Coroner's Finding: SOMMERVILLE Adam

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 9th day of April and the 21st day of May 2020, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Adam Sommerville.

The said Court finds that Adam Sommerville aged 73 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 29th day of June 2016 as a result of metastatic small cell lung cancer and sepsis. 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 Adam Sommerville was born on 31 May 1943 and died on 29 June 2016 at the age of 73 years. A pathology review of Mr Sommerville’s medical records by Dr Iain McIntyre in discussion with Professor Roger Byard, specialist forensic pathologist, from Forensic Science South Australia was tendered to the Court1. The cause of death is stated as metastatic small cell lung cancer and sepsis, and I so find.

1.2. Mr Sommerville's body was identified by his daughter, Ms Adrina Epworth2. At the time of his death Mr Sommerville was in the custody of the Department for Correctional Services. As such, his was a death in custody requiring a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003.

1 Exhibit C2 2 Exhibit C1

1.3. On 9 November 2012 Mr Sommerville had been arrested for child sex offences committed between 1985 and 1987. He was granted bail on that date.

1.4. On 26 May 2015 he was convicted of several sexual offences in the District Court of South Australia and remanded in custody. He began serving his sentence on that day and was at the Adelaide Remand Centre before he was transferred to Yatala Labour Prison. Mr Sommerville was sentenced to a head sentence of eight years with a nonparole period of 18 months3. Mr Sommerville died just over 13 months later. The low non-parole period was directly linked to his state of health.

2. Medical history 2.1. Mr Sommerville presented to Dr Thean Tan at the Lyell McEwin Hospital in September 2014 with a right lower lobe lung lesion during the treatment of stage 2 bowel cancer4.

Dr Tan was treating Mr Sommerville as the medical oncologist throughout the course of his illness. A biopsy confirmed the presence of small cell lung cancer.

Mr Sommerville underwent four cycles of chemotherapy with six weeks of radiotherapy at the North Adelaide Cancer Centre at the Lyell McEwin Hospital. He completed chemotherapy in December 2014 and underwent a prophylactic cranial irradiation (PCI) in February 2015.

2.2. In May 2015 Mr Sommerville experienced a relapse of his cancer. He had symptomatic progression of the left trapezius muscle manifesting as a painful lump. He underwent palliative radiotherapy with Dr Scott Carruthers from the Department of Radiotherapy at the Royal Adelaide Hospital (RAH).

2.3. At the time of his remand in custody Mr Sommerville presented at the Adelaide Remand Centre with a diagnosis of small cell lung cancer, ischaemic heart disease, hypertension, asthma, hyperlipidaemia and gastric reflux. Mr Sommerville was transferred to Yatala Labour Prison on 3 June 2015. He was treated at the health centre for pain and symptom management in consultation with the Department of Medical Oncology and Palliative Care Team at the RAH.

2.4. On 7 September 2015 Mr Sommerville was admitted to the RAH for chemotherapy.

The chemotherapy was put on hold due to the presence of a chest infection of a lung lesion. The chest infection was treated with two weeks of antibiotics in consultation 3 Exhibit C9 – Sentencing remarks of His Honour Judge Muscat dated 2 July 2015 The sentence was backdated to 26 May 2015 4 Exhibit C3

with the infectious disease team at the RAH. He was returned to Yatala Labour Prison on 10 September 2015. He was then transferred to Mount Gambier Prison on 18 September 2015 and had several transfers from Mount Gambier Prison to Yatala Labour Prison so that he could be continually assessed and treated at the RAH.

2.5. On 9 October 2015 Mr Sommerville commenced Norspan, a fairly potent analgesia used for pain relief in the treatment of cancer. On 4 November 2015 he underwent radiotherapy at the RAH and on 26 November 2015 he was admitted to the Mount Gambier Hospital for 36 hours of IV amoxicillin. Mr Sommerville was permanently transferred back to Yatala Labour Prison on 23 March 2016 as the care he required was greater than Mount Gambier's Prison could provide. Furthermore, the travelling back and forth was taking its toll on his health.

2.6. In March 2016 Mr Sommerville presented at the RAH with a significant enlarged mass which was engulfing his neck. He received urgent inpatient radiotherapy due to his significant discomfort. Dr Tan's prognosis at the time was the cancer appeared to have stabilised, clinically, with shrinkages of the neck mass. Dr Tan determined that Mr Sommerville was well enough to continue treatment as an outpatient while in the Yatala Labour Prison infirmary.

2.7. Mr Sommerville's condition deteriorated following completion of his fourth cycle of CAV chemotherapy with signs of cancer progression.

2.8. On 9 June 2016 he was admitted to the RAH for aggressive fluid resuscitation antibiotic therapy. He subsequently developed a clostridium difficile diarrhoea which was treated with further antibiotics. During this time his cancer had progressed further as evidenced by extension of the cutaneous metastasis involving nearly 25% of his posterior chest wall.

3. Mr Sommerville’s decline and ultimate death 3.1. During his end stage care medical staff advocated for Mr Sommerville to be placed at Gawler Hospital so he could be closer to his partner, Ms Margaret Holmes, but this was not approved by the Department for Correctional Services. A $40 fuel voucher was provided to Ms Holmes from the Social Work and Counselling Department to assist her travel. The Department for Correctional Services allowed fairly open access to Ms Holmes to visit Mr Sommerville for end of life care and support.

3.2. Mr Sommerville was approved to be transferred to Modbury Hospice on 28 June 2016, but his condition rapidly deteriorated and transport was no longer appropriate. Comfort care was fully implemented on 29 June 2016. On that day Dr Tan and his team noted that Mr Sommerville had entered the terminal phase of his illness and subcutaneous morphine and Haloperidol was implemented. Mr Sommerville passed away on 29 June 2016 at 10:05pm.

4. Issue considered at inquest and conclusion 4.1. Mr Sommerville's partner of 12 years, Margaret Holmes, provided a statement to the Court5. Ms Holmes raised concerns about the treatment Mr Sommerville received whilst in prison. She stated that conditions at Yatala Labour Prison and the treatment of Mr Sommerville were inadequate and 'disgusting'. She raised no concerns about his treatment at the RAH.

4.2. Mr Sommerville’s death in custody was investigated by Detective Brevet Sergeant Ann Schaefer of SAPOL’s Major Crime Investigation Branch. Detective Schaefer’s investigation found that the care and treatment provided by SA Prison Health Service and the RAH was appropriate in the circumstances. It was also determined that Mr Sommerville was in lawful custody at the time of his death with a pre-existing diagnosis of cancer which eventually took his life. Detective Schaefer did not find any evidence to support Ms Holmes' claims. I agree with the findings of Detective Schaefer.

5. Recommendations 5.1. I have no recommendations to make 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 21st day of May, 2020.

Deputy State Coroner Inquest Number 13/2020 (1181/2016) 5 Exhibit C4