Coroner's Finding: DICKINSON Raymond George

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 11th day of April and the 27th day of July 2017, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Raymond George Dickinson.

The said Court finds that Raymond George Dickinson aged 64 years, late of Mount Gambier Prison, Benara Road, Mount Gambier, South Australia died at Mount Gambier, South Australia on the 22nd day of November 2014 as a result of hypertensive and valvular heart disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for Inquest 1.1. On 22 November 2014 Raymond George Dickinson died at the Mount Gambier Prison where he was serving a prison sentence. He was 64 years of age when he died from natural causes. Mr Dickinson’s death was a death in custody for which an Inquest was mandatory.

1.2. A post-mortem examination carried out by Dr Stephen Wills, a forensic pathologist at Forensic Science South Australia, established that Mr Dickinson’s cause of death was hypertensive and valvular heart disease1. The principal pathological findings at autopsy were: '(1) obesity with a body mass index of 39.6; (2) cardiomegaly above the 97th percentile for body mass with left ventricular hypertrophy; (3) aortic valve sclerosis and dilatation.' 1 Exhibit C2a

1.3. Dr Wills states in his report: 'Taking all of the findings into consideration, and in the absence of an alternative anatomic or toxicological cause, it is my opinion that this gentleman has most likely died as a result of hypertensive and valvular heart disease. Individuals with significantly enlarged hearts are known to be at increased risk of cardiac dysfunction, arrhythmia and sudden, unexpected death. Aortic stenosis with left ventricular hypertrophy is also a risk factor for sudden arrhythmic death. The presence of a fused, sclerotic aortic valve with increased overall valve circumference is likely to have resulted clinically in mixed aortic valve disease.' 2

1.4. I accept all that evidence. I find that the cause of Mr Dickinson’s death was hypertensive and valvular heart disease.

2. Background and medical history 2.1. Mr Dickinson was serving a term of imprisonment at the Mount Gambier Prison. On 10 December 2013 he had been sentenced in the District Court in relation to certain offences. He was given a head sentence of four years and six months with a non-parole period of three years. Mr Dickinson had been in custody since 8 November 2013. With his sentence backdated to his admission date he would have been eligible for release on parole on 8 November 2016.

2.2. Mr Dickinson was initially incarcerated in the Yatala Labour Prison. He was transferred to the Mount Gambier Prison on 22 November 2013. Apart from being transferred back to Yatala for his sentencing on 10 December 2013 he remained in Mount Gambier for the duration of his incarceration.

2.3. I find that Mr Dickinson’s custody was at all times lawful.

2.4. Mr Dickinson had an already diagnosed heart condition when incarcerated in 2013.

This had been managed in the community by his general practitioner, Dr Peter Birdsey, and his cardiologist from SA Heart, Dr Richard Hillock.

2.5. On 1 December 2008 Mr Dickinson had been diagnosed with hypertension. He was referred to the cardiologist, Dr Hillock. On 13 February 2009 Dr Hillock made the following diagnosis: '1. Normal left ventricular size and function with mild left ventricular hypertrophy

2. Mild aortic stenosis with mild aortic regurgitation 2 Exhibit C2a

3. Relatively low frequency ventricular ectopic burden on Holter

4. No convincing exertional symptoms … Given his good symptomatic status and the benign findings on his Holter, I do not think we need to take that any further at the moment. The valvular disease should be closely monitored and I will take the opportunity of repeating a surveillance echo in a year to exclude early deterioration. If he was to develop exertional symptoms, I would be keen to stress test and take things further. Many thanks for involving me in his care.' 3

2.6. There were subsequent reviews. On 15 February 2012 Dr Hillock noted that Mr Dickinson’s weight was a significant problem at 150 kilograms. He stated: 'The echo shows normal left ventricular size and function with mild concentric hypertrophy. The aortic valve is still mild with a mean gradient of 20mmHg. It has not changed in the last 2 years and a surveillance echo in 5 years is reasonable.' 4

2.7. The five year review would not have been due until February 2017. In the intervening period Mr Dickinson was sent to prison where he ultimately died.

2.8. On 15 November 2013, while in Yatala Labour Prison, Mr Dickinson complained of chest pain. He was transferred to the infirmary for an ECG and ultimately taken to the Royal Adelaide Hospital (RAH) as a priority one patient. He underwent coronary angiography in hospital. This revealed normal coronary arteries. It is noted that this particular episode occurred on a background of apparently threatening and frightening behaviour from other inmates.

2.9. On 19 November 2013 Mr Dickinson was returned to the Yatala infirmary from the RAH. On 20 November he was seen by the doctor at the prison infirmary and was cleared for transfer back to his Division.

2.10. On 22 November 2013 Mr Dickinson was transferred to Mount Gambier Prison and his medical treatment was then overseen by Dr Letitia Kavanagh, a local medical practitioner.

2.11. On 12 December 2013 Mr Dickinson attended the Mount Gambier Prison medical clinic for review after his recent transfer.

3 Exhibit C8a 4 Exhibit C8c

2.12. On 22 February 2014 Mr Dickinson requested to see a nurse because he had a dizzy spell. There was no nurse there at the time, however it was noted that he could see the nurse the following day and his name was placed on the list. It was also put on the doctor's list for 25 February 2014. Department for Correctional Services staff continued to monitor Mr Dickinson on that occasion. When they later spoke to him he advised that he was feeling all right. He was told to raise any concerns with them as the night went on.

2.13. On 23 February 2014 Mr Dickinson was seen by the nurse due to the issues he had reported the previous day. He advised that he had no chest pain, no shortness of breath and no nausea or vomiting. He stated that he felt he was a bit stressed because he did not have any support from his family.

2.14. On 15 April 2014 Mr Dickinson presented to Dr Kavanagh at Mount Gambier complaining of difficulties swallowing. Dr Kavanagh referred him to a surgeon, Dr Gunning, for a gastroscopy.

2.15. On 5 September 2014 Mr Dickinson attended at the Mount Gambier Hospital for an endoscopy and barium swallow with Dr Gunning. On 30 September 2014 he saw Dr Gunning at the prison clinic for the results which were within the normal range. The symptoms were thought to possibly be due to anxiety.

2.16. Whilst in Mount Gambier Mr Dickinson was prescribed daily aspirin, Olmesartan which is a blood pressure medication and Telfast for his allergies. He was provided PRN5 Stemetil for dizziness. If he had a dizzy spell he was able to access Stemetil and he had Panadol Osteo on a PRN basis for his arthritis.

3. The events of 22 November 2014 3.1. Mr Dickinson was observed by his cellmate, Mr Edwin Thomas, at about 2:30pm on 22 November 2014 to be playing cards in D Unit with four or five other inmates. Mr Thomas then observed Mr Dickinson return to the cell at approximately 3pm and noticed nothing unusual about him at this time.

3.2. Following this Mr Thomas walked laps of the yard. He walked past the shared cell on several occasions and on each occasion he reported observing Mr Dickinson lying on 5 As required

his left side on the bottom bunk in the cell with his head positioned near the bunk steps, facing the television in the cell. Mr Thomas assumed Mr Dickinson was watching television.

3.3. A short time later Mr Thomas observed a female prison officer, Ms Mandy Jones6, attend the cell to complete an intercom check. He observed the officer leave the cell, return and then summon assistance. He heard Mr Dickinson's name being called by the guards as if they were trying to rouse him.

3.4. Ms Jones located Mr Dickinson deceased. Her statement details as follows: 'At about 4:20pm on 22 November 2014 I was doing intercom checks in the D Unit. When I did the check on D19 I think that the door was open. I could see that Mr Dickinson was laying on the lower of the two bunks. He was lying on his left side facing away from the wall. He had his reading glasses on his face but were not sitting properly on the bridge of his nose; they were a bit wonky. He was holding a book in his hand. I don't know what hand he was holding the book with. I thought he was asleep and continued with the intercom checks. I did the remaining six cells before walking past D19. Mr Dickinson had not moved. There was nobody else in the cell at the time. Between three and five minutes later I went to the office and spoke with the supervisor, Nevyn Wilson. I asked him to come back to D19 to wake up Mr Dickinson. I don't know why I went back to D19.

Supervisor Wilson spoke “Mr Dickinson, Mr Dickinson” and there was no response.'

3.5. I accept Ms Jones’ evidence. When Mr Wilson arrived at the cell he attempted to rouse Mr Dickinson but could not. He immediately called for an ambulance. CPR was then administered to Mr Dickinson without success. As well, oxygen was administered.

Attempted defibrillation revealed that Mr Dickinson had no shockable rhythm. He had died. CPR was nevertheless maintained until the arrival of the South Australian Ambulance Service who were also unable to revive the deceased. I find that appropriate efforts were made in an attempt to resuscitate the deceased.

3.6. Detective Brevet Sergeant Justin Leverington of the Police Corrections Section, SAPOL was the investigating officer in this matter. He provided a report to the Court7.

He concluded as follows: '1. Mr Dickinson was lawfully incarcerated due to having been found guilty of numerous indictable offences and therefore his was a legitimate death in custody.

2. There were no suspicious circumstances surrounding the death of Mr Dickinson or that any third party was involved.

6 Exhibit C4 7 Exhibit C13a

3. No deficiency in the care and attention afforded to Mr Dickinson whilst being incarcerated was identified either at Yatala Labour Prison or Mount Gambier Prison.' I agree with those conclusions and have nothing further to add.

4. Recommendations 4.1. There are no recommendations.

Key Words: Death in Custody; Natural Causes; Prisoner In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 27th day of July, 2017.

Deputy State Coroner Inquest Number 7/2017 (2046/2014)