Coroner's Finding: D'ARCY-EVANS Andrew Eyre

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 24th day of June 2016 and the 5th day of September 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Andrew Eyre D'Arcy-Evans.

The said Court finds that Andrew Eyre D'Arcy-Evans aged 30 years, late of 14 Bellerive Circuit, Seaford Rise, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 12th day of August 2014 as a result of disseminated mycobacterium avium complex infection complicating HIV infection. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Andrew Eyre D'Arcy-Evans was 30 years of age when he died on 12 August 2014 at the Flinders Medical Centre. An opinion as to his cause of death was provided by Dr John Gilbert of Forensic Science South Australia as disseminated mycobacterium avium complex infection complicating HIV infection1, and I so find.

2. Reason for Inquest 2.1. At the time of his death Mr D'Arcy-Evans was the subject of orders under the Guardianship and Administration Act 1993. Because of these orders he was regarded, in the eyes of the law, as detained. Accordingly his 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) of that Act and for no other reason.

1 Exhibit C2a

3. Background 3.1. At the age of approximately nine years Mr D’Arcy-Evans had an accident involving skull fractures. He suffered life threatening head injuries and required a craniotomy and evacuation of an occipital lobe intracerebral haemorrhage. He recovered from this reasonably well, but it left him with a permanent hearing impairment.

3.2. He was never formally diagnosed with a mental illness, however it was thought that he might suffer from bipolar disorder. His mother, who raised him and with whom he lived, suffered from significant mental health problems and they impacted considerably on Mr D'Arcy-Evans. Upon leaving high school at 16 years, he went straight onto a disability pension due to the brain injury and the hearing impairment. Following high school Mr D’Arcy-Evans was socially isolated.

3.3. In 2003 Mr D’Arcy-Evans travelled to Papua New Guinea where he spent several months. Not long after he arrived back in Australia he became unwell. Blood tests confirmed HIV. Mr D'Arcy-Evans was offered medication to treat him, but he refused because he believed that if he ate healthy food and maintained a healthy lifestyle he would be all right.

3.4. In 2012 he was hospitalised at the Flinders Medical Centre due to a very low viral count and was diagnosed with fully developed AIDS. Neither he nor his mother believed the medical staff and flatly refused all treatments offered.

3.5. Mr D'Arcy-Evans subsequently travelled to Melbourne and underwent Ozone Therapy Treatment on two separate occasions. He continued to refuse conventional medical treatment and his condition started to deteriorate very quickly.

3.6. In 2013 there were psychiatric assessments to determine whether or not he was detainable. It was determined that he was not detainable at that time. He would not agree to transfusions for the anaemia he was suffering from, but was compliant with antiretroviral medication. As a result of his behaviour regarding medications and the concerns the clinicians held in relation to that, an application was made to the Guardianship Board for a guardianship order. An order was duly granted in July 2013.

It appointed the Public Advocate as Guardian, with powers including with respect to his residence, detention, and treatment.

3.7. On 12 August 2014 Mr D'Arcy-Evans was admitted to the Flinders Medical Centre. He was hypotensive, hypothermic, hypoglycaemic with a weak radial pulse, a nonrecordable oxygen saturation and pinpoint pupils. Despite treatment he suffered a systolic arrest and was pronounced life extinct thereafter. His death was not unexpected because of the progression of his disease.

4. Conclusion 4.1. Mr D’Arcy-Evans died of natural causes. I have nothing further to add.

Key Words: Detah in Custody; Section 32 Powers; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the enter day then tab day of enter month then tab, enter year.

State Coroner Inquest Number 33/2016 (Original File Number 1381/2014)