Coroner's Finding: Johnson Peter Andrew

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 13th day of July 2011 and the 14th day of November 2012, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Peter Andrew Johnson.

The said Court finds that Peter Andrew Johnson aged 61 years, late of 5/0 Church Street, Highgate, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 14th day of September 2009 as a result of paraneoplastic syndrome caused by metastatic adenocarcinoma of the lung. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Peter Andrew Johnson died on 14 September 2009. He was aged 61 years. His medical notes were reviewed by Dr Iain McIntyre of Forensic Science South Australia and forensic pathologist, Dr Langlois1. They gave the cause of death as paraneoplastic syndrome caused by metastatic adenocarcinoma of the lung, and I so find.

2. Reason for Inquest 2.1. At the time of his death Mr Johnson was subject to a 21-day mental health detention order and, accordingly, his was a death in custody within the meaning of the Coroner’s Act 2003 and this Inquest was held as required by section 21(1)(a) of that Act.

1 Exhibit C2a

2.2. The detention order was made because of Mr Johnson’s deteriorating mental state which in turn was caused by his advanced cancer.

2.3. Mr Johnson’s medical history and admission to hospital 2.4. Mr Johnson was diagnosed with lung cancer in March 2007. He underwent a right upper lobectomy in April 2007 to remove the affected lung. In September 2007 he began suffering from seizures and investigations detected three brain tumours.

Despite removal of those tumours they reappeared, requiring two further rounds of surgery. Unfortunately Mr Johnson’s condition became terminal and he declined over a period of some 18 months. Mr Johnson’s final admission to hospital was to the Flinders Medical Centre to which he was transferred from Ashford Hospital where the detention orders had been put in place. His physical health deteriorated and, as expected, he died as a result of the metastasising cancers on 14 September 2009.

3. Conclusion 3.1. It is clear that Mr Johnson received appropriate medical care at all times during his detention and 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 14th day of November, 2012.

State Coroner Inquest Number 25/2011 (1442/2009)