Coroner's Finding: DEERING Peter Charles

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 15th day of May and the 25th day of June 2020, by the Coroner’s Court of the said State, constituted of Brian Malcolm Nitschke, Deputy State Coroner, into the death of Peter Charles Deering.

The said Court finds that Peter Charles Deering aged 66 years, late of Glenside Hospital, 226 Fullarton Road, Glenside, South Australia died at The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, South Australia on the 6th day of March 2017 as a result of metastatic oesophageal cancer. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Peter Charles Deering was born on 1 January 1951 and died on 6 March 2017 at the Queen Elizabeth Hospital. He was 66 years old.

1.2. Dr Samuel Greenwood from the Queen Elizabeth Hospital Palliative Care Team provided an opinion as to the cause of Mr Deering’s death in his ‘Death Report to Coroner - Medical Practitioner’s Deposition’ as metastatic oesophageal cancer, and I so find. No post mortem or pathology review was performed in relation to Mr Deering.

His death was expected.

2. Reason for inquest 2.1. This is a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mr Deering was detained indefinitely under section 77A of the Criminal Law Consolidation Act 1935. Section 77A was subsequently repealed and replaced by

sections 23 and 24 of the Criminal Law Sentencing Act 1988 and then replaced again, after Mr Deering’s death, by the current sections 57 and 59 of the Sentencing Act 2017.

At the time of his death, Mr Deering was detained under a Licence Order pursuant to section 24 of the repealed Criminal Law Sentencing Act1.

2.2. There are no concerns in relation to the lawfulness of custody.

3. Background 3.1. Mr Deering was not married and had no children. He had three siblings but was only in contact with his sister, June Deering, who lives in Queensland.

3.2. On 10 September 1986 Mr Deering was convicted of four counts of rape involving one victim. On 16 December 1986, he was sentenced to nine years imprisonment and declared incapable of controlling his sexual instincts. Pursuant to the relevant legislation at the time2 an order was made that he be detained in an institution at Her Majesty’s pleasure.

3.3. Mr Deering was detained at James Nash House before his transfer to Glenside Inpatient Rehabilitation Services on 17 March 1997 when he was released on Licence pursuant to Section 24 of the Criminal Law (Sentencing) Act 1988. This was due to expire on 16 March 2000 and was thereafter reviewed approximately every three years.3

3.4. Mr Deering remained at Glenside Hospital until his health began to deteriorate in 2016.

4. Mr Deering’s criminal and medical history 4.1. Between 1975 and 1986 Mr Deering had a criminal history that included assault police, assault occasioning actual bodily harm, larceny, drug offending, abduct person for ransom, assault with intent to commit felony and false imprisonment.4

4.2. Mr Deering had a medical history that included lymphadenopathy, Chronic Obstruction Pulmonary Disease, dysphagia, schizophrenia, Parkinson’s Disease, anaemia and osteo-arthritis. Mr Deering was a smoker.5 1 Exhibits C7a to C7e 2 Section 77A of the Criminal Law Consolidation Act 1935 3 Final Separation Summary, Glenside Hospital, 27 January 2017 4 Investigating Officer’s Report, Exhibit C7, page 13 5 Exhibit C3, pages 3-4

4.3. Mr Deering had a long-standing history of paranoid schizophrenia, first diagnosed in 1979 and by 1985 he had approximately six admissions to Glenside Hospital.

5. Mr Deering’s decline in health and death 5.1. In late 2016 Mr Deering was investigated for weight loss of 7kg and dysphagia6. He was admitted to the Royal Adelaide Hospital on 6 January 2017 and remained there until 17 January 2017 when he was returned for three days to Glenside Hospital. A CT scan at the Royal Adelaide Hospital showed metastatic disease involving his lung, liver, spleen and lymph nodes. An endoscopy confirmed a 12cm long oesophageal mass and histology of the mass confirmed adenocarcinoma7. In consultation with Mr Deering it was decided that he would be provided with palliative care.

5.2. Mr Deering was admitted to The Queen Elizabeth Hospital on 20 January 2017 after being transferred from Glenside Hospital. Mr Deering remained at The Queen Elizabeth Hospital receiving palliative care until his death.

5.3. Dr Emma Burns, Palliative Consultant, described Mr Deering during his admission at The Queen Elizabeth Hospital as: '.. a very settled patient…He was generally quite comfortable and he didn’t identify many distressing issues. The management of his physical symptom issues was not complicated – he was symptomatically a relatively straightforward patient to look after.' 8

5.4. Dr Burns stated that Mr Deering’s clozapine levels were difficult to manage, however once addressed he stabilised for a period and did not require a great deal of medical input. Mr Deering’s condition deteriorated very slowly and he maintained his ability to mobilise around his room until the last days of his life.9

5.5. Registered Nurse, Sita Thapa, conducted a daily medication round with Mr Deering at about 8:45am on 6 March 2017. He was unresponsive and breathing in a very shallow manner.10

5.6. Ms Janina Urban was a Ward Support Attendant at The Queen Elizabeth Hospital. At about 9:15am on 6 March 2017, Ms Urbin entered Mr Deering’s room of the Palliative 6 Difficulty swallowing 7 Exhibit C4, page 3 8 Exhibit C4, page 10 9 Exhibit C4, page 11 10 Exhibit C3, page 2

Care ward. Ms Urbin noticed that Mr Deering was not breathing and his skin was a different colour. She spoke with Nurse Thapa and said that she thought that Mr Deering had passed away.11 Nurse Thapa entered Mr Deering’s room and checked his pulse, confirming that his heart was no longer beating. Dr Samuel Greenwood certified life extinct at 9:25am.12

6. Conclusions and recommendations 6.1. A death in custody investigation was undertaken by Brevet Sergeant Alby Van Donderen of the Eastern Adelaide Criminal Investigation Branch13. Brevet Sergeant Van Donderen concluded that Mr Deering was in lawful detention at the time of his death. Mr Deering’s death was expected.

6.2. The investigation further revealed that the care and treatment Mr Deering received both at the Royal Adelaide Hospital and The Queen Elizabeth Hospital was appropriate in the circumstances. I agree with the conclusions expressed by Brevet Sergeant Van Donderen.

6.3. I have no recommendations to make in this matter.

Key Words: Death in Custody; Natural Causes; Criminal Law Consolidation Act In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 25th day of June, 2020.

Deputy State Coroner Inquest Number 29/2020 (0426/2017) 11 Exhibit C2 12 Death Report to Coroner Medical Practitioner’s Deposition 13 Exhibit C7