Coroner's Finding: CAILES Kevin Arnold

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 16th day of February 2016 and the 4th day of August 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Kevin Arnold Cailes.

The said Court finds that Kevin Arnold Cailes aged 53 years, late of 20 Kincaid Road, Elizabeth East, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 25th day of December 2013 as a result of sepsis due to spontaneous peritonitis on a background of end stage liver failure. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Kevin Arnold Cailes was 53 years of age when he died on 25 December 2013 at the Royal Adelaide Hospital. On 31 December 2013 Dr Iain McIntyre from Forensic Science South Australia conducted a pathology review in relation to Mr Cailes' death and considered that the cause was sepsis due to spontaneous peritonitis in a man with end stage liver failure1. I therefore find that the cause of Mr Cailes’ death was sepsis due to spontaneous peritonitis on a background of end stage liver failure.

2. Background 2.1. When Mr Cailes was about 9 years of age he was involved in an incident which resulted in the death of his younger brother. Following this Mr Cailes suffered from poor mental health, mostly chronic post-traumatic stress disorder. Mr Cailes experienced a life of 1 Exhibit C2a

depression and chronic alcoholism, drinking to excess to numb the effects of flashbacks from the incident and of abuse he suffered. Mr Cailes was prone to angry outbursts and would engage in self-harming behaviour to relieve his pain and tension. He was a chain smoker from the age of about 17 years.

2.2. In 2011 Mr Cailes was diagnosed with cirrhosis of the liver with alcoholism as the likely cause. He was told by numerous doctors thereafter that he had to give up drinking to avoid an early death. Mr Cailes made it plain that he was not going to stop drinking, regardless of the outcome. In fact Mr Cailes increased his alcohol consumption following the diagnosis.

2.3. In 2013 Mr Cailes was residing with his wife in a home at Hallett in South Australia.

On 18 June 2013 Mr Cailes was seen by Dr Conway of the Jamestown Medical Centre.

He presented with vomiting and was noted to be twitching. The twitching was thought to indicate a hepatic encephalopathy. This meant that Mr Cailes' liver was beginning to fail such that the toxins were building up in his brain and nerves, causing the irritation and twitching. Appointments were made for Mr Cailes for follow up, however he never attended any of those appointments.

2.4. On 1 July 2013 Mr Cailes was arrested for an aggravated assault which involved punching his wife in the head and swinging her into a wall at their home. Mr Cailes was released on bail to his home address with strict conditions about conduct in the home. On 26 July 2013 he breached his bail with aggressive behaviour and by damaging property at the home address while intoxicated. Mr Cailes was arrested and later released on bail to reside at the men’s shelter in Port Pirie. It was a condition of Mr Cailes’ bail that he could not attend within 10 kilometres of Hallett.

2.5. On 1 August 2013 Mr Cailes was served with a court imposed intervention order in relation to his wife. From 1 to 14 August 2013 Mr Cailes resided at the shelter as directed. During that period Mr Cailes was arrested on at least seven occasions for various offending including dishonesty offences, street offences and breaches of bail, all of these unrelated to his wife. On 14 August 2013 Mr Cailes was arrested and bail was refused. He was remanded to the Port Augusta Prison and immediately admitted to Port Augusta Hospital for observation and assessment before being returned to the

prison. Mr Cailes was transferred back to the Port Augusta Hospital due to his health being poor and requiring constant observations.

2.6. Prison was deemed an unsuitable environment for Mr Cailes due to the level of care he required. In light of this he was transferred to the Yatala Labour Prison which allowed him access to the Royal Adelaide Hospital where appropriate care could be provided.

From 17 to 27 August 2013 Mr Cailes was admitted to the Royal Adelaide Hospital for treatment and monitoring. On 27 August 2013 Mr Cailes returned to Yatala Labour Prison where he spent time in the cells and the infirmary. A discharge plan was initiated for return to prison, including medications.

2.7. Mr Cailes struggled in the cell complex due to incontinence, inability to care for himself, falling out of bed and suffering a cognitive deficit. He frequently returned to the infirmary and was often unsettled, confused and required prompting for basic needs.

He experienced blood noses, incontinence, loss of appetite, restlessness and disorientation. On 13 September 2013 he was transferred from Yatala Labour Prison to the Royal Adelaide Hospital complaining of chest pains. He spent the night under investigation and was returned to Yatala Labour Prison the following day where he remained in the infirmary from 14 to 18 September 2013. On 18 September 2013 he returned to Royal Adelaide Hospital and was discharged back to the Yatala Labour Prison infirmary on 19 September 2013.

2.8. Mr Cailes’ condition over this period of time fluctuated between calm and cooperative to yelling out randomly with unrealistic demands and confusion. He was cared for by infirmary staff with medication administered as directed by the Royal Adelaide Hospital. On 21 September 2013 Mr Cailes returned to the Royal Adelaide Hospital with increased abdominal pain, confusion, dizziness and nausea. He was discharged to the Yatala Labour Prison infirmary the following day where he was incontinent and vomiting. Mr Cailes settled and remained in the infirmary under staff observation.

2.9. On 28 September 2013 Mr Cailes complained of feeling unwell and cold and had consumed minimal food or fluid. He was lethargic and unsteady on his feet and he stumbled resulting in an injury to his head. Mr Cailes was transferred to the Royal Adelaide Hospital for assessment and observation, following which he was returned to

the prison. From 28 September to 4 October 2013 he continued to be unsteady on his feet. His mood was generally flat and withdrawn.

2.10. On 4 October 2013 Mr Cailes was transferred to the Royal Adelaide Hospital for a review of low blood pressure and returned to the prison the following day. He was found by nursing staff later that day on the floor on his hands and knees with a bloodied left elbow and knee and was incontinent. Mr Cailes’ wounds were cleaned and dressed.

He underwent an assessment at this time and no other issues were identified. His medical condition relating to the cirrhosis and the hepatic encephalopathy continued to deteriorate and he was constantly feeling unwell and unsteady.

2.11. On 6 October 2013 the Royal Adelaide Hospital diagnosed him as being in advanced stage liver failure with Child C cirrhosis with hepatic encephalopathy and confusion.

He was given diuretic medication and placed on a fluid reduction plan with consumption limited to one litre per day. He was given medication to calm his behaviour and sedate him. Despite this Mr Cailes still had a tendency to become agitated and wander the wards. He was obtrusive to nursing staff and attempted to leave the hospital. It was clear at this stage that Mr Cailes was not capable of caring for himself.

3. Reason for Inquest 3.1. On 25 October 2016 the Port Pirie Magistrates Court granted Mr Cailes bail due to his declining health. Two of the conditions of his bail were that he reside at his sister’s premises in Elizabeth East and that he have no contact with his wife. On 27 November 2013 a Guardianship Board hearing was held and an order made appointing Mr Cailes’ sister as his guardian. In addition special powers were sought and granted under section 32 of the Guardianship and Administration Act 1993 which allowed the guardian to determine where Mr Cailes would reside and to detain him in that place if required.

Given the detention aspect of this order Mr Cailes’ death was a death in custody within the meaning of that expression in the Coroners Act 2003, and this Inquest was held as required by section 21(1)(a).

4. The events leading up to Mr Cailes’ death 4.1. On 29 November 2013 Mr Cailes was released from the Royal Adelaide Hospital into the care of his sister. In accordance with the bail conditions and the section 32 order Mr Cailes resided at his sister’s address in Elizabeth East. Mr Cailes’ was the subject of strict medical conditions in relation to his bail. On 1 December 2013 Mr Cailes’ sister presented with him to the Royal Adelaide Hospital as he was not sleeping, was continually attempting to drink excessive fluids, was leaving gas appliances on in the home and handled knives while being unsteady on his feet. She felt that her home was not a safe or suitable environment to monitor or administer his medical requirements.

4.2. Mr Cailes was admitted to ward Q8 at the Royal Adelaide Hospital between 1 and 25 December 2013 when he died. During that period his health continued to decline.

He remained restless, confused, disoriented and constantly wandering. He was at risk of absconding and tolerated only small amounts of food and fluid. On 10 December 2013 it was determined that no palliative care involvement was required unless he was released back into the community. On 14 December 2013 Mr Cailes suffered another fall. He was assessed and treated with dressings. Observations were undertaken and no further injuries were sustained. Over the ensuing days Mr Cailes became more drowsy and confused. By 19 December 2013 it was clear that Mr Cailes health was deteriorating. He was showing symptoms of bacteraemia. He did not request any pain relief at that stage.

4.3. On 20 December 2013 Mr Cailes’ condition declined overnight and a fever developed.

Blood samples were taken and confirmed a presence of E coli and sepsis, secondary to spontaneous bacterial peritonitis. A medical opinion, based on this development, was that death was imminent. All medical treatments were ceased at that time and basic palliative care was provided; being oxygen, pain relief and general hygiene needs.

4.4. On 23 December 2013 Mr Cailes began to experience leg shakes and was treated with morphine. It was observed that his urine was dark orange and very concentrated. He was refusing to eat and drink and he no longer experienced bowel movements. On 24 December 2013 Mr Cailes was quite peaceful and he slept well. He remained drowsy when awake, but was comfortable. He was administered morphine and he died

peacefully in his bed with family around him the following morning on 25 December 2013.

5. Recommendations 5.1. I am satisfied that the medical treatment that was administered to Mr Cailes during his period of incarceration and hospitalisation was lawful and appropriate and I therefore have no recommendations to make in this matter.

Key Words: Death in Custody; Natural Causes; Section 32 Powers In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 4th day of August, 2016.

State Coroner Inquest Number 4/2016 (2181/2013)