Coroner's Finding: MAYGER John Christopher

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 September 2013 and the 28th day of November 2014, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of John Christopher Mayger.

The said Court finds that John Christopher Mayger aged 58 years, late of Adelaide Pre Release Centre, Grand Junction Road, Northfield, South Australia died at Northfield, South Australia on the 8th day of November 2011 as a result of ischaemic and hypertensive heart disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death 1.1. John Christopher Mayger, aged 58 years, died suddenly on 8 November 2011. An autopsy was conducted by Dr John Gilbert, forensic pathologist from Forensic Science SA1. Mr Mayger was found to have cardiac enlargement due to biventricular hypertrophy. There was scarring and thinning of the posterior wall of the left ventricle, consistent with previous myocardial infarction. There was also critical narrowing of each of the three main coronary arteries, due to atheroma. Dr Gilbert gave the cause of death as ischaemic and hypertensive heart disease, and I so find.

2. Reason for Inquest 2.1. At the time of his death Mr Mayger was serving a custodial sentence of five years and eight months, with a non-parole period of three years and two months. He had been convicted of possession methylamphetamine for sale on 3 November 2008. As he had Exhibit C2a – Report of Dr Gilbert

been in custody since 30 September 2008, his sentence was deemed to have commenced at that time, making him eligible for parole on about 30 November 2011.

2.2. Between 30 September 2008 and his death in November 2011, Mr Mayger was accommodated in the Adelaide Remand Centre, the Port Lincoln Prison, Port Augusta Prison and the Adelaide Pre-release Centre. He was residing in the pre-release centre when he died.

2.3. Accordingly, Mr Mayger’s death was a death in custody within the meaning of the Coroners Act 2003 and this Inquest was required to be held by virtue of section 21(1)(a) of that Act.

3. Background and the events leading to Mr Mayger’s death 3.1. Upon his entry to prison Mr Mayger reported that he had suffered two previous heart attacks in about 1993 or 1994, and that he had had stents inserted as a result. That operation occurred in the Royal Adelaide Hospital in 1994 and was undertaken by Dr Leo Mahar, who Mr Mayger had contact with again shortly before his death.

3.2. Mr Mayger did not report ongoing cardiac symptoms and indicated that he was not taking medication regularly. He reported that he was a heavy smoker and had been for most of his life, smoking up to 40 cigarettes a day. Upon admission his blood pressure was good at 110/ . On 1 November 2008 Mr Mayger reported chest pains and a cardiograph was undertaken which did not reveal any new abnormalities. It was thought that the pain was non-cardiac related on this occasion, and he was told to undergo an exercise stress test if he experienced any further chest pains.

3.3. In August 2009 Mr Mayger underwent routine blood tests regarding his cholesterol, diabetes status and his kidney function. These were all unremarkable, apart from him having high triglycerides and low HDL, which is a lipid pattern often associated with cardiac disease. He was commenced on Crestor at this time for his cholesterol as it was high.

3.4. Mr Mayger had a history of cardiac problems, including his two attacks prior to admission to prison. Whilst in prison he had regular contact with the SA Prison Health Service, and he also had contact with a cardiologist, Dr Leo Mahar, at the Royal Adelaide Hospital.

3.5. Whilst in the Port Lincoln Prison on 21 May 2010 Mr Mayger reported more pain.

He was sent to the local hospital for assessment and treatment, however no cardiac cause was found. About a month later he was assessed by local physician, Dr Rufus McLeay. Mr Mayger described his pain as coming on after lifting some crates.

Dr McLeay performed an exercise test during which Mr Mayger did not experience angina, or develop ECG abnormalities.

3.6. Dr McLeay concluded at that time that significant coronary artery obstruction was unlikely, but he could not guarantee that Mr Mayger would not have a heart attack in the future. Mr Mayger's cholesterol profile, continued heavy smoking and a history of previous heart attacks were risk factors for him suffering further cardiac events.

3.7. Mr Mayger was commenced on aspirin as a blood thinner and Coversyl for high blood pressure and ischaemic heart disease. He was also on medication for indigestion. In August 2011 Mr Mayger reported calf pains. Dr Nawana at the pre-release centre suspected peripheral arterial disease and requested an arterial ultrasound scan at the Royal Adelaide Hospital.

3.8. At the time of his death Mr Mayger had not attended for that scan. Dr Gilbert, in his post mortem report2, makes no mention of any arterial disease in the legs, and as such it is not necessarily a contributing factor to his death.

3.9. On 14 October 2011 Mr Mayger was referred to Dr Mahar at the Royal Adelaide Hospital after being booked in to the Emergency Department. He had experienced some palpitations, that is thumping of the heart and chest; he did not complain of any pain in the chest. He did report the claudication, a condition in which cramping pain in the leg is induced by exercise, and typically caused by obstruction to the arteries of his leg.

3.10. Upon examination Dr Mahar found that Mr Mayger was overweight, his venous pressure was normal, heart sounds were normal, he had a clear chest, poor pulses below the left femoral; the pulses on the right however were satisfactory. He did have some fairly frequent mis-beats while Dr Mahar was examining him, and he thought he might have had multiple ectopics, a form of cardiac arrhythmia.

3.11. Dr Mahar organised a dobutamine sestamibi scan as Mr Mayger was not able to walk on the treadmill at this time. This scan is a special test using nuclear meds to see if Exhibit C2a

there are any blocked coronary arteries. Depending on the results further angiography, or indeed angioplasty, might have been required. An appointment with a vascular surgeon was also made regarding his leg, and he was to wear a halter monitor on his chest to investigate the palpitations. Mr Mayger’s death occurred shortly after this appointment and further investigations were never completed.

3.12. On the day of his death, and leading up to his death, Mr Mayger is reported to have been his usual self. His son, Adam Mayger who was also in gaol and sharing a cottage with him at the pre-release centre, said he thought his father was a ‘bit stressed out that morning’, as Adam was being paroled that day. Mr Mayger had applied for parole himself at this stage and was awaiting a response to his application.

Otherwise, the other inmates who shared the unit with Mr Mayger considered him to be his usual self, and to be well.

3.13. At about 2:30pm on 8 November 2011, Mr Mayger was found collapsed in the shower of his unit at the pre-release centre. Despite resuscitative efforts life was declared extinct at 3:10pm. Nobody else had been present in the unit at the time of his collapse; he was found by another of his roommates attending back at the unit.

4. Recommendations 4.1. There were no issues surrounding Mr Mayger’s medical care or treatment and it is not necessary for me to make any recommendations 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 28th day of November, 2014.

State Coroner Inquest Number 28/2013 (1807/2011)