Coroner's Finding: ISSACSON David Jacob

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 14th day of April 2016 and the 25th day of August 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of David Jacob Issacson.

The said Court finds that David Jacob Issacson aged 52 years, late of 42 Lansdowne Terrace, Walkerville, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 9th day of April 2014 as a result of disseminated carcinoma of the gallbladder. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. David Jacob Issacson was 52 years of age when he died at the Royal Adelaide Hospital on 9 April 2014. Because he was detained under the Mental Health Act 2009 at the time of his death, Mr Issacson’s 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

2. Background 2.1. Mr Issacson was diagnosed with a schizo-affective disorder at 19 years of age.

Following that diagnosis, he had multiple admissions to mental health facilities.

Mr Issacson was overweight and suffered from diabetes and hepatitis C. He was a heavy smoker, averaging about 50 cigarettes a day with a long history of substance abuse, including amphetamine, cannabis and alcohol.

2.2. Mr Issacson would often travel to Sydney. During these trips he would fail to take his medication, become unwell and this would inevitably result in confrontations with police, followed by hospitalisation. When Mr Issacson became unwell he would be aggressive, threatening and violent towards his mother, who was his primary carer. He would also experience bizarre paranoid delusions.

3. The events leading to Mr Issacson’s death 3.1. In February 2014 Mr Issacson arranged a trip to Tel Aviv. The plan was to leave Adelaide on 18 March 2014 and return on 8 June 2014. He duly flew to Tel Aviv on 18 March 2014, however returned early on 1 April 2014. On 2 April 2014 Mr Issacson presented at the Marden Medical Centre with stomach pains. He was seen by Dr Turnbull, a general practitioner. Mr Issacson reported that he felt bad, had not urinated in days and his stomach was bloated. He was noted to have slurred speech and signs of paranoia. Dr Turnbull arranged for a taxi to take Mr Issacson immediately to the Royal Adelaide Hospital. Mr Issacson was assessed in the Emergency Department of the Royal Adelaide Hospital, diagnosed with constipation and discharged home.

3.2. He re-presented to the Marden Medical Centre on 3 April 2014 with ongoing stomach pain and was again referred to the Royal Adelaide Hospital. On this occasion he was admitted. On 7 April 2014 Mr Issacson attempted to abscond from the hospital and was placed under a Level 1 Inpatient Treatment Order pursuant to the Mental Health Act 2009 as a result. That order was confirmed on 8 April 2014 by consultant psychiatrist, Dr Jon Symon.

3.3. Mr Issacson was diagnosed with advanced stomach cancer on 8 April 2014 and unfortunately he died the following day, Wednesday 9 April 2014.

4. Cause of death 4.1. A pathology review to determine Mr Issacson’s cause of death was undertaken by Dr Iain McIntyre of Forensic Science South Australia. It was Dr McIntyre’s opinion that the cause of death was ‘disseminated carcinoma of the gallbladder’1, and I so find.

1 Exhibit C2a

4.2. The following comments were made by Dr McIntyre in his report: 'On 3 April 2014, he was admitted to the RAH with abdominal pain and distension. Ultrasonography showed ascites and a cirrhotic liver. On 7 April 2014 he was found to have malignant cells in his ascetic fluid. At that time he became agitated and tried to abscond from the hospital. He was detained under the Mental Health Act and an urgent CT scan of his abdomen was performed. This showed a carcinoma of the gallbladder with extensive metastases. He opted for a palliative approach to his cancer and referrals were made to the Palliative Care Team and the psychiatry department. However, before these could be actioned he suffered a deterioration and died.'

5. Conclusion 5.1. I am satisfied that Mr Issacson’s treatment was appropriate.

6. Recommendations 6.1. I have no recommendation to make in this case.

Key Words: Death in Custody; Natural Causes; Inpatient Treatment Order In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 25th day of August, 2016.

State Coroner Inquest Number 13/2016 (0590/2014)