Coroner's Finding: VAN GELDER Herman

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 9th day of March 2010 and the 7th day of December 2011, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Herman Van Gelder.

The said Court finds that Herman Van Gelder aged 40 years, late of the Adelaide Remand Centre, 208 Currie Street, Adelaide, South Australia died at the Royal Adelaide Hospital, North Terrace, South Australia on the 5th day of September 2008 as a result of large bowel obstruction complicating disseminated carcinoma of rectum. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Mr Herman Van Gelder was 40 years of age when he died in custody of natural causes on 5 September 2008 at the Royal Adelaide Hospital (RAH). At the time of his death Mr Van Gelder was serving a prison sentence of 13 years and 10 months with a non-parole period of 9 years, having been convicted of multiple counts of rape in relation to his partner’s 12 year-old daughter. Mr Van Gelder had been sentenced on 26 August 2002 when he was aged 34 years. His death was a death in custody within the meaning of section 21(1)(a) of the Coroners Act 2003 and this Inquest was held as required by that section.

2. Cause of death 2.1. A pathology review was undertaken by Dr John Gilbert of Forensic Science South Australia. His report, dated 8 September 20081, cites the cause of death as ‘large bowel obstruction complicating disseminated carcinoma of rectum’. I find that to 1 Exhibit C4a

have been the cause of Mr Van Gelder’s death. Dr Gilbert further stated that the death was natural and appeared to be unrelated to Mr Van Gelder’s custody. I find that also to have been the case.

3. Events leading to Mr Van Gelder’s death 3.1. At the commencement of his incarceration, Mr Van Gelder was not showing any symptoms of illness. The following sets out a timeline of the development of his illness.

November 2003 Mr Van Gelder noticed bleeding from the bowel (single episode) Another episode of bleeding from the bowel May 2004 Referral to surgeon Colonoscopy performed 28 September 2004 (polyp - probable malignant change, inconclusive) 5 October 2004 Colonoscopy performed Mr Van Gelder underwent bowel resection Diagnosed with adeno carcinoma (no evidence of metastatic disease at 23 December 2004 this time, referral for adjuvant therapy) Radiotherapy utilised as chemotherapy not possible as infections occurring from surgery Routine checks carried out Routine checkup (including a scan of his chest) undertaken and August 2006 metastases revealed September 2006 Scan undertaken and nodules revealed Scan undertaken and nodules shown to have increased in size February 2007 Chemotherapy commenced for lung cancer Five cycles of first and second line chemotherapy instituted at the 2007

RAH Evidence of recurrent cancer in pelvis detected February 2008 Chemotherapy ceased and symptom control only initiated Symptomatic care undertaken in ARC

4. Admission to the Royal Adelaide Hospital and events leading to death 4.1. Mr Van Gelder was admitted to the RAH on 30 March 2008 with testicular swelling and pain, abdominal pain, nausea and vomiting. He was thought clinically to have a strangulated right inguinal hernia, but an emergency laparotomy showed a necrotising fasciitis involving the perineum and anterior abdominal wall. The abdomen was left open post-operatively and he was transferred to the Intensive Care Unit where further debridement was performed. Mr Van Gelder was discharged from the Intensive Care Unit on 3 April 2008 with a plan for comfort and system based care. He had further debridements (including left orchidectomy) later that month and wound closure with

skin grafting was attempted on 2 May 2008. On 16 May 2008 Mr Van Gelder was transferred to palliative care.

4.2. On 8 July 2008, due to the malignant large bowel obstruction, a caecostomy tube was inserted under CT guidance. The CT showed progression of the pelvic disease and further lung and liver metastases. At that stage Mr Van Gelder had decided against further surgery to relieve the bowel obstruction. A continual but gradual deterioration occurred with weight loss, diminished energy and increasing analgesia requirements.

4.3. On 4 September 2008 Mr Van Gelder was noted to be in poor condition with signs of bowel obstruction, poorly controlled pain and an increase in size of the pelvic tumour mass. He was considered to be in the terminal phase of his illness. His analgesics were adjusted upwards at this time and sedatives and tranquilising agents were ordered on an ‘as required’ basis. Mr Van Gelder’s family were notified of his poor prognosis and he subsequently died at 5:50pm on 5 September 2008.

5. Conclusions 5.1. Mr Van Gelder’s death was investigated by Detective Brevet Sergeant Gregory Barton of the Police Corrections Section. I agree with Detective Barton’s conclusion that Mr Van Gelder’s treatment and care were managed appropriately. It is clear that Mr Van Gelder died from a natural disease that ran its course. Mr Van Gelder’s death was not in any sense preventable. There is no suggestion that Mr Van Gelder’s illness was affected by his custodial sentence.

6. Recommendations 6.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 7th day of December, 2011.

Deputy State Coroner Inquest Number 5/2010 (1265/2008)