Coroner's Finding: WATSON James David

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 James David Watson.

The said Court finds that James David Watson aged 64 years, late of Yatala Labour Prison, Peter Brown Drive, Northfield, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 30th day of January 2016 as a result of respiratory failure and sepsis on a background of end-stage disseminated small cell lung cancer. 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 James David Watson died on 30 January 2016 at the Royal Adelaide Hospital. He was 64 years of age. The cause of death at pathology review was respiratory failure and sepsis on a background of end-stage disseminated small cell lung cancer1, and I so find.

1.2. At the time of Mr Watson's death he was a prisoner serving a lengthy custodial sentence for the offence of murder. 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 section21(1)(a) of that Act.

1 Exhibit C2a

2. Background and medical history 2.1. Mr Watson was arrested in September 1985 on suspicion of the murder of a 14-yearold schoolgirl, Fiona Perkins. He was found guilty by a jury and sentenced to life in prison with a non-parole period of 24 years on 29 August 1986. When the Truth in Sentencing Act came into operation in 1994, the non-parole period was recalculated to 16 years and four months, putting Mr Watson's parole expiry date as January 2002. The first bid by Mr Watson for parole was refused by the Parole Board. On every subsequent occasion the Board supported his release, but the Governor of the day refused it. Hence he was still in custody at the time of his death in 2016.

2.2. The Prison Health records reveal that Mr Watson had a number of ailments over the decades of his imprisonment. They included chronic venous insufficiency, hepatitis C, chronic neuropathic pain, obstructive sleep apnoea, asthma, hypotensive cellulitis, deranged liver function, congestive cardiac failure and osteoporosis.

2.3. In December 2014 Mr Watson had a fall which caused a leg fracture. He was transferred to the Yatala Labour Prison for surgery to be organised and for rehabilitation to be provided. Once at Yatala, and due to his ongoing health needs, he was admitted to the infirmary on an ongoing basis. He remained at the Yatala Labour Prison.

2.4. In August 2015 Mr Watson complained of lower abdominal pain which had been getting progressively worse. He was referred to the Royal Adelaide Hospital for tests which revealed extensive small cell neuroendocrine malignancy. The discharge summary stated that whilst a course of chemotherapy was indicated, Mr Watson's condition was ultimately terminal and an outpatient's palliative care appointment was arranged for September 2015. Mr Watson underwent therapeutic chemotherapy with some good effect in the short term, and this was done as an outpatient while he was housed at the Yatala Labour Prison 24-hour Health Centre.

3. Mr Watson’s death 3.1. On 19 January 2016 Mr Watson suffered a collapse and was transferred to the Emergency Department of the Royal Adelaide Hospital. On examination Mr Watson was febrile and hypotensive, but with good oxygen saturations at that time. He was prescribed antibiotics for leg cellulitis and transferred to the medical oncology ward.

Once there he was seen by consultant oncologist, Dr Tan. A chest X-ray showed

features of respiratory distress syndrome and fluid overload requiring diuretic medication. Mr Watson also became neutropenic. His condition continued to decline despite maximal therapy.

3.2. Mr Watson, with the support of his sister who was present in the weeks prior to his death, gave informed consent to dispense with cardiopulmonary resuscitation or invasive procedures in the event of a cardiorespiratory arrest. With that in place Mr Watson was transferred to the palliative care team at the Royal Adelaide Hospital on 25 January 2016.

3.3. From that time Mr Watson was managed with subcutaneous infusion of morphine and Midazolam. Both the medical oncology team and the palliative care team had input into his end-of-life pathway to keep him comfortable. He died on 30 January 2016.

4. Conclusion 4.1. The care provided by the Royal Adelaide Hospital was appropriate and guided by the wishes of Mr Watson.

4.2. I have no recommendation to make in this case.

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 13/2019 (0220/2016)