Coroner's Finding: ABDULLA Gilbert William Victor

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 21st day of March 2019 and the 14th day of May 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Gilbert William Victor Abdulla.

The said Court finds that Gilbert William Victor Abdulla aged 31 years, late of Mount Gambier Prison, Benara Road, Mount Gambier, South Australia died at Mount Gambier, South Australia on the 4th day of April 2016 as a result of ischaemic heart disease.

The said Court finds that the circumstances of his death were as follows:

1. Introduction, reason for Inquest and cause of death 1.1. Gilbert William Victor Abdulla died on 4 April 2016. He was 31 years of age. At the time of his death Mr Abdulla was a sentenced prisoner at the Mount Gambier Gaol. His death is therefore a death in custody within the meaning of that expression in the Coroners Act 2003 and this inquest was held as required by s21(1)(a) of that Act.

1.2. An autopsy was performed by forensic pathologist Dr Karen Heath who gave the cause of death as ischaemic heart disease1, and I so find.

2. Mr Abdulla’s health 2.1. Dr Heath reported cardiomegaly, left ventricular hypertrophy, mild to moderate coronary artery atherosclerosis, transmural scarring of the posterior wall of the left ventricle consistent with previous myocardial infarction, stenting of the right coronary artery in good order, mild hepatic congestion, mild to moderate hepatic steatosis, 1 Exhibit C2a

moderate pulmonary anthracosis and mild-moderate pulmonary emphysema.

Mr Abdulla was also morbidly obese.

2.2. For a 31-year-old man this represents significant disease. There is no doubt that Mr Abdulla commenced the relevant period of imprisonment with this significant disease and poorly controlled diabetes. Further to that, and despite the best efforts of those employed within the prison health system, this did not change.

2.3. Dr Letitia Kavanagh worked as a medical officer at the Mount Gambier Prison three days a week. Dr Kavanagh stated that she was surprised and concerned at the state of Mr Abdulla’s health when he commenced his sentence of imprisonment. She was concerned about his uncontrolled diabetes, his heavy smoking, and his excessively high cholesterol results.

2.4. Dr Kavanagh made it clear that she found it difficult to address Mr Abdulla's health issues as he was 'unprepared to address his lifestyle-related factors such as his smoking, weight and diet'2. Dr Kavanagh applied her best efforts to help Mr Abdulla and his ailing health.

2.5. In April 2013 Mr Abdulla suffered an acute inferolateral ST elevation myocardial infarction. He was transferred to Adelaide and underwent unsuccessful thrombolysis which then proceeded to stenting of his right coronary arteries

2.6. In January 2014 Mr Abdulla was exhibiting signs of cardiac failure - breathlessness; oedema in his ankles; neither of which responded to steroids or antibiotics.

Dr Kavanagh requested a chest X-ray which showed some mild cardiomegaly and she referred him to a cardiologist in January 2014.

2.7. Mr Abdulla was seen by cardiologist, Dr Majo Joseph, at Flinders Medical Centre on 2 May 2014 with the diagnosis being mild heart failure combined with some chronic obstructive pulmonary disease. He suggested fluid restriction to help with this and at that time Dr Kavanagh was of the view that Mr Abdulla's health issues would be better addressed if he was not housed at the Mount Gambier Prison, but somewhere more central such as Yatala Labour Prison. She had two reasons for this. Firstly, his 2 Exhibit C11, page 2

compliance with medication was appalling and he hampered efforts to restrict his fluids.

Secondly, the regime of dispensing medication required that prisoners line up in a certain area and Mr Abdulla complained that he was too breathless to do this, although there are no entries in any of the casenotes to reflect that he did not take his medication when it was prescribed.

2.8. Dr Kavanagh wrote to Prison Health to express her concerns and in response to this Mr Abdulla was transferred to the Yatala Labour Prison on 14 May 2014. Whilst at Yatala, Mr Abdulla was placed on a diabetic pathway. He was referred to a dentist and optometrist. He received numerous visits from the Aboriginal liaison officers where his health management was emphasised. He was also referred to a specialist Aboriginal diabetes education officer and the casenotes reflect that the interventions that he undertook had a positive impact on his health and wellbeing, although it was very shortlived. The following month Mr Abdulla gained weight; he failed to obey instructions in relation to fasting for his blood tests and was eating sugary snacks and drinking sugary drinks.

2.9. Mr Abdulla was assessed by the prison medical officer in Yatala on 28 October 2014 in relation to his excessive sleeping patterns and put on the list for a sleep study to assess his sleep apnoea as he was snoring. This was not able to be done until June 2015 and nursing notes around this time reflect that Mr Abdulla had gained approximately 20kg since the commencement of his sentence.

2.10. He was then returned to the Mount Gambier Prison and while Dr Kavanagh was unhappy with his transfer back, the offender casenotes reflect that the move was to facilitate his participation in the SOTAP course; the sexual offender treatment program.

He was ineligible for parole if he did not complete this.

2.11. Upon his return to Mount Gambier, Mr Abdulla was again assessed by Dr Kavanagh who found him to be, once again, in a very poor diabetic state and he displayed continued ambivalence about his health. She noted that he was consuming sugary drinks and sweets.

2.12. It is clear from the statement of Dr Kavanagh that despite her best efforts to improve Mr Abdulla's health he continued to eat the wrong foods, he continued smoking, and

resisted taking his medications regularly and as prescribed. Unsurprisingly, Mr Abdulla's health continued to decline and his uncontrolled diabetes led to problems with his eyesight and his circulation.

2.13. Dr Kavanagh also saw Mr Abdulla for his psychiatric health and stated that he found the sexual behaviour course very harrowing because it brought up memories of his childhood.

3. Mr Abdulla’s death 3.1. Mr Abdulla was housed in a cottage cell at the Mount Gambier Gaol with another prisoner, Mr Soteriou. Mr Soteriou stated that he was lying on his bed and Mr Abdulla was sitting in a plastic chair watching television at approximately 9pm. Mr Soteriou saw Mr Abdulla having what he thought was a fit.

3.2. He observed Mr Abdulla fall off the chair onto the ground whilst yelling as if he was in pain. He then grabbed the side of his bed with both hands and started rocking back and forth.

3.3. Mr Soteriou used the intercom in the cell to call for help and a short time later three prison officers arrived and commenced cardiopulmonary resuscitation.

3.4. Sandra Jones, Intensive Care Paramedic with the South Australian Ambulance Service, stated that the prison contacted South Australian Ambulance Service at 9:16pm. The ambulance was despatched at 9:18pm. Ms Jones' crew arrived at 9:36pm by which time another ambulance crew was already at the scene administering CPR.

3.5. Ms Jones said that all the efforts to resuscitate Mr Abdulla were unsuccessful, him being in asystole the entire time. In my opinion the response by prison officers was swift and the response and resuscitation efforts by the South Australian Ambulance Service were all appropriate.

3.6. Conclusion 3.7. In my opinion Mr Abdulla’s care within the prison system was appropriate. All that could be done for him was done, but unfortunately he would not comply with the lifestyle changes that were necessary for his own wellbeing.

3.8. I find that the efforts of Dr Kavanagh were commendable. She clearly went about trying to put Mr Abdulla on a different path to improve his health, and did all she could have in the circumstances.

Key Words: Death in Custody; Prisoner; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 14th day of May, 2019.

State Coroner Inquest Number 16/2019 (0603/2016)