Coroner's Finding: SPIERO Marcel Edward

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 26th day of March 2014, the 13th day of May 2014 and the 17th day of July 2015, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Marcel Edward Spiero.

The said Court finds that Marcel Edward Spiero aged 53 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 22nd day of November 2011 as a result of infected ascites (E-coli) in a man with cirrhosis of the liver, hepatocellular carcinoma and diffuse B-cell lymphoma. The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Marcel Edward Spiero died at the Royal Adelaide Hospital (the RAH) on 22 November 2011. He was 53 years of age. Mr Spiero died of natural causes. On 14 November 2011 he had been admitted to the RAH in septic shock with acute abdominal pain. Ascites was found in the abdominal cavity and was aspirated. The ascites was sent for culture and grew E-coli. Mr Spiero developed hepatic encephalopathy and his condition deteriorated. A decision was made, with family input, that further care should be palliative in nature.

2. Cause of death 2.1. The clinical notes from Mr Spiero’s admission at the Royal Adelaide Hospital were reviewed at Forensic Science South Australia. The cause of death could be

determined from the casenotes with some certainty so an autopsy was not recommended. In the pathology review of Dr Iain McIntyre, as discussed with Associate Professor Neil Langlois of Forensic Science South Australia, the cause of Mr Spiero’s death is described as sepsis from infected ascites (E-coli) in a man with cirrhosis of the liver, hepatocellular carcinoma and diffuse B-cell lymphoma1. I find that to have been the cause of Mr Spiero’s death.

3. Background 3.1. Mr Spiero had a criminal history. His ultimate death in 2011 was as a prisoner. He had spent much of the 1990s, and almost the entirety of the next decade, in prison. He was released on parole in April 2010. His parole was due to expire on 25 March

4. There were a number of breaches of parole that landed Mr Spiero back in prison. During one of his periods of release Mr Spiero was diagnosed with hepatocellular carcinoma. The diagnosis was made by way of an MRI scan that took place on 7 October 2010. On 11 October 2010 Mr Spiero was arrested for unlawful possession in respect of which bail was refused. He was remanded in custody. This charge was ultimately withdrawn in December 2010 and Mr Spiero was again released.

3.2. In November 2011 Mr Spiero was admitted to the Flinders Medical Centre and received radio frequency ablation treatment for his hepatocellular carcinoma. He was not in custody at this time. He was discharged from the Flinders Medical Centre on 15 January 2011.

3.3. On 31 January 2011 Mr Spiero was arrested on a Parole Board warrant and again taken into custody. This breach of parole had consisted of his returning a positive urinalysis for methylamphetamine and failing to return for further urinalysis as required by a Correctional Services officer.

3.4. On 17 May 2011 Mr Spiero was discharged from custody and placed back on parole.

3.5. On 31 May 2011, whilst on parole, Mr Spiero was admitted to the Flinders Medical Centre with pain in his lower back due to a tumour in his right soleus muscle. A biopsy of the tumour was conducted and it revealed a large B-cell lymphoma. The 1 Exhibit C2a

management of this condition was complicated by Mr Spiero’s hepatitis C virus infection. Mr Spiero by this time had chronic liver disease.

3.6. Mr Spiero would remain on parole within the community until he was again arrested on 27 October 2011. This was as the result of a breach of parole conditions, namely a positive return for methylamphetamine usage in September and October of 2011.

There were other breaches. He was again taken into custody, this time at Yatala Labour Prison. In the intervening period between his release in May and his arrest in October Mr Spiero had undergone a number of cycles of chemotherapy at the Flinders Medical Centre.

3.7. When taken into custody in October 2011 he was placed in the infirmary of the Yatala Labour Prison. This placement was due to his deteriorating medical condition.

Whilst in the infirmary Mr Spiero was cooperative with staff, took all of his medication and tolerated all food and fluids that were provided to him.

3.8. On 11 November 2011 Correctional Services officers escorted Mr Spiero to the Flinders Medical Centre for his fourth cycle of chemotherapy. At this time Mr Spiero appeared well and his only complaint was swelling of his ankles which had occurred for a period of about three weeks following his previous chemotherapy cycle. He continued to be in good spirits, was bright, reactive and tolerated all food and liquids.

3.9. On the morning of 14 November 2011 infirmary staff at Yatala Labour Prison discovered that Mr Spiero was in severe pain in and around his lower stomach area.

Mr Spiero was administered with morphine and conveyed to the Royal Adelaide Hospital by ambulance. He would remain in the Royal Adelaide Hospital until his death on 22 November 2011.

4. Conclusion 4.1. At the time of his death Mr Spiero was a prisoner within Yatala Labour Prison.

Notwithstanding the fact that he died at the Royal Adelaide Hospital, his death was a death in custody. For that reason this Inquest was mandatory.

4.2. Mr Spiero’s custody at the time of his death was lawful.

4.3. As indicated earlier Mr Spiero’s death was from natural causes. There is no suggestion that at any stage while in custody he was denied proper medical treatment.

5. Recommendations 5.1. The Court does not see any need to make any recommendations in respect of 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 17th day of July, 2015.

Deputy State Coroner Inquest Number 4/2014 (1885/2011)