Coroner's Finding: APOSTOLIDIS Jack

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 20th day of November 2018 and the 12th day of June 2019, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Jack Apostolidis.

The said Court finds that Jack Apostolidis aged 64 years, late of 30 Gilbert Street, Gilberton, South Australia died at Gilberton, South Australia on the 19th day of November 2015 as a result of multi organ failure due to metastatic adenocarcinoma of the lung. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for inquest 1.1. Jack Apostolidis was 64 years old when he died on 19 November 2015 at his home address in Gilberton. Although at the time of Mr Apostolidis' death he was serving a sentence of imprisonment for an offence of aggravated causing harm with intent, he had been released from prison so that he could serve the remainder of his sentence on home detention. The premises situated at Gilberton at which Mr Apostolidis died was his place of detention. Therefore, pursuant to provisions of the Coroner's Act 2003 this was a death in custody in respect of which an inquest into the cause and circumstances of his death was mandatory. These are the findings of that inquest.

2. Cause of death 2.1. The cause of Mr Apostolidis' death was determined by way of a pathology review conducted by Dr Iain McIntyre in consultation with Professor Neil Langlois of Forensic Science Centre of South Australia on 25 November 2015. Dr McIntyre was able to determine the cause of death from Mr Apostolidis’ clinical record with some certainty.

As a result, an autopsy was not necessary. Based on Dr McIntyre’s pathology review1 I find that the cause of Mr Apostolidis' death was multi organ failure due to metastatic adenocarcinoma of the lung.

3. Background and medical history 3.1. Mr Apostolidis was born in Greece and was one of three children. He migrated to Australia when he was three years old. He left school at 14 and worked in the hospitality industry from that time. He was the father of three children. Mr Apostolidis was close to his family. During his final days he was nursed by his sister and mother.

By then his illness was at the palliative stage.

3.2. Mr Apostolidis’ prior medical history recorded multiple health conditions including Type 2 diabetes, ischaemic heart disease and peripheral vascular disease requiring coronary bypass surgery in 2003 and stent surgery in October 2009. In December 2014 whilst he was in the custody of the Department for Correctional Services, Mr Apostolidis underwent a coronary artery bypass graft.

3.3. Mr Apostolidis was convicted and sentenced in 2014. The period in custody that Mr Apostolidis spent following his conviction involved serious health episodes.

Subsequent to the coronary artery bypass graft in December 2014 he experienced ongoing episodes of chest pain. A code black was called on 14 March 2015 requiring Mr Apostolidis to be transferred to the Royal Adelaide Hospital to have a stent inserted.

By 5 May 2015 Mr Apostolidis was granted release on home detention.

3.4. On 10 June 2015, while still on home detention, Mr Apostolidis attended the Royal Adelaide Hospital oncology clinic. He was diagnosed with metastatic small cell adenocarcinoma of the lung with bone and pericardial spread. The cancer was treated with radiotherapy and chemotherapy with palliative intent. The chemotherapy had a secondary effect of causing an acute kidney injury. Due to ongoing physical deterioration Mr Apostolidis was readmitted to the Royal Adelaide Hospital for care and treatment on 14 October 2015.

3.5. Mr Apostolidis’ treatment was overseen by Dr Jonathan Hogan-Doran. On 24 October 2015 Mr Apostolidis was discharged from the Royal Adelaide Hospital. He was discharged under the community palliative care team. His further care was for comfort measures only. On 19 November 2015 Mr Apostolidis died at home.

1 Exhibit C2a

4. The coronial investigation 4.1. The circumstances of Mr Apostolidis' death were investigated by SAPOL on behalf of the State Coroner. The report of Detective Brevet Sergeant Justin Leverington sets out in detail the timeline of events concerning Mr Apostolidis’ custody and health issues2.

4.2. Detective Brevet Sergeant Leverington has not identified any material deficiency in Mr Apostolidis’ care while in custody which included treatment for his heart condition which necessitated his transfer to the Royal Adelaide Hospital for treatment and surgery. Mr Apostolidis' cancer diagnosis was not made until he was released on home detention bail. I have no reason to differ from Mr Leverington’s analysis of Mr Apostolidis’ care.

4.3. Mr Apostolidis’ electronic monitoring had been removed when his condition was considered terminal. This was appropriate.

5. Conclusions 5.1. Mr Apostolidis’ custody was lawful.

5.2. Mr Apostolidis died of natural causes due to the progression of cancer which had spread to his lungs, bones and heart. His death was not unexpected. He was receiving palliative care in the weeks prior to his death. There is no suggestion that his custodial status contributed to his death.

6. Recommendations 6.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Home Detention; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 12th day of June, 2019.

Deputy State Coroner Inquest Number 35/2018 (2123/2015) 2 Exhibit C11a