Coroner's Finding: HARKIN Leonard Norman

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 4th day of October 2006, and the 16th day of November 2006, by the Coroner’s Court of the said State, constituted of Elizabeth Ann Sheppard, Coroner for the said State, into the death of Leonard Norman Harkin.

The said Court finds that Leonard Norman Harkin aged 51 years, late of Mobilong Prison, Maurice Road, Murray Bridge died at Mobilong Prison, Murray Bridge, South Australia on the 20th day of June 2003 as a result of ischaemic heart disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. At the time of Mr Harkin’s death, he was serving a sentence of imprisonment in Mobilong Prison at Murray Bridge. Mr Harkin was due to be considered for release on parole in September 20081.

1.2. Mr Harkin was originally taken into custody at the City Watch House and charged with murder on 24 September 2001. The following day Mr Harkin was brought into the Adelaide Remand Centre and after spending some time at James Nash House, he was incarcerated in Yatala Labour Prison. On 14 March 2003 Mr Harkin pleaded guilty to manslaughter and was sentenced by Justice Duggan to 12 years imprisonment with a non-parole period of 7 years. He was transferred to Mobilong Prison on 26 May 2003.

1.3. Because at the time of his death Mr Harkin was incarcerated in Mobilong Prison, his death is regarded as a “death in custody” within the meaning of the provisions of the 1 Exhibit C5a

Coroner’s Act 2003 and therefore an Inquest is mandatory pursuant to Section 21(1)(a) of that Act.

2. Events of 20 June 2003 2.1. At approximately 10:30am on 20 June 2003 Mr Harkin together with fellow prisoner Stanley Wells were being transferred from Sturt Unit to Light Unit within Mobilong Prison. They transported their personal property in a trolley which the two men pushed along an external pathway between the units. The trolley was relatively full and included a television set.

2.2. According to prisoner Wells, the trolley that he and Mr Harkin were pushing had a defective wheel which made it hard to push along. Mr Wells claimed that it was tiring and they had to stop about three times to rest. When they arrived at Light Unit, Mr Wells claimed that Mr Harkin complained about having chest pain2.

2.3. Prisoner Heenan was Mr Harkin’s new cellmate in Light Unit. He noticed that between 10:00 and 10:30am Mr Harkin looked pale and unwell. He heard Mr Harkin say that he was “fucked” from pushing the trolley. Mr Heenan offered to give up the bottom bunk for Mr Harkin so that he did not have to use extra effort to climb up to the top bunk3.

2.4. At about 11:30am Mr Harkin approached prison officers John Gaston and Andrew Ridington in the Unit office and complained of pains in his chest. Mr Harkin had made previous complaints of chest pain, which had been investigated by medical practitioners whilst he had been incarcerated. The medical investigations did not reveal any evidence of heart disease but Mr Harkin was provided with nitrolingual spray to relieve his symptoms. Mr Harkin reported to the officers that he had tried to use his spray but that it had no affect.

2.5. Officer Ridington telephoned the medical centre and spoke with Registered Nurse Margaret Long who was the only nurse on duty. He reported to her what Mr Harkin had told him about his symptoms. He was advised by Nurse Long to send Mr Harkin to the medical centre4. Officer Ridington directed Mr Harkin to walk to the medical centre. Officer Ridington claimed that at the time he left him, Mr Harkin appeared to 2 Exhibit C26af 3 Exhibit C26ae 4 Exhibit C8a

look normal and was not pale or distressed. The distance between Mr Harkin’s new cell and the unit office was 31.15 metres. When he was directed to go to the medical centre Mr Harkin had to go outside the unit and walk an additional 164.2 metres, part of which was slightly uphill.

2.6. Within approximately two minutes of that telephone conversation, Mr Harkin walked into the medical centre and was assisted onto the examination couch by Nurse Long.

Mr Harkin was given one puff of nitrolingual spray under his tongue and then his blood pressure and pulse rate were taken, giving a blood pressure reading of 90/75 and a pulse rate of 92. Nurse Long took into account his low blood pressure and increased pulse rate and noticed that Mr Harkin appeared to be pale and sweaty. In combination these signs suggested to her that something was wrong. Nurse Long considered that she should contact the local medical practitioner in Murray Bridge but as things turned out she did not have time to do that.

2.7. Within about 10 minutes following Mr Harkin’s arrival at the medical centre, Nurse Long noticed that he appeared to lose consciousness. His pulse could not be felt and he stopped breathing. Nurse Long activated the duress alarm to get urgent assistance and commenced cardiopulmonary resuscitation (CPR). She also called for an ambulance. Other officers quickly joined her and assisted with CPR. A second nurse was called back to duty and arrived within minutes, also providing her assistance5.

2.8. At 11:55am two ambulances arrived at Mobilong Prison with paramedics who quickly entered the medical centre and took over the CPR6. Ambulance Officer John Pohl managed with some difficulty to insert an intravenous line and he administered three separate doses of adrenalin in an attempt to revive Mr Harkin, unfortunately without success. An attempt at defibrillation also failed to revive Mr Harkin. The attempts at CPR continued for a period of some 30 minutes with telephone advice from Dr Peter Seals from Bridge Clinic in Murray Bridge. After consultation between ambulances officers and Dr Seals, a decision was taken to cease resuscitation attempts at 12:25pm7.

5 Exhibit C10a 6 Exhibit C18a and Exhibit C19a 7 Exhibit C19a and Exhibit C20a

2.9. Dr Seals attended the prison and certified life extinct at 1:30pm.8.

3. Post mortem examination A post mortem examination was conducted on 23 June 2003 by Professor Roger William Byard, Forensic Pathologist of Forensic Science SA. During his examination Professor Byard observed marked coronary artery atherosclerosis and he concluded that the cause of death was ischaemic heart disease. Professor Byard explained that the atherosclerosis was marked in two of the three major epicardial coronary arteries.

Professor Byard’s observations and opinions are set out in a report, the contents of which I accept and find that Mr Harkin died as a result of ischaemic heart disease9.

4. Toxicology Analysis of a sample of Mr Harkin’s blood after his death revealed the presence of substances consistent with the administration of prescribed antidepressant and antipsychotic medication10. There is no suggestion that these medications played any role in Mr Harkin’s death.

5. Previous investigations for chest pain 5.1. During the twenty-one month period of Mr Harkin’s incarceration, he presented on several occasions complaining of chest pain. In October 2001 he was admitted to the Royal Adelaide Hospital and remained there for three days whilst he was investigated for possible cardiac disease. Preliminary tests conducted failed to reveal any significant “cardiac ischaemia” but further investigations were recommended because of Mr Harkin’s significant risk factors including his high cholesterol level and the fact that he continued to smoke cigarettes. An exercise stress test was conducted on 14 November 2001 giving a negative result which suggested that ischaemic heart disease was unlikely.

5.2. Attempts were made to address Mr Harkin’s risk factors including encouragement to stop smoking. Unfortunately, nicotine replacement therapies were regarded as inappropriate for Mr Harkin because other medication being taken for depression meant that his nicotine replacement therapy would be contraindicated. He was 8 Exhibit C2a 9 Exhibit C3a 10 Exhibit C4a

provided with the GTN spray to relieve symptoms of chest pain, the last prescription for which was provided on 15 August 2002. He was permitted to carry this spray with him at all times. There were no further episodes of chest pain reported to medical practitioners by Mr Harkin until the day of his death on 20 June 200311.

6. Overview of the management of Mr Harkin by Dr Edward Morgan 6.1. Dr Morgan is a medical practitioner employed full-time by the Corrections Department in Victoria. He has worked in prison health care systems for six years.

He is also a forensic physician who works part-time for the Victorian Institute of Forensic Medicine.

6.2. Dr Morgan was requested to examine statements obtained following an investigation into Mr Harkin’s death as well as the relevant medical notes concerning Mr Harkin’s previous investigations at the Royal Adelaide Hospital and to provide his opinion as to the appropriateness of the management of Mr Harkin, in particular by Nurse Long in the medical centre and Corrections officers who were involved in managing Mr Harkin’s complaint of chest pain on the morning of his death. Dr Morgan was also asked to examine the appropriateness of the resuscitation attempts and any other related matters that may have affected Mr Harkin’s outcome. Dr Morgan provided a comprehensive report setting out a summary of the relevant facts and expressing his opinion on the issues as requested. I refer to these opinions shortly.

6.3. At the time of Mr Harkin’s death, the records indicate that he was taking several medications including: ‘Avanza 60mg Pericyazine 5-10mg Omeprazole 20mg Simvastatin 40mg Olanzapine 5mg Sodium Valproate 500mg – am 100mg – pm’12

6.4. According to entries made by nurses and medical practitioners in Mr Harkin’s prison medical notes, it is apparent that Mr Harkin did have chest pain after he was investigated at the Royal Adelaide Hospital but that the pain resolved with the use of the GTN spray. During the bulk of his consultations for other health issues, with 11 Exhibit C6a 12 Exhibit C10a

medical practitioners including a general practitioner and a psychiatrist, Mr Harkin made no mention of chest pain nor his use of the GTN spray for his symptoms.

Typical entries in Mr Harkin’s prison health file by nurses relate to episodes of chest pain which was relieved by the GTN spray. Notes of this nature were recorded on 15 December 2001, 10 and 12 January 2002. There are also entries concerning complaints of dyspepsia which did not respond to nitrolingual spray and for which Dr Karpinski prescribed Losec.

6.5. On 3 May 2002 Mr Harkin is noted to have complained to a nurse of chest pain but that by the time he was examined in the infirmary he claimed that the chest pain had gone and he refused any further intervention. On 28 May 2002, a nursing note records another complaint, this time of mid-sternal chest pain, worse on movement, which according to Dr Karpinski did not appear to be cardiac in nature. Mr Harkin was given analgesia for the pain.

6.6. Throughout Mr Harkin’s incarceration he was reviewed periodically by a psychiatrist for depression. The records suggest that there were no complaints of chest pain on these occasions. On 22 April 2003 Mr Harkin was assessed by nursing and medical staff for a suspected fever. Investigations conducted included a chest x-ray which proved to be normal. When Mr Harkin was transferred to Mobilong Prison he was assessed by a nurse on arrival and made no complaint of chest pain.

6.7. Appropriateness of Correctional Services staff in referring Mr Harkin to the infirmary Dr Morgan considered the question as to whether or not Mr Harkin, having complained of chest pain, ought to have been advised to walk to the medical centre rather than have the nurse come to Mr Harkin. Dr Morgan expressed his opinion concerning this issue as follows: ‘While a complaint of chest pain should be recognised by any person to be potentially serious, I believe it was appropriate for the correctional officers to seek the advice of the nurse on duty. Mr Harkin at this point was conscious, alert and appeared well. The correctional staff then acted upon the instructions given to them by the more appropriately qualified nurse. They followed the advice of the nurse and allow him to travel independently to the infirmary, travel that took 2 minutes, over a relatively short distance. Given Mr Harkin was conscious, alert and capable of mobilizing independently it would seem reasonable for custodial staff for him to walk to the infirmary. From the descriptions of Mr Harkins presentation I do not believe correctional staff or indeed the nurse on duty could have appreciated the seriousness of his

complaint at the time he presented to them. His failure to inform staff of the duration of his symptoms may have falsely reassured them that the pain had only recently begun. I do not feel that Mr Harkin's presentation would have constituted a medical emergency at this point in time, and therefore the failure to call a 'code black' was understandable. The decision of the nurse to have him present to the medical centre rather than her going to the scene can be understood given she was the only nurse on duty. Leaving the medical centre would have meant leaving the comfort of a controlled and equipped environment where she had access to equipment and drugs that would be useful in assessment and treatment. She was obviously faced with a difficult decision in this regard, however given Mr Harkin's presentation, hers was a reasonable recommendation. I doubt it ultimately made any difference to the outcome; in fact Mr Harkin's chances of resuscitation were probably improved by him getting to the medical centre as soon as possible, something that may have been delayed by the nurse travelling to him.’13

6.8. Adequacy of treatment Mr Harkin received in the infirmary Dr Morgan essentially had no criticism of Registered Nurse Long with the manner in which she managed Mr Harkin given the fact that she was initially without any support. Dr Morgan set out his opinion on this issue as follows: ‘When Mr Harkin entered the medical centre the seriousness of his condition would be unclear. For example low blood pressure and rapid heart rate is a side effect of Nitrolingual spray which both Mr Harkin and then the nurse had administered. It would also be unclear at this point whether the patient would improve with the initial treatment instituted. The nurse's priority was on assessment and attending to Mr Harkin's immediate medical needs. It appears Ms Long had failed to administer oxygen or give aspirin which would be part of the immediate therapy, though I do not believe this would have significantly altered the outcome. She also appeared to fail to take an adequate history which might have alerted her to the duration of his symptoms and the effectiveness of treatment already administered by Mr Harkin. It is only conjecture however that knowing the pain had been present for over an hour might have prompted her to summon assistance earlier. Again the complexity of working on her own in a primary care setting should not be underestimated and clearly she faced a situation that deteriorates suddenly under very difficult circumstances.’14

6.9. Dr Morgan acknowledged that Nurse Long appeared to recognise the seriousness of Mr Harkin’s rapid deterioration and that her immediate attempt to seek ambulance and other support was appropriate in the circumstance. In Dr Morgan’s view Nurse Long acted promptly and in a professional manner. I accept Dr Morgan’s assessment of the situation and find that Nurse Long acted appropriately in difficult circumstances.

13 Exhibit C6a, pages 4-5 14 Exhibit C6a, page 5

6.10. Dr Morgan also commended the prompt attendance and assistance provided by Correctional Services staff and made particular note of the assistance provided by Officer Darren Stock, a former enrolled nurse who drew upon previous nursing experience to provide active assistance in CPR. An examination of the records revealed to Dr Morgan that ambulance staff identified that Mr Harkin had gone into ventricular fibrillation which in Dr Morgan’s opinion is an extremely lethal arrhythmia which failed to revert with the administration of adrenalin and also electrical defibrillation15.

6.11. In Dr Morgan’s opinion the actions of ambulance staff and the decision taken in consultation with Dr Peter Seals to cease resuscitation attempts was “entirely appropriate”. I find that the actions taken by Correctional service officers and ambulance officers in an attempt to revive Mr Harkin were commendable.

6.12. Could any further action have been taken which might have prevented Mr Harkin’s death during his period of incarceration?

Having reviewed the investigations and responses which occurred as a result of Mr Harkin’s previous complaints of chest pain, Dr Morgan formed the following view: ‘I believe that all reasonable steps were taken throughout Mr Harkins incarceration to manage and investigate the cause of his chest pain. The test conducted while not absolutely sensitive for detecting ischemic heart disease would have indicated to medical staff that Mr Harkin was unlikely to be experiencing unstable angina and a low risk of an acute ischemic event. Even when admitted to hospital for several days with an episode very similar to that preceding his death, no demonstrable impairment or damage to his heart could be found. Only a more invasive test such as a coronary angiogram could have detected the level of disease found at autopsy. The risk of performing such a test would be significant and such an invasive investigation would only have been indicated had the stress test been positive or his symptoms progressed. In fact it appears that the frequency of his chest pain appeared to decrease toward the end of his life and what pain he did have would resolve quickly with simple treatment, possibly suggesting it was of a non sinister nature. I also feel there is uncertainty over whether many of the episodes of chest pain were in fact of an ischemic nature. It is highly possible that another cause such as gastroesophageal spasm (which can also be relieved by GTN spray) may have been the cause of the pain he described earlier in his sentence.

I believe the event that resulted in his death was unpredictable and no amount of investigation at a local level would have predicted or prevented it.’16 15 Exhibit C6a, page 6 16 Exhibit C6a, page7

6.13. Should more have been done to assist Mr Harkin to cease cigarette smoking?

Dr Morgan acknowledges the challenges by both prisoners and staff in successfully ceasing cigarette smoking within the prison environment. Dr Morgan considered that the relapse rates are very high and many anti-smoking aids including gums and patches are banned for security reasons.

6.14. Dr Morgan noted that Mr Harkin had been referred to counselling to assist him to give up smoking. In his opinion the inability to cease smoking during the period of Mr Harkin’s incarceration would not have had any significant influence on the ultimate outcome.

6.15. Cholesterol lowering treatment In Dr Morgan’s opinion Mr Harkin’s anti-cholesterol medication appeared to have the desired effect in reducing his cholesterol to within normal limits as measured by results of a blood test recorded on 23 April 2003. Dr Morgan also noted that Mr Harkin was provided with low fat meals in an effort to minimise his cholesterol and to assist him in weight reduction. He noted that Mr Harkin was also screened for diabetes mellitus and his blood pressure monitored several times throughout the period of his incarceration. Overall, these measures taken, in Dr Morgan’s view indicate that the Prison Health Service took “appropriate steps to recognise and address Mr Harkin’s other risk factors for coronary heart disease”.

6.16. I accept the opinions expressed by Dr Morgan in his comprehensive review of the management of Mr Harkin and find that the Prison Health Service and the Correctional Service officers managed Mr Harkin’s chronic health issues appropriately.

7. Action taken by the Department for Correctional Services as a result of events concerned in Mr Harkin’s death

7.1. Darrell Smedley, Manager of Intelligence and Investigations Unit of the Department for Correctional Services, conducted an investigation into the circumstances surrounding Mr Harkin’s death. During his investigation, he examined the processes which were followed concerning the identification of Mr Harkin’s chest pain during his period of incarceration as well as those followed when he presented to the Correctional Services officers on 20 June 2003. Mr Smedley also reviewed whether

there had been adequate adherence to established procedures and whether those procedures required any alteration.

7.2. Apart from one issue examined, I do not intend to dwell upon the recommendations following these inquiries, because in my view, they have no causal relevance to Mr Harkin’s death.

7.3. One issue examined which is relevant, is the question of maintenance of laundry trolleys used by prisoners for moving personal possessions and possibly other items from time to time. It seems likely that the extra effort exerted by Mr Harkin in pushing the trolley with a defective wheel may have acted as a trigger for the cardiac event which led to his death. Although logically, I accept that it may have come on with any number of other activities and possibly even if the trolley wheel had not been defective. I note that Mr Smedley has recommended that a schedule for regular maintenance of laundry trolleys be developed.

7.4. I was pleased to receive a response to Mr Smedley’s recommendation from Mr Peter Severin, Chief Executive Officer of the Department for Correctional Services in which he states that the recommendations made by Mr Smedley for maintenance of laundry trolleys and further improvement in procedures have been implemented17.

7.5. During the course of the police investigation into Mr Harkin’s death, Detective Sergeant Andrew Bissell measured the total distance that Mr Harkin would have walked when proceeding from Sturt Unit to Light Unit and then onto the medical centre. The total distance walked was said to be 723.45 metres. A video recording was made to reconstruct this journey and to illustrate the uphill portions travelled along the way18.

7.6. Having reviewed the video footage of the slightly uphill track between Light Unit and the medical centre, one can see in hindsight, that even walking this additional 163 or so metres when Mr Harkin was suffering chest pain, may have placed extra demands upon his heart. There is no evidence which would enable me to find that if a wheelchair had been used to transport Mr Harkin to the medical centre, his death could have been avoided. Nevertheless, I consider that it would be prudent for the Department for Correctional Services to ensure that a wheelchair is available for use 17 Letter dated 25 September 2006 to Ms E Sheppard 18 Exhibit C7a, Exhibit C26a, Exhibit C26s

in all Correctional institutions to transport prisoners who complain of chest pain and are required to be assessed in the infirmary.

8. Recommendation 8.1. In accordance with the provisions of Section 25(2) of the Coroner’s Act 2003, the following recommendation is made in anticipation that it might prevent or reduce the likelihood of or recurrence of an event, similar to the event, the subject of this Inquest.

8.2. That the Department for Correctional Services take the necessary steps to ensure that a wheelchair is available for use at each Correctional Institution to transport prisoners to the infirmary in appropriate circumstances and that suitable guidance is provided to Correctional Service officers concerning when wheelchairs are to be used.

Key Words: Correctional Services; Death in custody; Heart disease; Ischaemic heart disease; Prison Medical Service.

In witness whereof the said Coroner has hereunto set and subscribed her hand and Seal the 16th day of November, 2006.

Coroner Inquest Number 34/2006 (1625/03)