Clinical Forensic Medicine Unit (CFMU) examined the statements as well as the medical records for Mr Taylor from WCC and the PAH and reported on them.

10. As part of the investigation, efforts were made to contact Mr Taylor’s four adult children who live in Victoria. It appears they had no contact with him while he was in prison and expressed no concerns about his treatment.

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

The Evidence Criminal history

12. Mr Taylor’s criminal history commenced in 1998, and primarily consisted of minor drug and property offending. He had not been sentenced to a term of imprisonment until his conviction on 14 November 2012, when he was sentenced to a total of six years imprisonment for sexual offences against a child, and one year for possessing child exploitation material. Those sentences were to be served cumulatively. He had been eligible for parole since 11 May 2015.

13. Consideration was given to applying for exceptional circumstances parole in May 2017 and a letter of support was provided by the PAH. However, Mr Taylor decided not to proceed with that application as he had nowhere to live and no support should he be paroled. He had been studying a business degree but was not in contact with family, had no close friends and no suitable substitute decision maker.2 Medical history and recent treatment

14. Mr Taylor did not regularly attend the WCC Medical Centre. Prior to March 2017, he only attended the medical centre for minor ailments such as rashes or back pain.

15. On 2 March 2017, he presented to the medical centre complaining of pain in his stomach and chest. No cause of the pain could be identified during an initial assessment. The following day an electrocardiogram (‘ECG’) was conducted as a precautionary measure. The ECG could not be conducted upon Mr Taylor’s initial presentation to the medical centre due to Queensland Corrective Services (‘QCS’) operational issues.

F iEnxdhinigbsit oEf4 th, pe aingqeu 3e4s t into the death of Darren Rodney Taylor 2

16. On 16 March 2017, Mr Taylor attended the medical centre again complaining of abdominal pain that was worse after meals and associated with reduced frequency of bowel motions. It was noted that he had an umbilical hernia and he was referred to Registered Nurse Tracey West3 to discuss pain management.

17. On 17 March 2017, RN West examined Mr Taylor again and noted he had intermittent abdominal pain and he was still constipated. RN West recorded that the umbilical hernia had been present for 10 years. Requests were made for pathology tests to be performed and for further observations to be repeated that evening.

18. Mr Taylor was administered two sachets of movicol, Coloxyl with senna to assist with bowel movement.4 He was advised that if he had any further pain he would be transferred to radiology for further treatment.

19. On 18 March 2017, Mr Taylor again presented to the medical centre with severe abdominal pain and was hypertensive. It was noted that the drugs used to relieve constipation had no effect. His pathology results revealed a lactate of 426 which could indicate a stone. The Lipase was 42 and CRP 39 which could indicate an ‘acute’ abdomen.5 As a result, Mr Taylor was transported to the PAHSU after an intravenous cannula was inserted for access and analgesia. Mr Taylor became hypertensive and his blood pressure went up further when he was given morphine.

20. An abdominal CT scan showed evidence of a large bowel obstruction as well as two large lesions in the liver, indicating metastatic disease (spread of cancer) along with an area of thickening in the colon suspicious for a primary malignancy. A liver biopsy was performed on 24 March 2017 that revealed a high-grade neuroendocrine cell carcinoma.6 The condition was not amenable to surgery and Mr Taylor was discharged on 30 March 2017 with a plan to commence chemotherapy.

21. On his return to WCC, Mr Taylor was offered all services for palliation, including pain management with MS Contin and OxyContin for breakthrough pain. He was offered weekly dietician reviews, nursing support and ongoing follow up appointments with PAHSU.

22. The first round of chemotherapy was administered on 12 April 2017. After just one cycle, Mr Taylor was reviewed at an outpatient clinic on 3 May 2017 where blood tests revealed an acute elevation in his liver function and a possible bile duct obstruction. As a result, Mr Taylor was admitted to the PAHSU. An abdominal CT confirmed interval enlargement of the liver mass 3 Ex B5 4 E x B 5 , p a r a . 1 4 5 Ex B5, para. 15 6 Ex E1, page 33 Findings of the inquest into the death of Darren Rodney Taylor 3

causing the biliary obstruction. On 9 May 2017, a biliary duct stent was successfully inserted and Mr Taylor was discharged the following day.

23. On 6 May 2017, Mr Taylor completed an ARP indicating he wanted comfort cares along with antibiotics. He did not want resuscitation or other advanced care.7

24. Mr Taylor presented to the WCC medical centre on 20 May 2017 with abdominal pain, intermittent fevers and appearing jaundiced. He was immediately transferred to PAHSU for further treatment and pain management. An abdominal CT scan revealed disease progression causing recurrent biliary obstruction leading to inflammation of the bile duct. He was commenced on intravenous antibiotics and then underwent the successful placement of a further two biliary stents. The admission was complicated by procedural induced pancreatitis. During this admission Mr Taylor was referred for consideration of palliative radiotherapy for his rapidly progressing, end-stage, chemorefractory, metastatic, high grade, large cell neuroendocrine carcinoma. He subsequently received five doses between 5 June 2017 and 16 June 2017. No further interventions were planned.8

25. He was discharged and returned to WCC on 30 May 2017. In light of his poor prognosis RN West discussed with Mr Taylor his suitability to be housed in the disability unit with a carer. Mr Taylor refused this offer as he had friends providing him support and he wanted to stay in his current unit.

Upon his return to WCC, RN West followed the clinical recommendation in the discharge summary from PAHSU to continue pain management with recommended analgesia and antibiotics. Regular review and treatment was provide to him until the time of his death.

26. On 10 June 2017, RN West reviewed Mr Taylor’s pain medications and in light of his increased pain, his regime was altered to provide more pain relief.

This resulted in Mr Taylor being administered medication outside the normal medication dispensing time, in order for optimal pain management for his condition.

27. On 7 July 2017, the WCC nursing staff had a teleconference with the palliative care team at the PAH. During this teleconference the WCC nursing staff were advised to again increase Mr Taylor’s opiate medication for optimal relief.

Events leading up to the death

28. At 6:00pm on 12 July 2017, while WCC nursing staff were conducting a medication round, another inmate alerted staff that Mr Taylor was unable to come and obtain his medication as he was in bed. After the medication round was completed staff attended his cell at approximately 6.30pm and located Mr Taylor in a confused state. A Code Blue was called.

7 Ex E5, pages 2 - 3 8 E x B 3 Findings of the inquest into the death of Darren Rodney Taylor 4

29. Mr Taylor was taken to the WCC medical centre for assessment and treatment. Upon arrival Mr Taylor’s oxygen saturations were 80%, his heart and respiration rates were stable, but a blood pressure could not be obtained. The Nurse Unit Manager attended and Dr Kahanna was contacted for a ‘phone order for pain relief’. An intravenous cannula was inserted and Mr Taylor was administered morphine.

30. The Queensland Ambulance Service (‘QAS’) attended and there was an initial debate as to whether Mr Taylor should be taken to the hospital, given his ARP directive. The decision was made to transport him to the PAHSU.

QAS staff were notified by the Clinical Director of the PAH, Dr Gayle Williams, to administer additional morphine and maxalon in order to transport Mr Taylor in the ambulance.

31. Upon arrival at the PAHSU he was diagnosed with multi-organ failure due to recurrent biliary sepsis that was likely terminal. Mr Taylor indicated that he wanted active treatment with antibiotics and medical management but understood he was unlikely to survive this.9 Antibiotics, fluid and glucose were administered intravenously.

32. The following day, Mr Taylor was in clear distress and a decision was made to cease active treatment and transition to comfort cares. Mr Taylor’s condition continued to deteriorate.

33. On 14 July 2017, Queensland Corrective Services Officer Tiffany Miles10 took up the post outside Mr Taylor’s hospital room. At approximately 5.38am she made a request for nursing staff to attend Mr Taylor’s room. Registered Nurses Ven der Meer, King and Sianjaya attended to Mr Taylor and observed he was not breathing, had no pulse or response to stimuli. No resuscitation efforts were commenced in accordance with his ARP.11

34. At approximately 5.45am the medical pump was removed and the nursing staff left Mr Taylor’s room. QCS Officer Miles was advised that it may be some time before a doctor saw Mr Taylor, given other medical emergencies.

At this time QCS Officer Miles informed QCS Acting Supervisor Anthony Hearn of Mr Taylor’s death and that it may take a while for a doctor to attend.

Supervisor Hearn directed QCS Office Miles to keep running the log of events and to secure the room as it was now a crime scene.

35. Dr Xi Jia attended Mr Taylor’s room and pronounced his death at 7.16am and Dr Jia signed a life extinct form. After this Supervisor Hearn contacted the Queensland Police Service (‘QPS’) and advised them about the death in custody.

9 E8, page 6, Report of Cienne Morton, BPT Medical Registrar of PAH, report page 2 of 3 1 0 R e f e r r e d a l s o t o a s Q C S O f f i c e r T i f fany Firrell 11 Ex B4 Findings of the inquest into the death of Darren Rodney Taylor 5

Autopsy

36. An external post-mortem examination was performed by forensic pathologist, Dr Beng Ong, on 17 July 2017 at Queensland Health Forensic and Scientific Services at Coopers Plains.12 A CT scan was also undertaken.

37. The external examination noted yellow discolouration of the skin consistent with jaundice. The skin showed the presence of bruises and further extension of bleeding at puncture mark sites indicating coagulopathy (impaired blood clotting ability), a known feature of organ failure.13 Some minimal recent abrasions were also noted to Mr Taylor’s abdomen and left leg.14

38. The CT scan identified numerous metastatic deposits within the liver and mesentery (tissue attached to the bowel) along with enlarged lymph nodes within the abdomen, in keeping with intraperitoneal (abdomen) spread. A lesion in the brain was also noted but thought to be more likely an incidental meningioma (benign lesion). The base of the lungs showed aspiration changes.

39. A toxicology test was not performed. However, a femoral blood sample was taken for toxicology analysis if required in the future.

40. Dr Ong found that the cause of Mr Taylor’s death was metastatic neuroendocrine carcinoma.15 Clinical Forensic Medicine Unit Review

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

42. Dr Home provided a report detailing his conclusions.16 His observations can be summarised as follows:

• Mr Taylor had no contact with medical services until 2 March 2017 when he first reported abdominal pain, initially thought to be the result of constipation;

• Although he was not transferred for hospital review until 18 March 2017, earlier referral would not have altered the outcome in this case as his malignancy had already spread and was not responding to chemotherapy; and 12 Ex A4 1 3 E x A 4 , p a g e 4 14 Ex A4, page 3 15 Ex A4, page 4 16 Ex A6 Findings of the inquest into the death of Darren Rodney Taylor 6

• When metastatic disease is present at the time of diagnosis, as was Mr Taylor’s case, the reported median survival is five to 14 months.

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

Conclusions

44. After considering the findings at autopsy, the CSIU investigation report and Dr Home’s review, I am satisfied there is no evidence to indicate that Mr Taylor died from anything other than natural causes. I am satisfied he received adequate and appropriate medical care while in prison and at the Princess Alexandra Hospital.

Findings Required by s. 45

45. 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 – Darren Rodney Taylor How he died - Mr Taylor died in custody as a result of a high grade neuroendocrine cell carcinoma with metastasis to the liver, abdomen and lymph nodes, for which he was diagnosed in 2017.

Unfortunately, his condition was not amendable to surgery and did not respond to chemotherapy.

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

Date of death – 14 July 2017 Cause of death – Metastatic neuroendocrine carcinoma

46. I close the inquest, and extend my condolences to Mr Taylor’s family.

Terry Ryan State Coroner Brisbane 6 December 2019 Findings of the inquest into the death of Darren Rodney Taylor 7