Coroner's Finding: DODSON Edward Leonard

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 25th day of August 2016, the 11th day of April 2017 amd 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 Leonard Edward Dodson.

The said Court finds that Leonard Edward Dodson aged 78 years, late of Port Lincoln Prison, Pound Lane, Port Lincoln, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 8th day of July 2014 as a result of metastatic malignancy (unknown primary) with contributing right sided heart failure. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Leonard Edward Dodson, born on 23 January 1936, was 78 years of age when he died from natural causes on 8 July 2014 at the Royal Adelaide Hospital (RAH). This death was reported to the State Coroner by clinicians at the RAH. It was reported because it was a death in custody. This Inquest was therefore mandatory by virtue of the provisions of the Coroners Act 2003.

1.2. On 19 July 2010 Mr Dodson appeared in the District Court of South Australia where he was sentenced for certain criminal offences committed between 1972 and 1982.

Mr Dodson was sentenced to 9 years imprisonment with a non-parole period of 4 years and 6 months. The sentence was ordered to commence on 15 July 2010, the date on which Mr Dodson was first taken into custody. His earliest release date would have been 14 January 2015. Mr Dodson was still serving that prison sentence at the time of his death. I find that Mr Dodson’s custody was at all times lawful.

2. Cause of death 2.1. A post-mortem examination of Mr Dodson’s remains was not conducted. Instead, his longitudinal medical history and the course of his most recent illness, as documented in a large number of files and clinical case notes, were examined by a medical practitioner experienced in providing opinions as to cause of death. The matter was also reviewed by a forensic pathologist at Forensic Science South Australia. The resulting pathology review that was conducted by Dr Iain McIntyre as discussed with Dr Cheryl Charlwood, the forensic pathologist, states that the suggested cause of death of Mr Dodson was metastatic malignancy (unknown primary) with contributing rightsided heart failure. A post-mortem examination of Mr Dodson’s remains was not recommended as the cause of death could be determined from the case notes with some certainty. I find the foregoing to have been the cause of Mr Dodson’s death. It will be noted that the metastatic malignancy, which was diagnosed by way of CT scans during Mr Dodson’s life, involved multiple liver lesions. Clinically, the primary source of the metastatic malignancy within the liver was not established with complete certainty during the course of Mr Dodson’s life. Although it was determined with some degree of certainty that Mr Dodson had experienced prostate cancer during his life, the metastatic malignancies within Mr Dodson’s liver were not positively established as having originated from his prostate cancer. As well, due to the fact that no autopsy was conducted after Mr Dodson’s death, the origin of the metastatic malignancy that had caused Mr Dodson’s death was not established post-mortem.

2.2. However, there can be no doubt that the metastatic malignancy within the liver was the cause of Mr Dodson’s death, contributed to as it was by right-sided heart failure which was a disease from which Mr Dodson was also known to be suffering.

3. Background 3.1. Mr Dodson was aged 74 years at the time of his incarceration. This was the first time that Mr Dodson had ever undergone any period of custody or imprisonment.

3.2. Mr Dodson had a medical history. The most significant illness that he had was chronic obstructive pulmonary disease which was first diagnosed in 2007. Treatment for this chronic illness was by way of Ventolin and Spiriva inhalers. There is no documented history of Mr Dodson suffering from any type of cancer, including prostate cancer, or

that he had any symptomatology of prostate cancer or other urological issues prior to his imprisonment in 2010.

3.3. Upon his initial admission into the custody of the Department for Correctional Services at the Adelaide Remand Centre in 2010, Mr Dodson underwent a general health assessment that was conducted by nursing staff of South Australian Prison Health Service (SAPHS), an arm of SA Health. The assessment was conducted in order to identify Mr Dodson’s best placement within the prison system. At the time of his assessment Mr Dodson was noted to be puffing and breathless. Mr Dodson underwent a full blood count as well as a prostate specific antigen (PSA) screening test as part of the assessment.

3.4. The results of the PSA screening test showed that Mr Dodson had a substantially raised PSA level of 20ng/ml. Mr Dodson reported a long history of urinary issues including poor stream, dribbling, frequency and urgency. There is no evidence that the deceased had previously reported this symptomatology to any other medical practitioner.

4. Mr Dodson’s clinical management by SAPHS 4.1. At the time Mr Dodson reported his history of urinary difficulties to the SAPHS he also reported a recent unintentional weight loss that could not be explained by his diet or change in circumstances. As a result, a urology outpatient referral was made in order to explore all those issues.

4.2. A second PSA screening test conducted on 19 October 2010 revealed that the PSA was still at an elevated level of 22.

4.3. On 27 October 2010 Mr Dodson attended the RAH urology outpatient service. The urology outpatient service concluded that Mr Dodson’s symptoms had completely settled after his fluid intake had increased. The service suspected that Mr Dodson’s elevated PSA and urinary symptoms may have been the result of a urinary tract infection. Another matter that was relevant was the fact that a rectal examination revealed a smooth and benign feeling prostate. Accordingly, Mr Dodson was discharged back into the care of SAPHS.

4.4. A further PSA screening test in December 2010 again revealed an elevated level of 20.

By that stage Mr Dodson had been transferred to the Port Lincoln Prison where his

medical needs were met by the local medical profession in conjunction with SAPHS nursing staff at that prison.

4.5. Mr Dodson was scheduled to undergo another appointment at the RAH urology outpatient service on 16 March 2011. He was transferred from Port Lincoln to Adelaide for this purpose. He attended the appointment but was advised by the RAH that although he was booked in, there was no doctor available to see him. I understand that as a result Mr Dodson did not undergo any further testing at this time and that he was transferred back to the Port Lincoln Prison.

4.6. On 13 April 2011 Mr Dodson advised SAPHS staff that he did not want to be transferred to Adelaide again for any medical appointments. He reconfirmed this decision to SAPHS nursing staff at Port Lincoln on 25 April 2011. On the first of these occasions it was recorded by nursing staff that Mr Dodson referred to his aborted medical appointment at the RAH and the fact that no doctor was available. It appears in the note that Mr Dodson’s desire not to go to Adelaide for medical appointments had been stated in the context of the pointless journey to Adelaide in March and the aborted appointment at the RAH. No other reason is recorded. No note of any encouragement or advice if any that he should be further investigated and attend in Adelaide for that purpose is recorded. His reiteration on 25 April 2011 that he did not want to go to Adelaide for any medical appointments in the future does not have any specific reason recorded for it. Again there is no note of any encouragement that may have been offered to Mr Dodson to change his mind. I note that in the statement of Elizabeth Sloggett1 who is the SAPHS Nurse Management Facilitator - Clinical Risk, and who is a registered nurse, it is asserted that on the two occasions in April 2011the importance of Mr Dodson attending urology appointments would have been explained to him but that the SAPHS is unable to force a patient to attend any medical appointment when they do not wish to do so.

4.7. As of April 2011 there must have been an ongoing reasonable suspicion that despite the original RAH urology outpatient service opinion to the effect that Mr Dodson’s symptoms may have been the result of a urinary tract infection, Mr Dodson was suffering from something more sinister than that. Whether any of that was explained 1 Exhibit C6

to him in an effort to convince Mr Dodson that he should again be transferred to Adelaide for urological assessment is not in any way recorded and is far from clear.

4.8. The issues identified in the preceding two paragraphs are the same as those that the Court identified in an Inquest relating to the death of another prisoner accommodated at Port Lincoln Prison. The Inquest was that of Franklin Delano Miller whose cause of death also was metastatic cancer2. In Miller’s case this Court had made certain observations about the need to record advice that is given to patients in circumstances very similar to those of Mr Dodson. I will say more about that later. I should add here, however, that the findings of the Court in the Miller case were delivered on 13 February 2013 which was after the events in April 2011 when Mr Dodson had indicated his refusal to again travel to Adelaide for urological assessment.

4.9. Between April 2011 and October 2012 there are numerous entries in Mr Dodson’s SAPHS progress notes relating to various attendances on the service for differing ailments and conditions. There is reference within the progress notes to bloods being taken from Mr Dodson for the purposes of PSA analysis on 29 November 2011. The result appears to be recorded within IMVS documentation as 29, which is again elevated. However, there does not appear to be any reference to this result within the progress notes.

4.10. On 14 October 2012 there was an appointment for a SAPHS health check in which Mr Dodson is recorded as feeling well. There is a recorded need for his PSA to be rechecked. There is also reference to Mr Dodson’s previously raised PSA levels and to the aborted March 2011 trip to Adelaide for urology review. It is also recorded that another referral needed to be rescheduled as there was a need for a biopsy to be taken of Mr Dodson’s prostate. There is also reference to the possibility that Mr Dodson might be able to see a urologist in Port Lincoln. In January 2013, at Port Lincoln, Mr Dodson would see a urologist, Dr Darren Foreman. I will discuss that matter in a moment.

4.11. The long hiatus between April 2011 and October 2012 during which Mr Dodson’s previously understood urological condition was not apparently explored is not specifically explained anywhere in the papers tendered to the Court. The statement of Ms Sloggett surmises that Mr Dodson was not a complainer and that as a rule he 2 Inquest 32/2009

generally appeared reluctant to highlight any health concerns with the Department for Correctional Services or SAPHS. She states that his health priorities did not appear to involve his prostate issues. He complained more about ear infections than anything to do with his prostate. Ms Sloggett surmises that this lack of concern or complaint by Mr Dodson is quite likely one of the primary reasons that a re-referral to a urology specialist for his consistently high PSA was not undertaken between his missed RAH appointment on 16 March 2011 and when the issue of urological review was revisited on 14 October 2012. There may be some accuracy in this observation, but on the other hand there does not appear to be much evidence in specific support of that theory.

4.12. The PSA analysis undertaken in October 2012 was again raised at 20.

4.13. Mr Dodson was referred to Dr Darren Foreman who is a urologist at South Terrace Urology. Dr Foreman provided a statement to the Inquest3. At the material time Dr Foreman practised at the Port Lincoln Hospital on a monthly basis providing a urology service to the Eyre Peninsula. His was the only urology service then available in the Port Lincoln area. According to Dr Foreman’s statement he had been visiting Port Lincoln since October 2010. He asserts that between 2010 and November 2014, when he provided his witness statement, he had seen approximately five to ten Port Lincoln Prison inmates all of whom had been referred to him as patients by the SAPHS.

All of this raises a question as to why Mr Dodson’s needing to visit Adelaide for urological assessment had ever been an issue.

4.14. Dr Foreman saw Mr Dodson on 8 January 2013. He presented with a PSA of 44 and reported significant problems with urinating. A digital rectal examination on this occasion revealed a moderately enlarged nodular prostrate which was clinically suspicious for cancer. A prostate biopsy was arranged for Mr Dodson to take place at the Port Lincoln Hospital on 4 March 2013.

4.15. On 7 March 2013 the results from the biopsy became available. They showed Gleason 4+3=7 prostate disease in two of the biopsy samples. This indicated that Mr Dodson had prostate cancer of an intermediate grade. As a result of that analysis Dr Foreman arranged for Mr Dodson to have a CT scan of his abdomen and pelvis in order to look for disease elsewhere such as within bone.

3 Exhibit C7

4.16. The CT scan was conducted at the Port Lincoln Hospital on 27 March 2013. The scan revealed two liver lesions. These liver lesions would be viewed as the metastatic lesions that ultimately caused Mr Dodson’s death. There were no other lesions such as bony metastatic lesions. At that time Dr Foreman came to the initial view that the likelihood was that Mr Dodson had microscopic metastatic prostate cancer. He recommended that Mr Dodson’s treatment be based on that clinical suspicion. The recommendation was that he receive Androgen deprivation therapy which aims to reduce the level of testosterone which can stimulate the growth of cancerous cells in the prostate glands.

To this end Mr Dodson was commenced on Zoladex implants every three months.

4.17. In his statement Dr Foreman explained that notwithstanding his initial impression that Mr Dodson probably had metastatic prostate cancer, the liver is an unusual primary ‘landing place’ for prostate cancer. Liver lesions are not commonly seen with prostate cancer. Accordingly, Dr Foreman recommended holding off a liver biopsy in the belief that if the liver lesions were prostate cancer metastases they would subsequently shrink with Androgen deprivation therapy. In the event they did not shrink and so Dr Foreman’s initial view that the liver lesions were probably prostate metastases would change. More of that in a moment.

4.18. On 24 June 2013 Dr Foreman again examined Mr Dodson. By this time Mr Dodson’s PSA had decreased to 2.2. This was a good result consistent with the Zoladex therapy and so Dr Foreman recommended that Mr Dodson continue with that treatment with six-monthly PSA checks. Mr Dodson still reported urinary frequency which Dr Foreman was hopeful would settle with continued hormone therapy as his prostate cancer decreased in size.

4.19. On 20 December 2013 Dr Foreman received a letter from Dr Kerr of the Lincoln Medical Centre advising of Mr Dodson’s increasing poor health as evidenced by a number of deranged levels including worsening liver function tests. As well, he had experienced significant weight loss.

4.20. Dr Foreman again saw Mr Dodson on 27 May 2014. Mr Dodson’s most recent PSA test which had taken place in September 2013 revealed that the PSA level had fallen even further to 0.47. At this point Dr Foreman was of the view that it was then appropriate for further investigation of the liver lesions to be conducted by way of CT scan. The CT scan of his chest, abdomen and pelvis showed progressive enlargement

of lesions within the liver. Another PSA test was organised. The PSA was now only

0.19. Considering that the abnormality in his liver had enlarged in size despite his PSA having decreased with hormone therapy, Dr Foreman now felt that his liver disease was most likely caused by another process. He recommended a liver biopsy and review by general surgeons. He also recommended continuing the Zoladex treatment. That was the last time that Dr Foreman saw Mr Dodson.

4.21. Ms Elizabeth Sloggett takes up the narrative in her statement. It appears that in January 2014 Mr Dodson became concerned about the possibility of deportation as a result of his criminal convictions. On 27 January 2014 SAPHS nursing staff were called to speak to Mr Dodson as a result of concerns by Departmental staff and fellow inmates that he was not eating sufficiently. When questioned about this Mr Dodson said that he had given up and wanted to die. He was encouraged by staff not to give up and to eat regular meals. Mr Dodson’s spirits appeared to rise. However, in the following months when seen by SAPHS staff he was noted to experience weight loss, general ill health, lack of mobility, incontinence and loss of appetite. Whenever spoken to Mr Dodson would seldom complain.

4.22. In June 2014, following Dr Foreman’s final appointment with Mr Dodson the previous month, Mr Dodson was sent to the Port Lincoln Hospital via ambulance. He had become increasingly weak and frail and his personal hygiene had deteriorated. He was experiencing faecal incontinence. When he was returned to the prison on 16 June 2014, it was determined that the prison could no longer care for Mr Dodson and so arrangements were made for Mr Dodson to be transferred by air to the RAH for further assessment. This occurred on 17 June 2014.

4.23. By this time Mr Dodson was assessed to be very ill and it was ultimately decided that he would no longer be suitable for a prison environment. It was decided that he would be transferred either to Mary Potter Hospice or to a nursing home for palliative care and support. However, Mr Dodson passed away in the RAH prior to this transfer occurring.

Mr Dodson had indicated that he did not want any further invasive investigations of his intra-abdominal malignancy from which I infer that the contemplated biopsy of his identified liver metastases was not undertaken.

4.24. As indicated earlier the precise origin of the metastatic liver malignancies was not identified during life or at post-mortem.

5. The expert evidence 5.1. I have already referred to the statement of Dr Foreman. In his statement Dr Foreman expresses his ultimate view that the liver metastases were unlikely to have had Mr Dodson’s undoubted prostate cancer as their origin. Furthermore, Dr Foreman expresses the opinion that Mr Dodson had experienced prostate cancer for years and that it was unlikely to have appeared in the past 18 months. The PSA of 20 in the year 2010 was indicative that the cancer was already fairly well advanced at that time.

Dr Foreman therefore expresses the view that the treatment he provided Mr Dodson from January 2013 and onwards was unlikely to have been different from what would have been recommended had he been seen in 2010.

5.2. The matter of Mr Dodson’s death, and specifically its possible original cause, was examined by an independent expert Dr David Elder who is a urologist. Dr Elder provided three reports to the Inquest4. In his first report5 Dr Elder refers to the downward progression of Mr Dodson’s PSA levels from the time that Dr Foreman first saw Mr Dodson in early 2013. The descending levels were an indication that Mr Dodson’s prostate cancer was in remission. However, despite the decline in PSA, his already identified liver metastases continued to progress in size as shown on subsequent CT scans in January 2014. Dr Elder notes that as there were no signs of any bone metastases, it was thought that the liver findings would be an unusual secondary site for prostate cancer. This of course was the same view that had ultimately been taken by Dr Foreman. Dr Elder opined that in 2013 a colonoscopy would perhaps have been the appropriate investigation of which there is no clear reference in the clinical records for Mr Dodson. A liver biopsy undertaken, although advised against in the context of suspected prostate cancer, may well have been diagnostic in defining the source of the liver metastases even in late 2013 when his prostate cancer was seen to be in remission.

5.3. In his second report6 Dr Elder expresses the opinion that one likely source of the liver metastases would be the gastrointestinal tract in respect of which an endoscopy with colonoscopy may have revealed relevant information. Dr Elder indicates, however, that 4 Exhibits C9a, C9b and C9d 5 Exhibit C9a 6 Exhibit C9b

palliative care which may then have been possible using chemotherapy would probably only have extended Mr Dodson’s life by a few months.

5.4. In his third report7 Dr Elder again observes that Mr Dodson’s prostate cancer had been controlled with Zoladex and that his PSA had settled to low levels. The cause of death was liver metastases from an unknown primary, not prostate but possibly the bowel.

Dr Elder states as follows: 'One could argue that earlier diagnosis and intervention may have changed the course of his disease. However, this would be unlikely to extend his life to any degree in the presence of liver metastases. Also, palliative treatment with chemotherapy would have diminished his quality of life in perhaps a less than supportive environment.'

5.5. I accept the evidence of Drs Foreman and Elder. I think it is highly unlikely that Mr Dodson’s fatal liver metastases had as their origin Mr Dodson’s undoubted prostate cancer. Mr Dodson’s prostate cancer had apparently gone into remission. It is likely that the liver metastases had a different primary source and it is possible that this source was Mr Dodson’s bowel. There is no evidence that any consideration was given to either performing a biopsy on the liver metastases in order to determine whether the primary source was bowel related. There is also no evidence that consideration was given to any investigation of the bowel, such as a colonoscopy, to determine whether or not there was the presence of cancer within the bowel.

6. Conclusions 6.1. Mr Dodson’s very high PSA levels were identified almost as soon as he was taken into custody in July 2010. Thus there was at that very early point in time a suspicion that Mr Dodson had prostate cancer. I accept the evidence of Dr Foreman and find that Mr Dodson had prostate cancer at that point in time.

6.2. A necessary urological investigation was arranged for March of 2011 and for this purpose Mr Dodson was transported to Adelaide. The appointment at the RAH urology clinic did not go ahead because there was no medical practitioner available to see Mr Dodson.

6.3. Thereafter Mr Dodson’s urological issues were put to one side until October 2012. A perusal of Mr Dodson’s progress notes between April 2011 and October 2012 reveal 7 Exhibit C9d

that he had numerous appointments for unrelated medical matters. I do not see any note regarding any enquiry relating to symptomatology consistent with a urological issue such as prostate cancer. That said, it may well be that Mr Dodson either was not experiencing any symptomatology or chose not to disclose it. Certainly he does not appear to have had any aversion to consulting the SAPHS on a regular basis for varying complaints.

6.4. The delay between April 2011 and October 2012 was unfortunate. In the event in January 2013 Mr Dodson did undergo urological assessment by a urologist who for the past three years had been regularly visiting Port Lincoln and had seen different prisoners accommodated at the Port Lincoln Prison. Why Mr Dodson was not one of those persons I do not know. If Mr Dodson’s sole difficulty was his reluctance to be transported to Adelaide for a urological assessment there was a urologist virtually on his doorstep in Port Lincoln. There is no evidence that Mr Dodson resisted seeing Dr Foreman in Port Lincoln in January 2013 or resisted Dr Foreman’s recommended investigations.

6.5. Metastatic liver disease was identified in Mr Dodson by way of a CT scan conducted at the Port Lincoln Hospital in March 2013. The belief ultimately was that these were not metastatic deposits of Mr Dodson’s prostate cancer. I think that is the likelihood of the situation and I so find. The origin of the metastases was never identified. The metastatic liver lesions were the cause of Mr Dodson’s death.

6.6. To my mind the delay in diagnosis of prostate cancer and the consequent delay in the initiation of its ultimate effective treatment by way of Androgen deprivation therapy did not contribute to Mr Dodson’s death. This is because the prostate cancer went into remission and there is no evidence to suggest that it was responsible for Mr Dodson’s death.

6.7. The liver metastases were the primary cause of Mr Dodson’s death. They were not of a prostatic origin. I accept the evidence of Dr Elder that it is possible that the liver metastases had the bowel as their origin. No investigation was ever conducted with this possibility in mind. In a sense the liver metastases had been identified fortuitously in the course of an investigation to determine whether Mr Dodson’s prostate cancer had spread. Whatever the origin of the liver metastases was, the disease had clearly spread to an inevitably fatal degree. However, I also accept Dr Elder’s evidence that earlier

diagnosis of the source and cause of the liver metastases is unlikely to have extended Mr Dodson’s life to any significant degree.

7. Recommendations 7.1. Pursuant to Section 25(2) of the Coroners Act 2003 the Court is empowered to make recommendations that in the opinion of the Court might prevent, or reduce the likelihood, of a recurrence of an event similar to the event that was the subject of the Inquest.

7.2. I have referred to the matter of Franklin Delano Miller. One issue identified in Mr Miller’s case was a reluctance on the part of prisoners at Port Lincoln to be transferred to Adelaide for the purpose of undergoing medical investigations. The reason for this was said to be that upon return to Port Lincoln certain privileges such as single cell accommodation may have been altered for the worse as far as the returning prisoner is concerned. I do not know whether such an issue had any impact on Mr Dodson. All that is known is that he indicated that he would not be undergoing any procedures or investigations in Adelaide. It is true of course that medical practitioners or correctional staff cannot force a prisoner to undergo medical treatment except in certain circumstances that do not apply here such as under the Mental Health Act 2009.

However, as observed in the Miller finding the Department for Correctional Services has complete control over where a prisoner is accommodated. If the Department is of the view that a prisoner should be accommodated in Adelaide so as to facilitate medical treatment then the Departmen

7.3. t has the right to dictate that.

7.4. I simply repeat the recommendations that were made in the Miller Inquest, added to as indicated: 'That the Medical Director of the South Australian Prison Health Service assign to a senior medical officer or officers within the Service the responsibility of maintaining oversight of the medical treatment and investigation of those prisoners within institutions operated by the Department for Correctional Services who are suspected of suffering from a serious or life threatening illness, especially in circumstances where the medical treatment and investigation of such prisoners is being conducted by medical practitioners who are not employees of the Service; That the Medical Director of the South Australian Prison Health Service remind medical practitioners, both employed within the Service or otherwise, who treat prisoners within

institutions operated by the Department for Correctional Services of the need to carefully explain to prisoners who are for whatever reason reluctant to undergo important medical treatment or investigation of the possible consequences of the failure of the prisoner to undergo such treatment or investigation and in particular to identify to the particular prisoner the worst case scenario that such an investigation might identify.

That the Medical Director of the South Australian Prison Health Service remind medical practitioners, both employed within the Service or otherwise, of the need to make detailed notations in a prisoner patient’s clinical record of the decision made by the prisoner not to undergo recommended medical treatment or investigation and of the stated reason for the prisoner refusing to undergo such medical treatment or investigation. I would add to this that there is also a need for a record to be made of any advice given to the prisoner that they should undergo the medical treatment or investigation.

That the Medical Director of the South Australian Prison Health Service and the Chief Executive Officer of the Department for Correctional Services be mindful of the fact that a refusal by a prisoner situated in a country correctional facility to undergo medical treatment or investigation that requires the prisoner to travel to Adelaide does not of itself mean that the prisoner cannot at least be compelled to travel to Adelaide and be accommodated in a correctional facility in Adelaide.

That the Medical Director of the South Australian Prison Health Service and the Chief Executive Officer of the Department for Correctional Services make every effort to ensure that the conditions enjoyed by a prisoner in a country correctional facility are not in any way jeopardised by the need for the prisoner to travel to Adelaide and be accommodated in an Adelaide correctional facility for the purpose of attending medical treatment or investigation.' 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 45/2016 (1161/2014)