Coroner's Finding: THOMPSON Wayne Robert McInnes

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 7th day of May and the 18th day of June 2020, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Wayne Robert McInnes Thompson.

The said Court finds that Wayne Robert McInnes Thompson aged 33 years, late of 13 Argosy Street, Seaford, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 3rd day of December 2015 as a result of multi organ failure due to sepsis on a background of severe ischaemic cardiomyopathy. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Wayne Robert McInnes Thompson was born on 24 February 1983 and died at the Flinders Medical Centre on 3 December 2016, aged 33 years. Mr Thompson was formally identified by his brother, Michael Thompson.

1.2. A pathology review of Mr Thompson’s medical records and clinical history was undertaken by Dr Iain McIntyre from Forensic Science South Australia. In his report Dr McIntyre stated the cause of Mr Thompson's death as multi-organ failure due to sepsis with severe ischaemic cardiomyopathy1, and I so find.

1.3. Mr Thompson was on home detention bail at the time of his death. On 5 July 2016 Mr Thompson had been remanded in custody following his arrest on drug and firearm charges. He was granted home detention bail on 27 July 2016 in relation to those 1 Exhibit C2a

charges. As such, his death was a in custody2 and subject to a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003.

2. Background and medical history 2.1. Mr Thompson was born in Liverpool, New South Wales and was a man of indigenous heritage. He lived with his father, Mr Clive Thompson3, until he married in his early 20s. Mr Thompson had two daughters from that marriage, Tianna born in 2009 and Savanah born in 2011. Mr Thompson was a qualified metal fabricator and was employed by Fielders for about a decade until his employment ended in early 2014.

Around that time his marriage ended as well.

2.2. After the marriage and until the time of his death Mr Thompson shared custody of Tiana and Savanah with his former wife. Mr Thompson moved to 13 Argosy Street, Seaford in the middle of 2016 and lived with some acquaintances. He lived at that address with Ashlie Hay, her partner, Toby Bracken and George Taka. Ms Hay and Mr Bracken were the leaseholders. Mr Thompson moved to the house when he commenced home detention.

2.3. Ms Hay observed that Mr Thompson had significant health issues4. At about 12:45pm on 30 November 2016 Ms Hay was awoken by Mr Thompson yelling for assistance.

Mr Thompson was sitting on the toilet in very poor health. Mr Thompson told her he was in extreme pain and was going to die. An ambulance was called and took Mr Thompson to the Flinders Medical Centre.

2.4. Mr Thompson had a past medical history of dilated cardiomyopathy and recurrent admissions for heart failure. He had multiple embolic episodes in the past affecting his spleen, kidneys, stomach and lungs. He had a history of substance abuse, including methylamphetamine. Mr Thompson's medical history was significant in his final two years as summarised in the statement of his general practitioner, Dr Shankar Mahadeva5 and expanded upon in the extended notes of the Flinders Medical Centre, Dr Mahadeva and the Department for Correctional Services6.

2 Custody includes home detention bail as defined in the Coroners Act 2003 3 Exhibit C3 4 Exhibit C6 5 Exhibit C7 6 Exhibits C13, C14 and C15

2.5. Dr Shankar Mahadeva was Mr Thompson's general practitioner from 16 November

2011. As his general practitioner, Dr Mahadeva was notified that Mr Thompson was admitted to the Flinders Medical Centre Intensive Critical Care Unit on 7 May 2015.

He had viral myocarditis exacerbated by the use of methylamphetamine. Dr Mahadeva was advised this incident resulted in severe damage to the heart tissue resulting in heart failure.

2.6. On 14 May 2015 Mr Thompson received a laparotomy as part of his intestine had to be removed due to restricted blood flow following the severe damage to his heart a week prior. This surgery resulted in Mr Thompson requiring a colostomy bag. Dr Mahadeva formed the medical opinion that, despite the seriousness of his condition following that health episode, that with good care Mr Thompson's prognosis was reasonable due to his age alone. However, Dr Mahadeva considered that that prognosis was subject to Mr Thompson complying with medication and medical appointments.

2.7. Dr Mahadeva recalled that Mr Thompson was unable or unwilling to comply strictly with the required regime and that was to his detriment. Dr Mahadeva had to actively pursue Mr Thompson, and sometimes his relatives, by phone to manage Mr Thompson's condition and the requisite medical dosages. Mr Thompson failed to attend some scheduled appointments. Dr Mahadeva stated that Mr Thompson's health problems were propagating over time rather than settling to a manageable state.

Dr Mahadeva stated that Mr Thompson was at risk of sudden death by pulmonary embolism. Mr Thompson was prescribed warfarin by his cardiologist to mitigate his risk of severe heart failure. However, unsuccessful compliance with the medication culminated in a pulmonary embolic event that was life threatening.

2.8. On 14 July 2015 Mr Thompson presented at the Flinders Medical Centre with shortness of breath and was admitted for congestive heart failure. He was released on 27 June

2015. On 7 September 2015 Dr Mahadeva changed Mr Thompson's medication to Xarelto as he was either non-compliant or unstable on Warfarin. In the circumstances Warfarin posed a far greater danger than the risk of the blood thinner, Xarelto.

2.9. On 27 October 2015 Mr Thompson was reviewed by his cardiologist, Robert Minson, who noted that he was 'A bit surprised that he has got as bad as he currently is'7.

7 Exhibit C14 – Dyson Family Practice casenotes including letters from Dr Minson

Mr Thompson had gained 14 kg with an oedema to the lower part of the body. His presentation warranted admission, but Mr Thompson declined for family reasons.

2.10. On 4 November 2015 Mr Thompson was admitted to the Flinders Medical Centre for cellulitis and worsening heart failure. He discharged on 8 November 2015. On 6 December 2015 Dr Mahadeva contacted Mr Thompson and advised him that he had dangerously low potassium levels. On 11 March 2016 Mr Thompson was admitted to the Flinders Medical Centre for congestive heart failure and was discharged on 15 March 2016.

3. Mr Thompson’s remand, home detention and decline in health 3.1. On 6 July 2016 Mr Thompson was arrested in relation to drug and firearms offences and was remanded at Yatala Labour Prison. He was admitted to the Prison Health Service and the Royal Adelaide Hospital on 7 July 2016 relating to his pre-existing medical conditions. Mr Thompson remained in custody until granted home detention bail on 27 July 2016 by the Port Adelaide Magistrates Court.

3.2. Mr Thompson attended Dr Mahadeva's surgery on 29 July 2016. On 3 August 2016 Dr Mahadeva reported that Mr Thompson appeared well and his cardiac position was well controlled. He was not experiencing shortness of breath which was confirmed with an oximetry reading confirming good lung and reasonable heart function.

Mr Thompson was tested for illicit substances whilst on home detention on 10 August, 24 August, 28 September and 17 October 2016. On those occasions he tested positive for methylamphetamine and amphetamine. On 30 October 2016 Mr Thompson was admitted to the Flinders Medical Centre with congestive heart failure and he was discharged on 3 November 2016.

3.3. At 2:40pm on 30 November 2016 Mr Thompson was admitted to the Intensive Critical Care Unit at Flinders Medical Centre. He was short of breath, hypoxic and complained of pain in his left leg. He was septic and in cardiogenic shock. Mr Thompson was resuscitated and commenced on vasopressor support and dialysis. He had an intraaortic balloon pump inserted in his right groin. Mr Thompson's medical condition rapidly deteriorated and he was intubated and mechanically ventilated.

3.4. Extracorporeal membrane oxygenation was initiated. Mr Thompson grew streptococcus pyogenes from his blood. His cellulitis worsened over 48 hours whilst

on maximum antibiotic and cardiorespiratory support. He was deemed unsuitable for any surgical measures. His grave prognosis was discussed with his family. On 3 December 2016 a decision was made to withdraw artificial life support and continue comfort care.

3.5. On 3 December 2016 intensive care specialist nurse, Nadia Ezhari8, was responsible for the nursing of Mr Thompson. Nurse Ezhari stated that Mr Thompson was last seen alive at 4:10pm. Dr Deepak Saini certified life extinct at 4:15pm.

4. Coronial investigation 4.1. Due to Mr Thompson's death being deemed a death in custody a police investigation was conducted. Detective Brevet Sergeant Simon Smithies conducted a thorough investigation into the death of Mr Thompson and provided a detailed report to the State Coroner9. Detective Smithies investigation revealed no concerns in relation to Mr Thompson's care and treatment at the Flinders Medical Centre, or in relation to the conditions of Mr Thompson's home detention.

4.2. Mr Thompson's father, Mr Clive Thompson, noted in his statement that his son was very depressed in the last month or so before he died. Mr Clive Thompson was not aware of his son suffering from any mental health issues prior to that time. Mr Clive Thompson stated his son was frustrated with his home detention conditions 'as he was unable to make medical appointments on multiple occasions'10. Mr Clive Thompson believed his son had to cancel some appointments with Dr Mahadeva as he could not confirm them with his Community Corrections officer. He understood he was also frustrated with limitations due to his home detention restricting his ability to leave his home detention address.

4.3. Detective Smithies reviewed the home detention documentation and found a call was made to the Community Corrections officer to collect Mr Thompson's heart medication on 28 July 2016. That was the day after his release on home detention. Following that a pass was arranged to purchase medication on the following day, 29 July 2016.

Dr Mahadeva confirmed that Mr Thompson attended the clinic that day.

8 Exhibit C4 9 Exhibit C12a 10 Exhibit C3

4.4. On 29 July 2016 a pass was granted to attend a specialist appointment on 4 August

2016. Mr Thompson failed to attend that appointment. On 18 August 2016 Mr Thompson failed to attend an appointment with Dr Mahadeva. On 27 September 2016 a pass was arranged for Mr Thompson to attend an appointment with Dr Mahadeva and also to purchase medication. On 10 October 2016 a pass was arranged for Mr Thompson to attend an appointment with Dr Mahadeva. On 24 October 2016 a pass was arranged for Mr Thompson to attend an appointment with Dr Mahadeva. On 7 November 2016 a pass was arranged to attend an appointment with a psychologist. On 21 November 2016 a pass was arranged for Mr Thompson to attend an appointment with Dr Mahadeva, an appointment which Mr Thompson failed to attend.

2017. Conclusion 5.1. It is my view that no errors of care can be identified in the application of the home detention conditions attached to Mr Thompson bail. I find that Mr Thompson's care and treatment at the Flinders Medical Centre was appropriate. I further find that Mr Thompson's home detention conditions were appropriately applied with respect to granting permission to leave the home as needed for medical purposes.

6. Recommendations 6.1. I make no recommendations in relation to this matter.

Key Words: Death in Custody; Home Detention Bail; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 18th day of June, 2020.

Deputy State Coroner Inquest Number 22/2020 (2319/2016)