Coroner's Finding: COLLINS Robert Edwin

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 5th day of February 2019 and the 15th day of April 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Robert Edwin Collins.

The said Court finds that Robert Edwin Collins aged 64 years, late of Yatala Labour Prison, Peter Brown Drive, Northfield, South Australia died at Northfield, South Australia on the 19th day of September 2015 as a result of end-stage interstitial lung 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. Mr Robert Edwin Collins was 64 years of age when he died at the Yatala Labour Prison in Northfield on 19 September 2015.

1.2. A review of Mr Collins’ medical history was conducted by Dr Willis from Forensic Science South Australia who expressed his opinion as to Mr Collins’ cause of death as end stage interstitial lung disease, and I so find.

1.3. At the time of his death Mr Collins was a prisoner having been found guilty of committing an offence of persistent sexual exploitation against a child. He had been sentenced to 12 years imprisonment. All avenues of appeal had been dismissed and Mr Collins was a serving prisoner in lawful custody at the time of his death. His was 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.

2. Background and medical history 2.1. Ms Elizabeth Sloggett is the nurse management facilitator for SA Prison Health Service.

Ms Sloggett provided a statement to the Court1. She reviewed the case notes for Mr Collins. She outlined Mr Collins' past medical history. The most serious issues were advanced interstitial pulmonary fibrosis, interstitial lung disease complicated with bouts of viral pneumonia, hypertension, peripheral vascular disease, osteoarthritis, arterial fibrillation and chronic leg ulcers.

2.2. Ms Sloggett stated that Mr Collins was at risk due to his poor mobility, obesity and peripheral vascular disease. He had been prescribed a range of medication. On admission he had weighed 176 kilograms, suffered from diabetes and was documented as a poor historian of his medical history. He was being managed at the Yatala Health Centre for 24-hour nursing care.

2.3. Mr Collins’ health conditions deteriorated on 16 and 17 July 2015 and he was admitted to the Royal Adelaide Hospital (RAH) for cataract surgery. He had a further admission to the RAH on 27 July 2015 for management of community acquired pneumonia.

2.4. On 23 August 2015 Mr Collins was transferred to the RAH due to his deteriorating conditions. He remained in hospital until 1 September 2015.

2.5. Whilst at the RAH a seven-step pathway resuscitation plan was discussed and signed by him on 27 August 2015. The plan documented that he was not to receive any treatment that prolonged his life and he was not for resuscitation. He was again reviewed by the palliative care team on 31 August 2015. His prognosis was very poor and comfort care was discussed and agreed.

2.6. From 1 September 2015 until his death Mr Collins was managed in the Yatala Health Centre. Ms Sloggett stated that the level of care provided to Mr Collins was equivalent to that provided to a high-level nursing home patient. This included full support for activities of daily living, medication management and pain management.

3. Mr Collins’ death is discovered 3.1. Correctional Officer Lowe provided a statement to the Court2. He stated that he was on duty at 6:25am on 19 September 2015 and completed his routine patrol of prisoners in 1 Exhibit C7 2 Exhibit C4

secured rooms. During his patrol he did not observe prisoners who displayed any signs of distress.

3.2. At 7:30am Registered Nurse Dolot entered Mr Collins’ room and could not find a pulse on the wrist. She took a pulse from his carotid artery on the right side of his neck. She stated that she could hear a very faint and slow pulse3. Ms Dolot did not perform any life saving measures as she was aware that Mr Collins was not for resuscitation.

3.3. Registered Nurse Jason Grech confirmed Mr Collins’ was deceased at 7:35am.

4. Police investigation into Mr Collins’ death in custody 4.1. A report was provided to the Court by Detective Brevet Sergeant Chilman4. Detective Chilman set out the criminal process in relation to which Mr Collins was convicted and the medical issues which arose at the time. In Judge Boylan’s sentencing remarks His Honour stated that had received advice from the Director of Prison Health Services and from the Department of Correctional Services that despite Mr Collins' health problems, he could be accommodated in the prison system, albeit with difficulty. Detective Chilman had no criticism of the care afforded to Mr Collins, and I have reached the same conclusion.

5. Recommendations 5.1. I am satisfied that the medical treatment that was administered to Mr Collins during his period of incarceration and hospitalisation was lawful and appropriate and I have no recommendations to make in this matter.

Key Words: Death in Custody; Prisoner; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 15th day of April, 2019.

State Coroner Inquest Number 5/2019 (1709/2015) 3 Exhibit C3 4 Exhibit C11a