Coroner's Finding: AZAPARTI Wyatt William

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 3rd and 4th days of April 2019 and the 7th day of June 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Wyatt William Azaparti.

The said Court finds that Wyatt William Azaparti aged 45 years, late of Port Augusta Prison, Augusta Highway, Stirling North, South Australia died at Stirling North, South Australia on or about the 6th day of April 2016 as a result of mixed drug toxicity (methadone and pregabalin) with possible contributing factor of morbid obesity. The said Court finds that the circumstances of his death were as follows:

1. Introduction, reason for Inquest and cause of death 1.1. Mr Wyatt William Azaparti died on or about 6 April 2016 while he was serving a period of imprisonment at the Port Augusta Prison. His death was therefore 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.

1.2. An autopsy was performed and the cause of death given by the forensic pathologist was mixed drug toxicity (methadone and pregabalin) with possible contributing factor of morbid obesity, and I so find.

1.3. Mr Azaparti was serving a term of imprisonment for the offences of aggravated serious criminal trespass, aggravated causing harm, theft and assault which occurred on 24 August 2014. He was 45 years of age.

2. Background and the circumstances leading to Mr Azaparti’s death 2.1. Mr Azaparti had an extensive criminal history. Amongst other offending he was a registered ANCOR sex offender for offences perpetrated in 2013 against a 13 year old girl.

2.2. Mr Azaparti suffered a serious foot injury sometime in the 1980s. As a result he suffered chronic pain. He used illicit drugs during his adult life, including heroin. He had been on the opioid substitution program between November 2013 and February 2014 with the Drug & Alcohol Services South Australia. He had chosen to leave that program in February 2014. When he was admitted to Yatala Labour Prison in August 2014 following arrest for the charges which resulted in the sentence he was serving at the time of his death, he complained of suffering from opioid withdrawal and claimed that he had been taking heroin in the community.

2.3. Mr Azaparti was provided with symptomatic treatment. He had requested to be placed on the methadone substitution program within the prison. That program is referred to in the notes as the POST program1. He was assessed for eligibility for that program by Dr Moskwa, a SA Prison Health Service doctor on 19 September 2014. Dr Moskwa noted that he had provided an inconsistent story in several respects. Dr Moskwa noted that Mr Azaparti had left the program in the community of his own volition. He noted that Mr Azaparti had now adopted a different attitude in prison. It was Dr Moskwa’s opinion that Mr Azaparti was not interested in getting off the illicit drugs such as heroin, but wanted to have something as a substitution when he could not get heroin. It was Dr Moskwa’s opinion that Mr Azaparti was not eligible for participation in the POST program. I am satisfied that this was a correct assessment and a proper application of the drug substitution program.

2.4. Notwithstanding Dr Moskwa’s decision to refuse access to the POST program, in early 2015 Dr Moskwa referred Mr Azaparti to the Pain Management Unit within the Royal Adelaide Hospital for an assessment. He provided a comprehensive letter of referral detailing accurately Mr Azaparti’s history. After assessment, Dr Briscoe, the Director of the Pain Management Unit, provided Dr Moskwa with a report. She stated that Mr Azaparti needed to ‘recognise that the current recommendation is that opioids do 1 Prison Opioid Substitution Treatment program

not have a role in the management of chronic pain’. She said that the Pain Management Unit would not consider putting him on opioids.

2.5. It appears that as a result of his inability to obtain entry to the drug substitution program in prison, Mr Azaparti resorted to obtaining methadone by unauthorised means. The only means at his disposal was through the practice of drug diversion that operated within the prisons. That involves obtaining regurgitated stomach contents from a prisoner who is on the methadone program and who has recently consumed his methadone dose. Given that Mr Azaparti was not on the POST program, and given the report of his cellmate that on the day before his death he consumed methadone, and given the presence of methadone in his body as found at autopsy, it is clear that Mr Azaparti did indeed resort to this illicit and dangerous method of obtaining and consuming methadone.

2.6. The evidence in this case did not enable me to draw any conclusion as to the source of the methadone. Certainly Mr Azaparti’s cellmate told a police officer on the day of Mr Azaparti’s death that he had consumed methadone the previous day and indicated the container in the cell that was used for that purpose. For reasons that have not been explained, the police officer did not seize the container and it appears that in due course it was thrown out as rubbish by the prison staff. As a consequence, an opportunity to identify the source of the methadone was lost.

2.7. I heard evidence about the efficacy of the methadone program within the prison, and particularly about the need for prisoners to be supervised after consumption of methadone to prevent them from regurgitating their stomach contents. It appears that the policy has changed and changed again in that respect. It appears also from the evidence that methadone substitution is no longer in vogue within the prison system due to the availability of other illicit substances such as ice and buprenorphine which, to use the words of the witness Ms Allen, who is the clinical services coordinator for Port Augusta Prison, are drugs which are ‘coming in through the front door’.

2.8. Conclusion 2.9. I find that the cause of Mr Azaparti’s death was as previously stated. The source of the methadone was another unidentified prisoner who was actually on the methadone program within Port Augusta Prison.

3. Recommendations 3.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Prisoner; Drug overdose In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 7th day of June, 2019.

State Coroner Inquest Number 18/2019 (0620/2016)