Coroner's Finding: GROOTVELD Gerard

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 29th day of July 2008 and the 3rd day of June 2009, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Gerard Grootveld.

The said Court finds that Gerard Grootveld aged 75 years, late of Yatala Labour Prison, Peter Brown Drive, Northfield, South Australia died at Mary Potter Hospice, 89 Strangways Terrace, North Adelaide, South Australia on the 21st day of December 2006 as a result of disseminated carcinoma of the prostate gland. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Mr Gerard Grootveld was born in Holland on 20 March 1931. He was 75 years of age at the time of his death on 21 December 2006. He was a prisoner at the time of his death.

1.2. Mr Grootveld had suffered from cancer of the prostate since 1998. In November 2006 it was discovered that Mr Grootveld’s prostate cancer had metastasised, for the most part into various parts of his skeleton. His death at the Mary Potter Hospice at the Calvary Hospital in December 2006 was as a result of the prostate cancer that had spread. Dr John Gilbert, a Senior Specialist Forensic Pathologist with Forensic Science South Australia, has examined the medical records of the deceased and in a pathological review dated 21 December 2006 expresses his opinion that the cause of Mr Grootveld’s death was disseminated carcinoma of the prostate gland. I find that to be the cause of Mr Grootveld’s death.

1.3. On 28 July 2006 Mr Grootveld, who was 75 years of age and had no relevant prior convictions, was sentenced in the District Court of South Australia to a term of imprisonment of 2½ years with a non-parole period of 12 months for two counts of producing cannabis involving 18 growing plants and one count of possessing cannabis for sale involving about 4 kilograms of female head. The Court refused to suspend the sentence. At the time of Mr Grootveld’s sentencing the District Court was aware that he suffered from prostate cancer and, as well, rheumatic fever, diabetes, high blood pressure and hip and shoulder ailments. He had difficulty walking due to a degenerative problem with his lower back and he had pins in his spine to stabilise it.

He required further surgery as a result of a recent fall and he was on medication for pain relief. It is said in the sentencing Judge’s remarks that, according to Mr Grootveld’s general practitioner, Mr Grootveld had, as a result of his prostate cancer, a life expectancy of 5 years, an assertion that was explicitly taken into account by the Court and which makes one contemplate what the life expectancy might be in a 75 year old man with Mr Grootveld’s myriad aliments save and except prostate cancer.

If the expectation that Mr Grootveld would live another 5 years had been realised, Mr Grootveld would not have died in custody. As it transpired he was dead by the end of the year.

1.4. Following Mr Grootveld’s sentencing he was admitted to the Yatala Labour Prison.

On 28 August 2006 Mr Grootveld was transferred to the Mobilong Prison where, due to his age and medical concerns, another prisoner was employed as his carer. It is apparent that Mr Grootveld’s health rapidly began to deteriorate after he had been taken into custody if not before. At one point in time the question of Mr Grootveld possibly being released on home detention was discussed but he was said not to be eligible for home detention until he had served half of his non-parole period, meaning that his earliest possible home detention release date would not occur until 28 January 2007 by which time he had died.

1.5. Mr Grootveld was returned to the Yatala Labour Prison on 4 October 2006 for medical reasons. He was confined to the prison infirmary with regular admittance to the Royal Adelaide Hospital (RAH) requiring ongoing treatment. Mr Grootveld’s prostate cancer metastases were identified in November 2006 by one of the medical officers of the South Australian Prison Health Service, but he had declined significantly even before then. This condition was assessed to be terminal. In the

event, Mr Grootveld was admitted to the RAH and he remained there until he was transferred to the Mary Potter Hospice on 19 December 2006. He died at the Hospice two days later on 21 December 2006.

1.6. At the RAH Mr Grootveld was subject to observations performed by Global Solutions Limited on behalf of the Department for Correctional Services. On 8 December 2006 an authority for unaccompanied leave was delegated by the Chief Executive of the Department for Correctional Services authorising Mr Grootveld, in effect, to remain at the RAH but on an unaccompanied leave basis.

1.7. On 19 December 2006 a further authority for unaccompanied leave enabled Mr Grootveld to be transferred and to be hospitalised within the Mary Potter Hospice.

1.8. The unaccompanied leave both at the RAH and the Mary Potter Hospice was predicated on the understanding that Mr Grootveld would remain within those institutions for the purpose of hospitalisation. I did not understand these leave periods to interrupt the serving of his sentence in any way. In my opinion, Mr Grootveld remained in custody as contemplated in the Coroners Act 2003 and on 21 December 2006 he died in that custody. Accordingly, an Inquest into his death was mandatory.

2. Medical treatment during Mr Grootveld’s incarceration 2.1. Much of Mr Grootveld’s medical treatment whilst in custody is described in the statements verified by affidavit of Dr Mary Brooksbank1. Dr Brooksbank is a palliative medicine specialist. She has been the Director of the Palliative Care Unit at the Ashford Hospital and Medical Director of the Mary Potter Hospice at the Calvary Hospital since 1995. She has reviewed the medical records of Mr Grootveld at the request of the police. She was aware of Mr Grootveld’s presence within the RAH from October 2006.

2.2. Dr Brooksbank describes Mr Grootveld’s rapid deterioration that for the most part became evident following his incarceration in July 2006. However, Dr Brooksbank questions the accuracy of the observation made by the sentencing Judge that, at the time of sentencing, Mr Grootveld had a life expectancy of 5 years, given what Dr Brooksbank understood to have been evidence of an already existing decline by that time. She suggests that it was not apparent as to how unwell Mr Grootveld really was 1 Exhibits C4a and C4b

at the time of sentencing. I do not know whether Mr Grootveld ever considered appealing against his sentence to the Court of Criminal Appeal.

2.3. Dr Brooksbank describes the administration of a whole body bone scan in early November 2006 that resulted in the detection of bone metastases which is a very commonplace complication of prostate cancer. The bone metastases in themselves would have been enough to explain Mr Grootveld’s ongoing deterioration. Mr Grootveld also suffered from bleeding from the bowel and his bladder. Mr Grootveld’s general deterioration and the extent of that deterioration whilst in custody was not uncommon in Dr Brooksbank’s opinion. It was consistent with the type of illness he was suffering. She points out that prostate cancer can be a very aggressive disease with a relatively short course, a fact that she suggests is not completely understood in the community.

2.4. Dr Brooksbank specifically expresses the view that the medical practitioners at the Yatala Labour Prison had handled Mr Grootveld’s ongoing medical concerns very well and that they conducted the appropriate investigations into his symptoms.

However, the evidence before me demonstrates that it became apparent that the Yatala Labour Prison infirmary was simply unable to deal with Mr Grootveld’s deterioration. To that end, Mr Grootveld’s hospitalisation at the RAH and the leave of absence to which I have already referred was suggested and granted.

2.5. On 5 December 2006 Mr Grootveld’s condition had deteriorated to the extent that active treatment at the RAH, other than palliative treatment, was withdrawn at the request of members of Mr Grootveld’s family. On 8 December 2006 the unaccompanied leave was granted for the ongoing RAH treatment and admission.

However, it is apparent that on 15 December 2006 Mr Grootveld underwent a cystoscopy and fulguration of the prostate gland in an attempt to stem bleeding from his bladder caused by invasion by the cancer. I understood that this was a palliative measure. He also had palliative radiotherapy treatment on 18 December 2006, the day before he was transferred to the Mary Potter Hospice. Other palliative measures including analgesia were administered.

2.6. Mr Grootveld died at the Mary Potter Hospice in the early hours of the morning of 21 December 2006.

2.7. Dr Gilbert, the Forensic Pathologist, has expressed the universally shared opinion that the deceased was treated appropriately for his medical problems both at the RAH and the Mary Potter Hospice. Furthermore, Mr Grootveld’s custodial circumstances during his admissions to those facilities did not have any bearing on the withdrawal of active treatment. In other words, there is no evidence to suggest that within those facilities Mr Grootveld was treated any differently from any other member of the community.

2.8. The evidence is also clear in my view that there can be no suggestion other than that Mr Grootveld’s treatment during his custodial circumstances in the prison environment itself was anything other than satisfactory and appropriate. Certainly this is the view of Dr Brooksbank as I have mentioned.

3. Recommendations 3.1. I make no recommendations to make in this matter.

Key Words: Death in Custody; Cancer In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 3rd day of June, 2009.

Deputy State Coroner Inquest Number 22/2008 (1887/2006)