Coroner's Finding: CANHAM Craig Nicholas

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 February and the 8th day of May 2020, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Craig Nicholas Canham.

The said Court finds that Craig Nicholas Canham aged 63 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at Northfield, South Australia on the 8th day of October 2016 as a result of cardiac arrhythmia complicating recent posterior myocardial infarct with underlying hypertrophic cardiomyopathy. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Craig Nicholas Canham died on 8 October 2016 at Yatala Labour Prison (YLP). He was 63 years of age.

1.2. A post mortem examination of Mr Canham’s remains was conducted by Dr John Gilbert, a forensic pathologist at Forensic Science South Australia. A specialised examination of the heart was performed by Dr Anthony Thomas of the Flinders Medical Centre. Dr Gilbert’s post mortem report1 expresses the cause of Mr Canham’s death as cardiac arrhythmia complicating recent posterior myocardial infarct with underlying hypertrophic cardiomyopathy. I accept that evidence and find that to have been the cause of death.

1 Exhibit C2

2. Reason for inquest 2.1. Mr Canham had been sentenced to 12 years imprisonment with a non-parole period of eight years in respect of two counts of persistent sexual exploitation of a child. At the time of his death Mr Canham was still serving that sentence within the YLP. His death was a death in custody. For that reason this inquest was mandatory pursuant to the provisions of the Coroners Act 2003. These are the findings of that inquest.

3. Background 3.1. Mr Canham had a medical history that included obesity, hypertension, spinal cord stenosis, cervical and lumbar degenerative disease, Scheuermann's disease, Paget's disease, and hypertrophic cardiomyopathy which was diagnosed when he was 27 years of age. Throughout his time in custody Mr Canham suffered from chronic back pain and knee pain. He was six foot six inches in height.

3.2. In January 2015 Mr Canham was transferred to Mount Gambier Prison. Due to his poor health and the fact that Mount Gambier Prison did not have the necessary facilities to appropriately manage his medical and physiotherapy needs, from time to time he was transferred between Mount Gambier Prison, Yatala Labour Prison and Port Augusta Prison. Specifically, between 15 April 2015 and his death on 8 October 2016, Mr Canham was transferred from Mount Gambier Prison to Yatala Labour Prison on eight occasions. On each occasion, with the exception of the final transfer, he was returned to Mount Gambier Prison.

3.3. While incarcerated at the Mount Gambier Prison Mr Canham was under the care of Dr Letitia Kavanagh who is a private general medical practitioner. Dr Kavanagh endeavoured to manage Mr Canham’s pain relief requirements. In her witness statement2 Dr Kavanagh refers to the inadequacy of facilities at Mount Gambier Prison.

She states that Mount Gambier Prison does not have the specialist facilities to provide proper care for prisoners with Mr Canham's extensive medical conditions. She asserts that the bedding was inadequate, that his constant transfers caused significant pain and that the Mount Gambier Prison does not have facilities to administer occupational therapy. Nevertheless, in Dr Kavanagh's opinion, the facility provided Mr Canham with the best care it was able to provide. However, she states that he should have been housed at the YLP or at another correctional institution closer to Adelaide. In 2 Exhibit C13

Dr Kavanagh’s opinion the lack of proper facilities at Mount Gambier contributed to Mr Canham's back pain. She states, however, that these circumstances would have had little or no impact on his heart and did not contribute to the cause of death in any event.

I have accepted that evidence.

4. The events surrounding Mr Canham’s death 4.1. On 30 September 2016 Mr Canham complained of indigestion to prison staff at Port Augusta Prison. He was treated with simple analgesia and antacid. The pain recurred transiently overnight and during the following morning. At 2pm he reported continual central chest pain. As a result he was transported to Port Augusta Hospital.

4.2. An ECG confirmed ST elevation acute coronary syndrome. Mr Canham was treated with a thrombolytic agent followed by anti-coagulation.

4.3. On 1 October 2016 Mr Canham was transferred with continuing chest pain to the Lyell McEwin Hospital (LMH) where he was under the care of Dr Margaret Arstall. Another ECG revealed continued ST elevation suggesting that thrombolysis had not achieved complete reperfusion. As a result Mr Canham underwent heart surgery. A coronary angiogram demonstrated significant residual thrombus and stenosis in the right coronary artery. The artery was stented with good effect.

4.4. Mr Canham was an inpatient at the LMH until 5 October 2016. During this period he reported no further chest pain consistent with angina, and no further cardiac arrhythmias were detected. On 5 October 2016 he was discharged to YLP. At discharge he was considered stable and well from a cardiac perspective. Mr Canham was admitted to the infirmary at YLP where he occupied a single room.

4.5. On 8 October 2016 at approximately 3:15pm Mr Canham spoke with nurse Sally Noyes3. At that time he displayed no signs of distress or discomfort. A short time later the prisoner in the room opposite heard a loud crash from Mr Canham's room. The prisoner could see that the deceased was on the floor and so he called for assistance.

4.6. Corrections Officer Townsend and nurses Sally Noyes and Elizabeth Sloggett entered Mr Canham's room. He was unresponsive, not breathing and was pulseless. They commenced CPR. The South Australia Ambulance Service was called. Four ambulance officers and the nurses attempted to resuscitate Mr Canham using assisted 3 Exhibit C6

ventilation, adrenaline and saline. He remained in asystole with occasional pulseless electrical activity. The ambulance intensive care paramedic, Ms Mardy Hunt, pronounced Mr Canham dead at 4:14pm on 8 October 2016.

5. Conclusions 5.1. The circumstances surrounding Mr Canham’s death were thoroughly investigated by Detective Brevet Sergeant James Clegg of the SAPOL Corrections Section4.

5.2. For obvious reasons Mr Clegg concluded that Mr Canham was lawfully in custody at the time of his death. I find that to have been the case.

5.3. Mr Clegg also has expressed the conclusion in his report that the Mount Gambier Prison did not have the necessary facilities available to properly care for the deceased having regard to his physical injuries and pain. This view of the matter echoes that of Dr Kavanagh. However, it seems clear that while Mr Canham’s pain issues and physical complaints would have been extremely uncomfortable for him, particularly having regard to the amount of travel that he would have had to undergo in an uncomfortable vehicle, and while this would seriously have affected the quality of his life, it did not contribute to his death. I so find.

5.4. I draw the views of Dr Kavanagh and the investigating officer, Mr Clegg, to the attention of the Department for Correctional Services and G4S which is the entity that operates the Mount Gambier Prison.

5.5. Mr Canham’s cause of death was plainly related to an underlying heart condition. I set out here an extract from the post mortem report of Dr John Gilbert: 'Whilst an inmate at Pt Augusta Prison, he presented with a 3-day history of intermittent epigastric and chest pain on 01/10/2016 and showed ECG changes consistent with an inferior STEMI. He was thrombolysed with tenecteplase and given aspirin and clopidogrel at the Port Augusta Hospital and then transferred to the Lyell McEwin Hospital. An angiogram showed thrombotic occlusion of the proximal and mid-course of the right coronary artery. This was treated with angioplasty and stenting with two drug eluting stents. This resulted in satisfactory recovery of coronary artery flow. Echocardiography on 04/10/2016 showed significant left ventricular hypertrophy most prominent in the basal interventricular septum and there was inferior hypokinesis attributable to the myocardial infarct. Mild to moderate mitral valve regurgitation was also noted.' 5 4 Exhibit C17a 5 Exhibit C2a, page 1

5.6. Dr Gilbert reported that the cardiac pathology at post mortem confirmed the presence of a recent, approximately ten day old transmural myocardial infarct (heart attack) involving walls of the left and right ventricles of the heart and other areas of the heart.

Dr Gilbert found that the right coronary artery was stented in accordance with the operation that Mr Canham had undergone. Each of the epicardial coronary arteries also showed severe coronary atherosclerosis. The heart also showed features of hypertrophic cardiomyopathy. The mitral valve was mildly stenotic with features of rheumatic valvular disease. Dr Gilbert opines that the sudden death in Mr Canham’s case can be readily explained on the basis of a cardiac arrhythmia stemming from the recent myocardial infarction and also predisposed to by the pre-existing hypertrophic cardiomyopathy. Rheumatic disease of the mitral valve was a possible aggravating factor. I accept all that evidence. All of this evidence tends to support the notion that Mr Canham’s custodial circumstances at the Mount Gambier prison did not contribute to his death.

5.7. Dr Gilbert has recommended that in view of Mr Canham’s hypertrophic cardiomyopathy, which is a genetic cardiovascular disease and is most frequently transmitted as an autosomal dominant trait, screening of the deceased's blood relatives for this disorder is strongly recommended if this has not already been undertaken.

5.8. I find that Mr Canham’s death from cardiac disease could not have been prevented. His custodial circumstances do not appear to have contributed to his death.

6. Recommendations 6.1. There are no recommendations in this matter.

Key Words: Death in Custody; Prison; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 8th day of May, 2020.

Deputy State Coroner Inquest Number 3/2020 (1951/2016)