Findings into the death of Trevor Charles Stone

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Trevor Charles Stone TITLE OF COURT: Coroners Court

JURISDICTION: BRISBANE FILE NO(s): 2021/2908 DELIVERED ON: 26 May 2025

DELIVERED AT: BRISBANE HEARING DATE(s): 20 May 2025 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, natural causes, death in custody.

REPRESENTATION: Counsel Assisting: Ms Nicole Macregeorgos Metro South Hospital and Ms Myla Ruttan Health Service Queensland Corrective Ms Josephine Villanueva Services

Contents

Introduction

1. Trevor Charles Stone was fifty-seven years of age when he passed away in palliative care in the Princess Alexandra Hospital (PAH) Secure Unit (SU) in the late evening of 29 June 2021. Mr Stone had been transported from the Borallon Training and Correctional Centre (BTCC) where he was serving a term of imprisonment for sexual offences, to the PAHSU on 22 June 2021. Mr Stone died of natural causes as a result of Stage 4 metastatic lung cancer. Mr Stone’s conditions of Type II diabetes, high blood pressure, lipid imbalances and coronary heart disease were also considered to have contributed to his death.

2. Mr Stone was a First Nations man. Where possible, I will use the term “passing” or “passed” in line with cultural practice except where, by virtue of the legislation, the term “death” must be used.1 Coronial jurisdiction

3. At the time of his passing, Mr Stone was a prisoner in custody as defined in Schedule 4 of the Corrective Services Act 2006 (Qld). Mr Stone’s passing is a reportable death under section 8(3)(g) of the Coroners Act 2003 (Qld) (the Act) as it is a ‘death in custody’.

4. In cases such as this, an inquest is mandatory pursuant to s27(1)(a)(i) of the Act.

An inquest is intended to provide the public and, most importantly, the family of the deceased, with transparency regarding the circumstances of the death, and to answer any questions which may have been raised following the death.

5. The role of the coroner is to independently investigate reportable deaths to establish, if possible, the identity of the deceased, the medical cause of death, and the circumstances surrounding the death – how the person died. Those circumstances are limited to events which are sufficiently connected to the death.

The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability. Those are matters for other courts.

6. The relevant standard of proof is that of the balance of probabilities, with reference to the Briginshaw2 standard. Accordingly, the more significant the issue for determination, the clearer and more persuasive the evidence must be for the coroner to be sufficiently satisfied on the balance of probabilities that the issue has been proven: But reasonable satisfaction is not a state of mind that is attained or established independently of the nature and consequence of the fact or facts to be proved. The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer…In such matters ‘reasonable satisfaction’ should not be produced by inexact proofs, indefinite testimony, or indirect inferences.3 1 Sorry Business. A guide to cultural competency and engagement between the Coroners Court of Queensland and Aboriginal and Torres Strait Islander people.

2 Briginshaw v Briginshaw (138) 60 CLR 336.

3 Briginshaw v Briginshaw (138) 60 CLR 336, 362 – 363 (Dixon J).

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7. In adjudicating the significance of the evidence, the impact of hindsight bias and affected bias must also be considered.4 As outlined in ‘The Australasian Coroners Manual’: Hindsight bias is the tendency after the event to assume that events are more predictable or foreseeable than they really were. What is clear in hindsight is rarely as clear before the fact…It is an obvious point, but one that nonetheless bears repeating, particularly when coroners are considering assigning blame or making adverse comments that may damage a person’s reputation.

… Coroners should attempt first to understand the circumstances as they appeared at the relevant time to the people who were there.

… Hindsight, of course, is a very useful tool for learning lessons from an unfortunate event. It is not useful for understanding how the involved people comprehended the situation as it developed. This distinction needs to be understood and rigorously applied.5 The investigation

8. The investigation into Mr Stone’s passing was led by Detective Acting Sergeant Jessica Sampson of the Queensland Police Service (QPS) Corrective Services Investigation Unit (CSIU).

9. After being notified of the passing on 29 June 2021, QPS officers from the CSIU, being Det. A/Sgt Sampson, Plain Clothes Senior Constable Jakki Hamilton and Scenes of Crime officer Sergeant Gavin Branningan, attended the PAH Secure Unit.

10. Police observed Mr Stone laying on the bed, with hospital blankets covering his body. An infusion pump was observed still connected to Mr Stone’s body. A green woollen hat was located nearby, as well as green leaves that had been used as part of a smoking ceremony earlier that day. No injuries or marks inconsistent with medical treatment were identified. Photographs were taken of Mr Stone in situ and he was then conveyed to then conveyed to Queensland Health Forensic and Science Services (as it then was).

11. On 30 June 2021, I made a direction for a targeted police investigation to occur.

A Coronial Investigation Report was prepared and provided to the Coroners Court in January 2022.

12. Det. A/Sgt Sampson conducted a thorough investigation in response to the targeted direction. She concluded that there were no suspicious circumstances surrounding Mr Stone’s passing, and he was provided with appropriate care and treatment while incarcerated.

4 Findings of the inquest into the death of Pasquale Roasario Giorgio, [140] – [142].

5 Hugh Dillon and Marie Hadley, The Australasian Coroner’s Manual (The Federation Press, 2015) 10.

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The inquest

13. The inquest was held at Brisbane on 20 May 2025. All statements, medical records, photographs and materials gathered during the investigation were admitted into evidence. No witnesses were called to give oral evidence. Counsel Assisting proceeded to submissions on the investigation material in lieu of any oral evidence.

14. The issues considered at the inquest were the issues required by s 45(2) of the Act, and whether Ms Stone had access to, and received appropriate medical care, while he was in custody.

15. I am satisfied that all material necessary to make the requisite findings was placed before me at the inquest.

The evidence Social and Medical History

16. Mr Stone was born on 3 November 1963 in Cairns, Queensland into a family of ten children. Unfortunately, Mr Stone suffered great adversity from a young age, having been subjected to physical and sexual abuse perpetrated by older relatives. At the age of seven, he was ejected from the family home and largely grew up on the streets. Records indicate that, as a child, Mr Stone often stole money and other goods to give to his mother due the violent treatment to which she was subjected. Mr Stone’s parents are now both deceased, and he was not in contact with any of his family before his passing. During his time in prison, he had formed a close friendship with his cellmate, Mr Carter, who was nominated to be his next of kin.

17. Mr Stone’s involvement in criminal activities commenced at an early age and resulted in him spending most of his adult life incarcerated. By the age of seventeen, Mr Stone’s offending had escalated, and he was sentenced to an eight-year period of imprisonment for two counts of rape and one count of sodomy, as well as concurrent periods of imprisonment for the lesser offences of unlawful use of a motor vehicle, indecent assault and stealing from the person.

This sentence was later appealed by the Crown on the ground that it was manifestly inadequate in relation to the two counts of rape. On 3 November 1981, the original sentence was quashed and in lieu thereof, Mr Stone was sentenced to twelve years imprisonment in respect of each count.

18. On 7 October 1988, Mr Stone was sentenced to seven years imprisonment in relation to carnal knowledge against the order of nature (sodomy) and a further two years of imprisonment to be served concurrently for the lesser offence of assault occasioning bodily harm.

19. Mr Stone’s most period of imprisonment at the time of his passing related to four counts of rape and indecent assault with a circumstance of aggravation, for which he was originally sentenced on 16 December 1997. On 16 November 1998, an indefinite custodial sentence was imposed, with a nominal period of fourteen years. Mr Stone’s indefinite sentence was reviewed in March 2011, November 2013 and November 2015. On each occasion, he was considered to be a serious danger to the community.

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20. On 20 September 2018, the indefinite sentence imposed upon Mr Stone was reviewed and subsequently discharged. In lieu thereof, Mr Stone was sentenced to eighteen years imprisonment, to be served cumulatively upon the sentence imposed on 16 November 1998. In total, Mr Stone was serving a period of incarceration of forty years and one month. He was eligible for parole from 16 December 2006 and his custodial end-date was recorded as 24 September 2021.

21. At the time of his passing, the Attorney-General was pursuing an application for orders under the Dangerous Prisoners (Sexual Offenders) Act 2003 (Qld).

Orders were made in the Supreme Court at Brisbane on 13 April 2021 for Mr Stone to undergo risk assessments by two court appointed psychiatrists.

Arrangements were made for those assessments to occur on 1 and 2 July 2021, however Mr Stone had passed away prior to those dates.

22. Mr Stone’s medical history was significant. In 2006, he was hospitalised following a heart attack. He had also been seen by the West Moreton Hospital and Health Service (WMHHS) Prison Health Service (PHS) for the following: a. Stage IV non-small cell lung cancer (NSCLC), adenocarcinoma; b. Type II diabetes mellitus on insulin; c. High blood pressure; and d. High cholesterol.6

23. At the time of his passing, Mr Stone was taking the following medications: a. Optisulin (30 units mane) for diabetes; b. Bisprolol [sic] (10mg mane) for improved heart function; c. Ramipril (7.5mg mane) for hypertension; d. Aspirin (100mg mane) to prevent ischaemic heart disease; e. Atorvastatin 40mg nocte) to treat high cholesterol; f. Metformin XR (1mg mane and nocte) for diabetes; g. Sitagliptin (100mg mane) for diabetes; h. Magnesium (1.5 mg mane and nocte) as a supplement; i. Metoclopramide (10 mg mane and nocte for nausea); j. Paracetamol/Codeine 1g/60mg 4 x per day PRN for pain relief; and k. Sustagen 3 x per day as a meal supplement.7

24. Mr Stone was an ex-smoker, with a twenty-year history of smoking approximately eight to ten cigarettes per day intermittently. He was also noted to be poorly compliant with his diabetic management. Mr Stone’s diabetes and heart condition continued to be regularly managed by the WMHHS PHS until his passing.

Diagnosis of lung cancer

25. On 4 July 2019, Mr Stone asked to see a doctor as he had a lump protruding from the left side of his neck. Mr Stone was seen by a nurse on 5 July 2019, where it was reported that the lump was solid, had increased in size over the past month and was painful. Mr Stone was noted to have a cough and had lost weight. It was determined a CT scan was required and a referral was sent to the PAH for this to occur.

6 Exhibit B5 – Statement of Dr Crystal Pidgeon, [9].

7 Exhibit B5 – Statement of Dr Crystal Pidgeon, [10].

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26. On 16 August 2019, Mr Stone underwent a CT scan to his neck, chest and abdomen at the PAH. Results showed that the lump on his neck was due to lymph node enlargement, and that he also had a growth in his lung.

27. Mr Stone’s case was reviewed at the Lung Cancer Conference (a multidisciplinary team meeting) on 3 October 2019, chaired by Dr Robert Sheehy. Mr Stone was formally diagnosed with Primary Non-small Cell Lung Cancer, Adenocarcinoma, Stage IVA. The multidisciplinary team agreed that Mr Stone was to undergo systemic chemotherapy. At this stage, it was noted that Mr Stone’s biomarker profile (which included a marker to assess benefit for immune checkpoint inhibitor) was low and the likelihood to respond was “…not superior to chemotherapy”.8 Mr Stone was referred to palliative care as his disease was incurable.

28. On 10 October 2019, Mr Stone met with the medical oncology team to discuss the systemic chemotherapy, as well as the role of palliative intent chemotherapy (being slowing the disease, improving quality of life and reducing cancer-related symptoms). Even with chemotherapy, Mr Stone’s life expectancy was approximately twelve months.

29. On 17 October 2019, Mr Stone commenced four cycles of carboplatin and pemetrexed, to which he responded positively. He then commenced standard maintenance therapy of pemetrexed only for four cycles. Scans confirmed that Mr Stone’s disease had stabilised by April 2020.

30. Mr Stone was given a break from the maintenance pemetrexed between April 2020 and July 2020. A plan was formulated for further clinical radiological assessment in July 2020.

31. On 16 July 2020, the doublet chemotherapy was recommenced after restaging scans found progressive disease. Due to Mr Stone’s previous positive response to this therapy, a similar result was expected. He also received five fractions of radiation to his left supraclavicular lymph node mass due to discomfort.

32. By December 2020, the disease had progressed which required a change in the chemotherapy regimen. However, Mr Stone was unable to tolerate the new treatment. Myelosuppression was identified as a major issue and his disease continued to worsen.9 At this time, Docetaxel chemotherapy, “…was considered the best therapeutic option likely to achieve a response rather than a single agent immune checkpoint inhibitor (being Nivolumab) by the thoracic oncology team”.10 This was due to the large burden of lung disease and the biomarker profile of Mr Stone’s cancer.

33. Mr Stone was reviewed by the palliative care team at the PAH where symptom management and advanced care planning was discussed with him. The endocrinology team also reviewed him, due to his dexamethasone causing high blood sugar levels (in relation to his diabetes). Mr Stone was advised that the focus of his care should be on avoiding hypoglycaemias, and given his other medical conditions, strict management of his blood sugar levels was not warranted.

8 Exhibit B1 – Report of Dr Brian Bell, 2.

9 Exhibit B1 – Report of Dr Brian Bell, 2.

10 Exhibit B1 – Report of Dr Brian Bell, 2.

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34. On 21 February 2021, Mr Stone presented to the medical centre at BTCC for his routine blood glucose level monitoring. He was observed to be pale, was holding the left side of his abdomen and was coughing up blood. Mr Stone had a fever, fast heart-rate and looked to be clinically dehydrated. Mr Stone was advised that he should be transferred to the PAH for urgent medical care. After initially declining to do so, he was transported to the PAH via Queensland Ambulance Service (QAS). Mr Stone was subsequently admitted to the PAH and diagnosed with pneumonia. He was later discharged with antibiotics on 25 February 2021.

35. On 4 March 2021, Dr Tasafin Hossain reviewed Mr Stone. Dr Hossain noted that the results of Mr Stone’s 19 February 2021 chest, abdomen and pelvis CT scan indicated, “Progressive disease in the pulmonary parenchyma and nodal disease”.11

36. After consultation with oncology consultants Dr Ladwa and Dr McCaffrey, it was determined that Mr Stone’s next line of treatment would consist of Docetaxel chemotherapy. Due to Mr Stone’s large burden of disease and the biomarkers of his cancer, Docetaxel chemotherapy was considered the best therapeutic option.

Immunotherapy was to be given if chemotherapy proved ineffective. Mr Stone subsequently received three cycles of Docetaxel between 12 March and 30 April 2021.

37. Despite this, it is noted that Dr Hossain’s progress note stated: D/W Dr Ladwa and Dr McCaffrey

• Next line treatment would be ideally Nivolumab immunotherapy -> however given no Medicare whilst imprisoned, not able to give this, not funded

• Therefore aim to start Docetaxel chemotherapy and request early release (due to be released/?paroled in Sep this year anyway) to allow administration of Nivolumab.12

38. Dr Hossain reviewed Mr Stone in the PAHSU and advised him his cancer was no longer responding to the treatment being provided and a change was required. In her statement dated 3 October 2024, Dr Hossain outlined that she: …discussed with Mr Stone that after his two previous chemotherapy regimes, it was often standard practice to trial immunotherapy during the treatment course, namely Nivolumab and that it was [her] understanding that his incarceration was a barrier to receiving this, but could potentially be overcome with writing a letter for early release thus in the meantime could start Docetaxel, which [was] also a standard treatment in this setting.13

39. By 20 May 2021, Mr Stone’s disease had further progressed. At this time, an immune checkpoint inhibitor was offered to Mr Stone, with the understanding that the chance of meaningful response was small.

40. Mr Stone received his first dose of Nivolumab (an immunotherapy) on 21 May 2021, after approval by the PA Drugs and Therapeutic Committee on 20 May 2021.

11 Exhibit B5 – Statement of Dr Crystal Pidgeon, [34].

12 Exhibit C2.6 – Medical Records, 161.

13 Exhibit B9 – Statement of Dr Tasafin Hossain, [10].

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41. Mr Stone continued to be regularly managed by the PAH endocrinology, oncology and palliative care teams until his admission on 22 June 2021. During this time, Mr Stone was admitted to the PAH on two occasions, the first being as a result of coughing up blood and chest tightening, and the second being for a lower respiratory tract infection, constipation and nausea. It was during the latter admission on 19 June 2021 that new brain metastases were found on a CT scan.

Mr Stone was subsequently referred to Associate Professor Margot Lehman on 21 June 2021 for radiation treatment.

22 June 2021 to 29 June 2021

42. On 22 June 2021, Mr Stone presented to the PAH Emergency Department by way of QAS transfer due to concerns from BTCC staff in relation to worsening confusion, functional decline, fatigue, nausea, anorexia and pain. Mr Stone was admitted and investigations undertaken.

43. On the morning of 23 June 2021, Mr Stone was reviewed by Dr Craig Hukins, Dr Kate Webster, Dr Peta Enbon and Dr Chou during consultant ward rounds. Mr Stone described symptoms of nausea, pain, constipation and progressive weakness. Mr Stone stated he now required a wheelchair to mobilise as his ability to walk had deteriorated prior to admission. Mr Stone was initially treated with, “dexamethasone, rehydration with IV fluids, aperients, simple and opioidbased analgesia, anti-emetic and nutritional supplements”.14 Upon the advice of the radiation oncology team, a brain MRI was also ordered in order to determine further treatment options.

44. On 24 June 2021, Mr Stone reported improvement in his nausea, pain and appetite. However, an MRI of Mr Stone’s brain was performed and the results showed a single right cerebellar metastatic deposit and six supratentorial deposits. Dr Chow discussed Mr Stone’s case with the radiation oncology team, and it was assessed that that Mr Stone was unsuitable for palliative whole brain radiation due to his functional impairment.

45. On 25 June 2021, Dr Webster discussed Mr Stone’s case with Medical Oncology Fellow Dr Calum O’Leary for an opinion in relation to Mr Stone’s suitability for further systemic therapy. Dr O’Leary reviewed Mr Stone and was of the opinion that he was not suitable for further systemic chemotherapy or immunotherapy.

As such, Mr Stone’s treatment transitioned to focusing on best supporting Mr Stone’s symptoms.

46. On 25 June 2021, Dr Hukins and Dr Webster explained to Mr Stone that his cancer was spreading aggressively and that there were no further treatment options available. Instead, his treatment would focus on managing his treatment through palliative care, to which Mr Stone was agreeable.

47. Mr Stone experienced further deterioration over the weekend of 26 to 27 June

2021. Mr Stone was reportedly experiencing more confusion and agitation, but appeared comfortable according to Dr Peter Bell.

2022. In the early hours of 28 June 2021, Mr Stone was documented to have had an unwitnessed fall. At 3:00am, Ward Call Dr Randall Johnson examined Mr Stone and he was not noted to have been injured. Dr Johnson provided Mr Stone with a sedative due to agitation.

14 Exhibit B2 – Statement of Dr Peta Enbon, [14].

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49. On the same day during the consultant ward rounds, Mr Stone was assessed to be entering the terminal phase of his illness. Mr Stone was unresponsive to voice or commands and his breathing uneven. A decision was made to transition Mr Stone to NIKI pump, which contained morphine, midazolam, haloperidol and breakthrough medications. In keeping with Mr Stone’s wishes, a smoking ceremony was organised by the Aboriginal and Torres Strait Islander Liaison Officer (ATSILO) and performed on 29 June 2021.

50. At 8:00pm on 29 June 2021, Corrective Services Officer (CSO) Danny Siddons conducted a half-hourly check on Mr Stone in the company of nursing staff, Rachel Dalgarno and Martin Power. CSO Siddons had known Mr Stone for approximately fifteen months as he escorted Mr Stone to various medical appointments in his capacity as Corrective Services Escort Officer. CSO Siddons observed Mr Stone was alive but struggling to breathe. Ms Dalgarno and Mr Power applied ointment to Mr Stone’s back in order to assist with bed sores.

51. At 8:20pm, CSO Siddons conducted a further check on Mr Stone. CSO Siddons failed to observe any movement of Mr Stone’s chest to indicate that he was breathing and as a result, immediately notified the nursing staff. Ms Dalgarno conducted checks for signs of life and confirmed that Mr Stone had passed away.

CSO Siddons informed his supervisor, CSO Troy Gibbs, at approximately 8:25pm that Mr Stone had passed away and the cell was subsequently secured as a crime scene.

52. At 10:47pm, Dr Matthew Ingram pronounced Mr Stone deceased.

Exceptional Circumstances Parole Application

53. On 11 October 2019, Mr Stone applied for Exceptional Circumstances Parole (ECP) which was considered by the Parole Board Queensland (PBQ) on 7 April

54. At the time, the PBQ formed the preliminary view that Mr Stone’s application should be declined as his risk level to the community was unacceptably high. However, the PBQ invited Mr Stone to send further written submissions and supporting documents for consideration.

55. On 1 June 2020, the PBQ met to further consider Mr Stone’s application after receipt of further written submissions dated 28 April 2020. The PBQ determined that no new information was contained in Mr Stone’s submissions that would alleviate their concerns and as such, remained of the view that the circumstances identified in his application did not warrant his release.

56. Records indicate that Mr Stone made a further Application for ECP in or around February/March 2021.

57. On 8 March 2021, Dr Hossain provided a letter of support to the PBQ. Dr Hossain noted that: Ideally, Trevor’s next line of treatment would be immunotherapy…however given he has no Medicare eligibility we have been unable to provide whilst incarcerated due to the high cost of his treatment. Therefore he will commence on chemotherapy next week with a view to switching to immunotherapy as soon as he is released hence the request for early compassionate parole, noting this is currently scheduled for September 2021.

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Unfortunately, Trevor’s disease is progressing quite quickly with potential of life expectancy of short months if we are unable to start on optimal treatment before he becomes too unwell and we would be looking to commence on immunotherapy as soon as possible.15

57. On 10 March 2021, the PHS received correspondence from the PBQ seeking a medical report to assist them in determining Mr Stone’s application. On 17 March 2021, Dr Thomas O’Gorman provided a response to the PBQ noting that Mr Stone’s terminal illness was progressing quickly and treatment options were limited because he was incarcerated. Dr O’Gorman stated that, “In a noncustodial setting he would be able to access and commence immunotherapy which the specialists believe would be beneficial for him”.16

58. On 25 March 2021, Queensland Corrective Service (QCS) received an email from the PBQ seeking information as to whether immunotherapy could be provided to Mr Stone in custody. Advice was obtained from the Director, Office for Prisoner Health and Wellbeing (OPHW), Mr Graham Kraak that: In relation to Mr Stone, the chemotherapy and/or immunotherapy needs to be provided in a hospital due to the nature of the treatment, preparations required to administer the treatment, and staffing expertise. This cannot be done in the correctional centre health clinic. If he was on parole or in custody he would still need to attend a hospital to receive treatments. The cost of the immunotherapy treatment referred to in the correspondence is about $10,000.00 per month.17

59. On the same date, the PBQ sent further correspondence to Mr Stone advising him that the proposed community accommodation, located in Jimboomba, was unsuitable for the purposes of his parole, and it would defer making a decision until upon receipt of an Accommodation Review and further information from

QCS.

60. Mr Stone passed away before the PBQ was able to give further consideration to his application.

Concerns

61. During his treatment at the PAH, Mr Stone was engaged with the ATSILO after being referred by the Cultural Liaison Officer (CLO) at BTCC. Mr Stone was also engaged with Mr Noel Herbert, Social Worker from the Aboriginal and Torres Strait Islander Legal Service (ATSILS).

62. On 1 July 2021, an email was received from Coronial Counsellor Clements outlining a phone call that he received from Mr Herbert on 30 June 2021. Mr Herbert indicated that he was ringing on Mr Carter’s behalf and that: He may wish to raise issues/concerns about the deceased apparently being denied access to “life prolonging” medication around 2.5 years ago, because he was a prisoner.18 15 Exhibit B5 – Statement of Dr Crystal Pidgeon, [73].

16 Exhibit B5 – Statement of Dr Crystal Pidgeon, [74].

17 Exhibit B5 – Statement of Dr Crystal Pidgeon, [75].

18 CCMS File 2021/2908 Stone, Trevor Charles - Email from Patrick Clements dated 1 July 2021.

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63. Mr Clements advised Mr Herbert that, “interested parties could write to the Office of State Coroner if wishing to raise concerns about a person’s care, treatment or management whilst in custody”.19

64. On 2 July 2021, the Court received an email from Mr Clements documenting a further telephone call from Mr Herbert, where he confirmed that “the ATSI Legal Service will be raising some concerns regarding the deceased’s health care and management”.20 Mr Clements provided Mr Herbert with the relevant address for any communication to be sent for the attention of the State Coroner. No further correspondence was received from Mr Herbert.

65. On 7 May 2025, CCQ contacted Mr Carter to confirm whether he had any concerns to raise. Mr Carter advised that he had no concerns and would not attend the inquest.

Response from the OPHW dated 13 June 2023

66. On 25 May 2023, a Form 25 was directed to the OPHW, Queensland Health, requesting information regarding the ability for prisoners to receive immunotherapy, with reference to any policy, procedure, Memorandum of Understanding (MoU) or legislation.

67. On 13 June 2023, CCQ received correspondence from Mr Kraak, Director of the OPHW in response. Mr Kraak provided the following information regarding the provision of health care to prisoners: Queensland Health is responsible for the provision of public health services for people in the custody of Queensland Corrective Services (QCS). These health services are funded by the State of Queensland (State) and delivered by eight Hospital and Health Services (HHSs) as statutory independent bodies which have been established under the Hospital and Health Services Boards Act 2011 (Qld).

To guide the provision of health services for people in the custody of QCS Queensland Health has established a Memorandum of Understanding (MoU) with QCS for prisoner health services.

… This MOU is a principle-based document and sets out the roles and responsibilities of QCS and Queensland Health for the delivery of health services for people in the custody of QCS.

This MoU is referenced in the service level agreement between the Department of Health and each of the eight HHSs that deliver prison health services and requires the respective HHS to “…provide services for prisoners consistent with the principles, responsibilities and requirements specified in the Memorandum of Understanding (Prisoner Health Services) between Queensland Health and Queensland Corrective Services.” … 19 CCMS File 2021/2908 Stone, Trevor Charles - Email from Patrick Clements dated 1 July 2021.

20 CCMS File 2021/2908 Stone, Trevor Charles - Email from Patrick Clements dated 1 July 2021.

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The MoU states that Queensland Health is responsible for funding the delivery of health services for prisoners through HHSs (Background B). In addition, the MoU refers to several legislative instruments such as the Humans Rights Act 2019 (Qld) and international covenants such as the United Nations Standard Minimum Rules for the Treatment of Prisoners (Nelson Mandela Rules) that guide the approach regarding the delivery of health services for people in prison. Specifically, there is a focus in the MoU that prisoners should have access to the same standard of health care that is available in the community, and this should be available without discrimination on the grounds of their legal status (MoU para 3.5 and 3.7).

Queensland has also developed a Guideline medication formulary and prescribing practices for prison health services…The Guideline recognises that the List of Approved Medicines (LAM) is the Statewide formulary of medications and applies to all people whether or not they are in prison. In summary, access to the LAM should not be limited just because a person is in prison. It also states that people in prison should have access to non-LAM medications in the same way that any other person has access to non-LAM medications. The overarching principle is that medications should be prescribed based on clinical need. The LAM is extensive and includes vast range of medications including numerous immunotherapy and chemotherapy medicines.21

68. Mr Kraak outlined the following in relation to a prisoner’s ability to access subsidised medication: Access to subsidised medication is provided by the Pharmaceutical Benefits Scheme (PBS) and is governed by the National Health Act 1953 (Commonwealth). The Pharmaceutical Benefits Advisory Committee is an independent medical body appointed by the Australian Government to determine eligibility and restricted criteria for access to medicines on the PBS. The PBS is available to all Australian residents who are eligible for Medicare rebateable services. Eligibility for Medicare is governed by the Health Insurance Act 1973 (Commonwealth) which was amended in 1976 to determine that prisoners, are the responsibility of state governments, and therefore are not eligible for Medicare rebateable services. Prisoners are also prohibited from accessing subsidised medications via the PBS.

There are some exceptions to this, for example the State is reimbursed for the cost of some specialised medicines for prisoners through the PBS Schedule 100 scheme. The criteria to access Scheme is determined by Pharmaceutical Benefits Advisory Committee. Eligibility criteria are published on the PBS website…and include criteria such as confirmation diagnosis, results of blood tests and type of medical specialists who are able to prescribe.

Notwithstanding this, prisoners should have access to medications that they require based on clinical need, as any other person in the community, whether this is subsidised through the PBS of fully funded by the State of Queensland.

Metro South Hospital and Health Service (MSHHS) has advised that it provides equitable access to appropriate medicines to patients experiencing financial hardship or who are Medicare ineligible. If patients meet these categories and there is a clinical need for the medication, an individual patient approvals (IPA) for medicines and other therapeutic goods application is made to the Princess Alexandra Drugs and Therapeutics Committee (the Committee). The Committee provides oversight and 21 Exhibit B4 – Statement of Graham Kraak, 1 – 2.

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governance of the IPA application in accordance with the Queensland Health’s Management and governance of individual patient approvals for medicines and other therapeutic goods guide…The Executive Director Medical Services or their delegate determines whether to approve the applications at the Princess Alexandra Hospital. 22

69. Mr Kraak confirmed that Mr Stone, “was provided several doses of Nivolumab, an immunotherapy medication listed on the LAM and funded by the State through the budget of MSHHS.23 Response from MSHHS dated 12 July 2023

70. MSHHS was subsequently requested to provide information regarding processes for access to medication for immunotherapy for prisoners brought to the PAHSU, having regard to the response from Mr Kraak of the OPHW.

71. On 12 July 2023, Dr Brian Bell, Executive Director Medical Services at the PAH, provided a response outlining the treatment provided to Mr Stone and provided information as to a prisoners’ access to medication for immunotherapy when brought in to the PAHSU.

Mr Stone’s condition & prognosis

72. Dr Bell outlined that Mr Stone’s case was complex, and was reviewed by the Thoracic Medical Oncology team consisting of: …five medical oncologists, one lung cancer nurse, two fellows (at this time), three senior registrars incorporated into a lung multidisciplinary team involving respiratory, radiation oncology and cardiothoracic surgeons and allied health. The thoracic medical oncology group meet on a weekly basis to discuss patient care in complex cases such as Mr Stone.24

73. In summary, the following treatment was provided to Mr Stone after his diagnosis in late September 2019:

• After his initial diagnosis, Mr Stone’s case was discussed at the Respiratory Multidisciplinary Team Meeting. The team came to a consensus where the decision for treatment was for systemic chemotherapy. It was noted that Mr Stone’s biomarker profile (which included a marker to assess benefit for immune checkpoint inhibitor) was low. As such, “…the likelihood to respond to immune checkpoint inhibitors was low and not superior to chemotherapy”.25 Dr Bell opined that Mr Stone’s overall survival rate at that point was twelve to eighteen months;

• On 10 October 2019, Mr Stone was reviewed in the medical oncology clinic and was commenced on four cycles of doublet chemotherapy in the form of carboplatin and pemetrexed. This was then followed by a maintenance single agent pemetrexed until 2 April 2019. There was a sustained response in his disease burden; 22 Exhibit B4 – Statement of Graham Kraak, 2 - 3.

23 Exhibit B4 – Statement of Graham Kraak, 2.

24 Exhibit B1 – Report of Dr Brian Bell, 1.

25 Exhibit B1 – Report of Dr Brian Bell, 2.

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• Between April 2020 and July 2020, Mr Stone was given a break from maintenance pemetrexed. Dr Bell said maintenance pemetrexed had little survival benefit and patients were often taken off chemotherapy for close monitoring;

• On 16 July 2020, doublet chemotherapy was recommenced after restaging scans found progressive disease. Mr Stone was responsive to the doublet chemotherapy;

• On 4 December 2020, Mr Stone’s burden of disease was found to have progressed which necessitated a change in the chemotherapy regime.

However, Mr Stone was intolerant to the new treatment; myelosuppression was identified as a major issue and his disease continued to progress despite the change in treatment (as evidenced on restaging scans on 19 February 2021);

• At this stage, Docetaxel chemotherapy, “…was considered the best therapeutic option likely to achieve a response rather than a single agent immune checkpoint inhibitor (being Nivolumab) by the thoracic oncology team”.26 This was due to the large burden of lung disease and the biomarker profile of Mr Stone’s cancer;

• From 12 March 2021 to 30 April 2021, Mr Stone received three cycles of Docetaxel, however it was found on 20 May 2021 that Mr Stone’s disease had further progressed. This indicated that the lung cancer had not responded to the chemotherapy. At this time, the immune checkpoint inhibitor was offered to Mr Stone, with the understanding that the chance of meaningful response was small;

• On 21 May 2021, Mr Stone received his first dose of Nivolumab (an immunotherapy) after approval by the PA Drugs and Therapeutic Committee;

• Despite this, Mr Stone’s condition continued to decline resulting in further admissions to the PAH. Multiple new large volume symptomatic brain metastases and were found. As Mr Stone was terminal, the treating team were of the view that, “further systemic therapy was not clinically appropriate, and that he would be treated best with supportive care (i.e.

palliative care)”.27

74. Ultimately, Dr Bell opined: For Mr Stone, the sequence of his treatment was based on what was thought to be most likely to provide him with therapeutic benefit at the specific stage of his disease.28 Access to immunotherapy

75. Dr Bell provided the following information in relation to the treatment options for prisoners: 26 Exhibit B1 – Report of Dr Brian Bell, 2.

27 Exhibit B1 – Report of Dr Brian Bell, 2.

28 Exhibit B1 – Report of Dr Brian Bell, 2.

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The treatment options for medical oncology patients, whether they are incarcerated or from the community, are considered equally according to their clinical needs and following the MSHHS processes around this. As advised to Mr Graham Kraak, Director Office for Prisoner Health and Wellbeing on 9 June 2023, MSH has governance process in place to allow equitable access to appropriate medicines to patients experiencing financial hardship or who are Medicare ineligible. Applications are made to the Committee, and the approval process is in accordance with the Queensland Health’s ‘Management and governance of individual patient approvals for medicines and other therapeutic goods’ guide’.

Further, the funding for immunotherapy comes from the health service’s budget (via the treating unit’s budget). Medication such as Nivolumab are supplied to the prisoner from the health service where the prisoner was discharged from. If clinically required, medication is also supplied to the prisoner upon discharge from the hospital. The PAH Pharmacy transports medication, if required, to Prison Health Services (PHS). This includes cancer-related medications on the basis that PHS does not have oncology Pharmacy.29 Reports of Associate Professor Dr Simon Durrant

76. Given the initial concerns raised by Mr Herbert on behalf of Mr Carter, as well as the issues recorded by Dr Hossain in her progress note, I sought expert opinion from an oncologist as to the adequacy and appropriateness of the medical treatment provided to Mr Stone. That oncologist, Associate Professor Dr Simon Durrant, provided his initial report to the Court on 26 April 2024 and an addendum report on 24 January 2025.

77. Ultimately, Dr Durrant was of the view that: …the treatment outlined was of a high professional standard and would not have been any better administered by any other institution within Australia.

Dr Ladwa also provide[d] a clear rationale for the timing and use of Nivolumab. He describe[d] how this agent was ineffective as the disease had an innate resistance to it.30

78. He went on to state that the additional material provided to him had allayed all of his concerns regarding any potential deficiencies in Mr Stone’s treatment and that Mr Stone’s treatment at the PAH was in accordance with the highest standard of clinical practice. Dr Durrant’s concerns regarding the availability of medication to incarcerated patients as opposed to Medicare-eligible members of the public remained.

79. I accept the opinion of Dr Durrant.

Autopsy results

80. On 1 July 2021, Forensic Pathologist, Dr Phillips, conducted an autopsy consisting of an external examination of the body and a full body CT scan. The CT scan showed “multiple opaque lesions throughout the brain and lungs. There was patchy segmental coronary artery calcification”.31 29 Exhibit B1 – Report of Dr Brian Bell, 1 – 2.

30 Exhibit E4 – Addendum Report of Dr Simon Durrant, 2.

31 Exhibit A2 – Autopsy Report, 5.

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81. Dr Phillips stated: In my opinion, the cause of death is metastatic lung adenocarcinoma. Diabetes mellitus, hypertension, dyslipidaemia and ischaemic heard disease are also considered to have contributed to death.32

82. The cause of death was recorded as: 1(a). Metastatic lung adenocarcinoma Other significant conditions

83. Diabetes mellitus, hypertension, dyslipidaemia, ischaemic heart disease.33 Conclusions

84. I am satisfied that Mr Stone died from natural causes. I find that none of the inmates, correctional or health care staff at the PAH or the BTCC caused or contributed to his death. There were no suspicious circumstances.

85. 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 established the adequacy of the health care provided to Mr Stone when measured against this benchmark.

85. While concerns were raised about the provision of immunotherapy to Mr Stone, I am satisfied that Mr Stone did receive that treatment when it was clinically indicated. Expert evidence provided by Dr Durrant in his addendum report noted that the treatment provided to Mr Stone, “was of a high professional standard and would not have been any better administered by any other institution within Australia”.34 I accept that opinion.

86. As noted in the response provided by the OPWH to the Court on 13 June 2023, Queensland Health is responsible for the provision of public health services to prisoners in the custody of QCS. Access to subsidised medication is governed by the National Health Act 1953 (Cth). While the PBS is available to all Australian residents with Medicare eligibility, this does not extend to prisoners as they are prohibited from accessing subsidised medications via the PBS. This decision rests with the Australian government.

87. Notwithstanding, the evidence tendered demonstrated that MSHHS has adequate mechanisms in place to provide equitable access to appropriate medication to those patients who are Medicare ineligible or suffering financial hardship. The evidence tendered also demonstrated the ongoing efforts made by the OPHW to advocate for prisoner access to the MBS and PBS.

32 Exhibit A2 – Autopsy Report, 5.

33 Exhibit A2 – Autopsy Report, 5.

34 Exhibit E4 – Addendum Report of Dr Simon Durrant, 2.

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Findings required by s. 45

88. I am required to find, as far as possible, the medical cause of death, who the deceased person was and when, where and how he came to his death. After considering all of the evidence, including the material contained in the exhibits, I am able to make the following findings: Identity of the deceased – Trevor Charles Stone How he died – Mr Stone was a First Nations man who was serving a very lengthy prison sentence for serious sexual offences. He had a number of comorbidities.

In October 2019, he was formally diagnosed with Primary Non-small Cell Lung Cancer, Adenocarcinoma, Stage IVA. Mr Stone was referred to palliative care due to his severely poor prognosis.

Despite some positive responses to treatment, Mr Stone experienced a steady decline in health in the months preceding his death as a consequence of end-stage lung cancer.

In June 2021, investigations revealed that Mr Stone’s cancer had metastasized to his brain.

Given he had reached the ceiling of care, Mr Stone agreed to commence palliation. Mr Stone died from natural causes.

Place of death – Princess Alexandra Hospital

WOOLLOONGABBA QLD 4102 AUSTRALIA Date of death – 29 June 2021 Cause of death – 1(a). Metastatic lung adenocarcinoma Other significant conditions

2. Diabetes mellitus, hypertension, dyslipidaemia, ischaemic heart disease.

Comments and recommendations

89. Section 46 of the Act 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.

90. In the circumstances, I accept that there are no comments or recommendations to be made that would assist in preventing similar deaths in the future, or that otherwise relate to public health or safety or the administration of justice.

91. I extend my condolences to Mr Stone’s family and friends.

92. I close the inquest.

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Terry Ryan State Coroner

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