Petzler, Dennis Michael

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Dennis Michael Petzler TITLE OF COURT: Coroners Court JURISDICTION: Brisbane FILE NO(s): 2018/3262 DELIVERED ON: 24 February 2021 DELIVERED AT: Brisbane HEARING DATE(s): 24 February 2021 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, death in custody, natural causes.

REPRESENTATION: Counsel Assisting: Josephine Villanueva Queensland Corrective Services: Vanessa Price CQHHS: Kristy Richardson

Contents Findings of the inquest into the death of Dennis Michael Petzler Page 2 of 9

Introduction

1. Dennis Petzler was a prisoner at the Capricornia Correctional Centre (CCC). On 2 July 2018, he was admitted to the Rockhampton Hospital and was diagnosed with metastatic lung/liver cancer of unknown origin.1

2. On 5 July 2018, he was discharged from the hospital and returned to CCC and referred to oncology for further management. On 15 July 2018, he returned to the hospital and was diagnosed with pneumonia. He remained in hospital until he died aged 59 years on 23 July 2018 of carcinomatosis (cancer spread widely throughout the body) as a consequence of adenocarcinoma of the pancreas.

The investigation

3. Detective Sergeant Stephen Carr from the Queensland Police Service (QPS) Corrective Services Investigation Unit (CSIU) led the investigation into the circumstances leading to Mr Petzler’s death.

4. After being notified of the death, police from the Rockhampton Station attended at the Rockhampton Hospital. A targeted direction for investigation was issued by the State Coroner the CSIU continued the investigation. Mr Petzler’s correctional records and his medical files from CCC and the Rockhampton Hospital were obtained.

5. The investigation was informed by statements from the relevant nursing and medical staff at CCC and medical staff at the Rockhampton Hospital.

6. Dr Ian Home from the Clinical Forensic Medicine Unit (CFMU) also examined Mr Petzler’s medical records and reported on them for the Coroners Court.

7. The CSIU investigation concluded that Mr Petzler died from natural causes, and that he was provided with adequate medical care at CCC. It also found that there were no suspicious circumstances associated with the death. I am satisfied that the CSIU investigation was professionally conducted and that all relevant material was accessed.

The inquest

8. As Mr Petzler died while in custody an inquest was required by s 27 of the Coroners Act 2003. All statements, records of interview, medical records, photographs and materials gathered during the investigations were tendered at the inquest. I acknowledge Ms Villanueva’s assistance in the preparation of a summary of the evidence that informed my findings.

1 Ex D1, CQHHS Medical Records at p.30.

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The evidence Personal history

9. Mr Petzler was survived by his daughter and son. His medical history included Hepatitis C, gastroesophageal reflux disease (GORD) and chronic right shoulder and back pain. He had been a smoker and previously abused illicit substances and alcohol.2

10. Mr Petzler had a lengthy criminal history with entries for property offences, drug related offence and offences of violence.3 On 27 September 2017, he was remanded in custody for offences of entering a dwelling with intent to commit an indictable offence in the night and with violence, threatening violence, wilful damage, and assault occasioning bodily harm.4 He breached court ordered parole as a result of committing these offences.5 He remained in custody and the charges were committed to the District Court in Bowen on 20 February 2018.

He applied for bail on the same date and his application was refused. He died before the charges were finalised.

11. Mr Petzler’s daughter provided a statement to police stating she had spoken to her father on the phone and seen him in the days leading up to his death. She said they spoke about his condition and her father did not have any concerns for his safety in prison.6 I extend my condolences to Mr Petzler’s family.

Cancer diagnosis

12. On 21 June 2018, Mr Petzler attended the CCC medical clinic complaining of persistent abdominal pain (2/10) and nausea. He told the nurse he had pain on the right side of his upper abdomen. However, he did not voice discomfort upon palpation. Following a discussion with a medical practitioner, Mr Petzler was not provided treatment.7

13. On 26 June 2018, Mr Petzler saw a nurse again and his observations were taken. His blood pressure was slightly high, and he was seen by Dr Peter McGoldrick.

14. On 28 June 2018, he was seen again by Dr McGoldrick. He advised that the pain in his abdomen had improved but the pain was triggered by spicy, fatty or voluminous food. He advised he still had lower back pain. He was observed to be afebrile, alert, co-operative and pleasant to deal with.8 2 Ex D1, CQHHS Medical Records at p.224.

3 Ex C1, Criminal History.

4 IOMS Offender File Verdict and Judgment Record dated 20 February 2018.

5 IOMS Offender File Information Notice Parole Board Queensland dated 4 October 2017.

6 Ex B2.

7 Ex D6, 21.06.18.

8 Ex D6, 26.06.18 Findings of the inquest into the death of Dennis Michael Petzler Page 4 of 9

15. Mr Petzler’s urine test showed traces of blood however those were macroscopically clear, and he had no other urinary issues. Dr McGoldrick’s principal diagnosis was settling gastritis but the blood in his urine needed to be investigated. Mr Petzler was to be reviewed in two weeks or earlier regarding his abdominal pain. He was told not to do prison work, not to consume fish oil and a follow up was to be issued for renal/bladder issue.

16. On 2 July 2018, Mr Petzler was seen by Dr McGoldrick again and observations were taken. The progress note recorded he was ‘symptomatic re malaise, anorexia lethargy, nausea’ and complained of pain on the tip of his right shoulder.9 Mr Petzler was referred and transferred to the Rockhampton Hospital.

17. A CT scan of Mr Petzler’s chest, abdomen and pelvis at the hospital revealed widespread metastatic disease displayed throughout both lung bases, the right lobe of the liver and upper abdominal para-aortic lymph nodes of unknown primary.10 A fine needle aspiration biopsy was performed on his left supraclavicular node with the initial report showing metastatic cells.11 The scan also showed a fracture in a vertebrae in his lower back which may have been caused by cancer, but also could have been consistent with a non-cancerous tumour.

18. Mr Petzler was prescribed dexamethasone, targin, pregabalin and endone as required. He was referred to the orthopaedic department for the non-union of his clavicle and a further referral was to be considered if needed. He remained in hospital and was to be reviewed by the oncology unit in one week.

Return to CCC

19. On 5 July 2018, Mr Petzler was seen by Dr Koduri and was advised that his cancer was not curable.12 He was discharged from the hospital and returned to CCC. His discharge summary was provided to the medical unit at the CCC. Mr Petzler was in constant pain while at the CCC and was provided pain relief and his medications. He complained of increased pain on 8 July 2018.

20. On 9 July 2018, Mr Petzler was seen by Dr McGoldrick. He was observed to be alert, pleasant and co-operative. Mr Petzler asked for his medications to be reviewed given his previous addiction to opiates. Mr Petzler spoke of insufficiency of the medication for his back and abdominal pain and ongoing nausea when he tried to eat.13 He advised Dr McGoldrick that he had previously mixed opiates, sniffed solvents in his early teens and inhaled pesticides as part of his previous employment.14 Mr Petzler’s medications were increased in dose and in frequency.

9 Ex D6, 02.07.18 10 Ex D1, CQHHS Medical Records at p.30.

11 Ibid.

12 Ex D1, CQHHS Medical Records at p.231.

13 Ex D6, 9.07.18.

14 Ibid.

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Events Leading up to the Death

21. Mr Petzler remained in constant pain and was reviewed and monitored as required until he was readmitted to the Rockhampton Hospital on 15 July 2018.

He had flu-like symptoms and shortness of breath.15 He was diagnosed with pneumonia/severe lower respiratory tract infection. A further CT scan of his chest and abdomen showed no real changes from the scan performed on 2 July 2018.

22. On 16 July 2018, Mr Petzler was referred to the ICU team as he was failing CPAP and BPAP. Mr Petzler was reviewed and, given the incurable nature of his cancer, was advised he was not a candidate for intubation/ventilation or ICU admission.16 Mr Petzler was also considered an unsuitable candidate for chemotherapy due to his very poor prognosis.17 Contact was made with Mr Petzler’ daughter to advise of his prognosis and a phone conversation between them was facilitated.

23. Mr Petzler was moved to the general ward and continued to be monitored. He was placed on humidified high flow nasal prongs for air and oxygen. He continued to be in pain despite being provided medication and his condition continued to deteriorate. On 19 July 2018, it was noted that his pneumonia had progressed in both lungs.18 His sister and his daughter were contacted to update them on his progress.

24. On 20 July 2018, Mr Petzler was commenced on a syringe driver for pain relief.

He was continually treated with supportive measures and appropriate antibiotic.

However, his condition continued to deteriorate despite the treatment with very high oxygen requirements.19

25. On 22 July 2018, Mr Petzler continued to display respiratory distress. The medical practitioner who saw Mr Petzler noted in the progress note “I feel that Dennis was not with me at the time of explanation about his condition, likely for comfort care”.20

26. A meeting was held with Mr Petzler’s daughter and son. They were advised of their father’s worsening condition and his wishes in relation to his Acute Resuscitation Plan. Police were also advised of Mr Petzler’s condition. A decision was made for antibiotics and regular observation to cease and the provision of comfort cares only.21 At 9.53pm, Mr Petzler appeared comfortable but had difficulty breathing. He was in the company of his son and daughter.

15 Ex D1, CQHHS Medical Records at p.44 16 Ex D1, CQHHS Medical Records at p.78-79.

17 Ex D1, CQHHS Medical Records at p.84.

18 Ex D1, CQHHS Medical Records at p.100.

19 Ex B1, Statement of Dr Al-Saffi at p.1.

20 Ex D1, CQHHS Medical Records at p.109.

21 Ex D1, CQHHS Medical Records at p.111.

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27. On 23 July 2018 at around 3.56am, a custodial officer who was guarding Mr Petzler observed Mr Petzler had died and notified medical staff.

Autopsy Examination

28. On 25 July 2018, an external post-mortem examination was conducted by Dr Nigel Buxton, who also reviewed Mr Petzler’s medical records from the Rockhampton Hospital. The family had asked that no internal examination take place.

29. Dr Buxton concluded that Mr Petzler’s death was a result of widespread metastatic malignant disease affecting the liver, bone, lungs and lymph nodes.22 Dr Buxton reported that the fine needle cytology performed on 2 July 2018 indicated that the primary source of the cancer was likely to have been in the upper gastrointestinal tract: either pancreato-biliary or gastric. Mr Petzler showed no evidence of jaundice as is generally seen in patients with primary tumours affecting the gall bladder and the common bowel duct and its tributaries.23

30. Dr Buxton considered that the fast progression of the disease from the initial diagnosis and death indicated that the primary cancer was pancreatic rather than gastric but without internal examination he could not be certain.24

31. On this basis, Dr Buxton found the cause of death to be carcinomatosis due to, or as a consequence of adenocarcinoma of the pancreas.

32. Dr Buxton stated that the care given to Mr Petzler at the Rockhampton Hospital appeared “quite appropriate” and there was no evidence to suggest a second person played a role in Mr Petzler’s death.25 Clinical Forensic Medicine Unit Review

33. At the request of my office, Senior Forensic Medical Officer, Dr Ian Home, provided advice about the health care provided to Mr Petzler. Dr Home noted Mr Petzler’s included a family history of gastric cancer affecting his father and pancreatic cancer affecting his uncle and two brothers.26

34. Dr Home noted that the first indication of any issue was a presentation on 21 June with abdominal pain and nausea with no abnormality detected on examination. That pain appeared to be resolving when medically reviewed on 28 June 2018. The initial diagnosis of gastritis appeared reasonable given the symptoms appeared to be aggravated by food intake. However, in response to involving pain Mr Petzler was referred to hospital for further review on 2 July 2018 at which time he was diagnosed with extensive metastatic disease that was incurable.

22 Ex A3, p. 2 23 Ibid.

24 Ibid.

25 Ibid.

26 Ex B5.

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35. Dr Home noted that it is not uncommon for pancreatic cancer to be diagnosed late in the disease process. He considered that even if Mr Petzler had been sent to hospital following his initial presentation the diagnosis and outcome would have been unchanged. Dr Home saw no reason to be critical of the care provided to Mr Petzler by the Capricornia Correctional Centre or the Rockhampton Base Hospital.

CONCLUSIONS

36. Mr Petzler died from a cancer that was not diagnosed until after it had metastasised extensively. I accept that there is nothing that could have been done to prevent his death. I also accept that there were no suspicious circumstances associated with the death.

37. There was no opportunity for the medical and nursing staff at the CCC or the Rockhampton Hospital to intervene earlier than they did. Mr Petzler died just over one month from his initial presentation with back and stomach pain at the CCC. His illness could not be treated.

38. He had been afforded a level of health care of a standard no less than he would have received in the community. He was seen by medical staff at CCC on 11 occasions and by nursing staff on 33 occasions following his reception to that centre on 3 October 2017. He was transferred to the Rockhampton Hospital when necessary and received appropriate treatment at that hospital.

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. As a result of considering all the evidence I can make the following findings: Identity of the deceased – Dennis Michael Petzler How he died – At the time of his death Mr Petzler had been imprisoned on remand for approximately 10 months. On 21 June 2018, he complained of persistent stomach pain for the first time. He was referred to the Rockhampton Hospital for further investigations on 2 July 2018. He was diagnosed with multiple carcinomas and then returned to the prison on 5 July 2018. After his health deteriorated, he was returned to the Rockhampton Hospital on 15 July 2018. He continued to deteriorate and was provided with end of life care.

Place of death – Rockhampton Hospital, Rockhampton, Queensland 4700 Findings of the inquest into the death of Dennis Michael Petzler Page 8 of 9

Date of death– 23 July 2018 Cause of death – 1(a) Carcinomatosis, due to, or as a consequence of 1 (b) Adenocarcinoma of the pancreas

40. I close the inquest.

Terry Ryan State Coroner Brisbane 24 February 2021 Findings of the inquest into the death of Dennis Michael Petzler Page 9 of 9