Coroner's Finding: Cannell, Peter Tasman

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 16th day of September and the 25th day of November 2021, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Peter Tasman Cannell.

The said Court finds that Peter Tasman Cannell aged 48 years, late of Mount Gambier Prison, Benara Road, Moorak, South Australia died at Moorak, South Australia on the 5th day of September 2019 as a result of multi-organ failure from acute gastrointestinal haemorrhage, associated with oesophageal varices on a background of liver cirrhosis. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for Inquest 1.1. Peter Tasman Cannell was born on 13 August 1971. He had been imprisoned since 13 October 2010 after a conviction for the violent rape of an 81 year old woman. He died on 5 September 2019 at the Flinders Medical Centre.1 He was 49 years old.

1.2. Mr Cannell’s medical casenotes were reviewed by Dr Alexandra Yuill and discussed with Dr Karen Heath, a forensic pathologist at Forensic Science South Australia. The pathology review report was tendered to this Court.2 The suggested cause of death is multi-organ failure from acute gastrointestinal haemorrhage associated with oesophageal varices on a background of liver cirrhosis. I accept the suggested cause of death and make a finding accordingly.

1 FMC 2 Exhibit C2a

1.3. This is a mandatory Inquest pursuant to Section 21 of the Coroners Act (2003) as Mr Cannell had been in the lawful custody of the Department for Correctional Services at the time of his death.

2. Background 2.1. Mr Cannell is of Aboriginal heritage and grew up in Shelford in rural Victoria as a son of Dorothy and Peter Cannell. He had a brother Matthew and a sister Melinda.

2.2. At the age of 10, Mr Cannell was made a ward of the State and placed in foster and boys' homes until he was 14 years old. The investigation report of Detective Brevet Sergeant James Clegg3 refers to him being subjected to physical and sexual abuse throughout that period of time and beginning to abuse drugs and alcohol from the age of 14.4

2.3. SAPOL records from the early 1990s indicate that, at least for a short period of time, Mr Cannell was working as a stockman. His brother stated that he worked for cash-in-hand on farms and shearing sheds around Australia.

2.4. It is noted that after starting his own security company in Darwin in 2003, Mr Cannell was involved in a motor vehicle accident that resulted in a craniotomy being performed on him. In 2005 he was a victim of a nightclub assault in St Kilda, Melbourne.

2.5. Throughout his life, Mr Cannell was involved in criminal activity. This started from a young age and he spent considerable time in prisons throughout Australia. Detective Cleggs’s report helpfully set out a summary of Mr Cannell's offending and sentences.5

3. Imprisonment 3.1. On 4 December 2012 Mr Cannell was sentenced by Judge Nicholson, as he then was, to a period of 10 years imprisonment with a non-parole period of six years and six months backdated to 16 October 2010.6 Mr Cannell was then transferred between numerous South Australian prisons until his final transfer to the Mount Gambier Gaol on 18 September 2017.

3 Exhibit C12a 4 Exhibit C12a, page 11 5 Exhibit 12a, paragraph 11 6 Exhibit C12c, Sentencing remarks

3.2. On 2 September 2019, Mr Cannell was transferred to the Mount Gambier Hospital and then finally to the Flinders Medical Centre where he died.

4. Medical history 4.1. Mr Cannell had a medical history that included liver cirrhosis, hepatitis C, thrombocytopenia7, iron deficiency anaemia, bipolar effective disorder, depression, mixed personality disorder with antisocial and borderline traits, epilepsy, ischaemic heart disease, obesity and PTSD. Mr Cannell was a smoker and also had a history of heavy alcohol use.

4.2. Dr Daniel Pronk is the medical director for the South Australian Prison Health Service.

He has provided a detailed history of Mr Cannell's medical treatment whilst he was in custody.8

4.3. Dr Pronk stated that in 2016 Mr Cannell reported a loss of blood during a bowel action.

He was referred for a colonoscopy which was completed on 4 May 2016. During that procedure a couple of polyps were found in the colon and some haemorrhoids were also treated. He was advised to have another colonoscopy but he refused the repeat attendance.

4.4. In 2018 Mr Cannell reported black stools which is regarded as a clinically concerning indicator for a loss of blood. However, he again refused to attend for a repeat colonoscopy.

4.5. Mr Cannell underwent an ultrasound of the abdomen in 2018 which showed cirrhosis of the liver. Dr Pronk stated that later in 2018 Mr Cannell seemed to reconsider his position regarding a colonoscopy and was referred back to the surgeon. It was recommended that he try to reduce his weight to between 110 kilograms and 120 kilograms prior to the procedure. Mr Cannell's health then improved and he did lose the weight as recommended. On 14 May 2019 he was weighed at 102 kilograms.

4.6. On 7 August 2019 Mr Cannell was seen by a prison medical officer and blood samples were taken. The results of those blood samples identified that his haemoglobin levels had dropped from 142 to 118 in a three month period. 118 is just below the reference 7 Low blood platelet count 8 Exhibit C8

range and in isolation is not normally cause for concern. He was referred to a specialist and was waiting for that appointment when he died.

5. Circumstances prior to death 5.1. Between 7:30pm and 8pm on 2 September 2019, Mr Cannell was in his cell with fellow prisoner Craig Helps when he began shaking as if he was shivering. He was sweating heavily and his speech was slurred. Mr Helps did state in his affidavit provided to the Inquest, that slurred speech was normal for Mr Cannell.9

5.2. When prison officers were performing their head count they stopped to ask Mr Cannell about his health. Mr Cannell assured the officers that he was okay. Mr Cannell then went to the bathroom, locking the door behind him. He said that he was going to take a shower. After approximately two minutes Mr Helps could hear Mr Cannell vomiting and asked if he was okay. Mr Cannell said that he was vomiting blood and that he did not need medical assistance.

5.3. Upon opening the bathroom door, Mr Helps could see large amounts of blood and used the prison intercom system to call for help. Nurse Roseline Kessell and G4S officer Heather Muller responded to a radio message from the control room for assistance.

There was an approximate two to three minute delay in opening the cell door due to the perceived requirement that two G4S officers were needed to be in attendance before a cell is to be opened.

5.4. Once the cell was opened, Nurse Kessell could see that Mr Cannell had been vomiting large amounts of blood. Whilst he was being taken from the cell in a wheelchair he vomited blood again. Nurse Kessell estimated that overall it was about one and a half litres of blood lost. An ambulance was then called.

5.5. Mr Cannell had low blood pressure and went into shock. The ambulance arrived at 8:26pm and Mr Cannell was rushed to the Mount Gambier Hospital where he underwent an upper gastroscopy. During the gastroscopy no bleeding varices could be found. Mr Cannell was placed on a ward but he continued to vomit blood and so a further gastroscopy was performed and there was banding of one bleeding varix.

9 Exhibit C3

5.6. Mr Cannell’s condition continued to rapidly deteriorate, prompting a blood transfusion and retrieval to the Flinders Medical Centre where he arrived at 8:48pm on 3 September 2019.

5.7. As detailed in the affidavit of intensive care consultant Shivesh Prakash, Mr Cannell was very unwell on arrival with profound shock and multiple organ failure.10

5.8. He underwent further transfusions and endoscopies to try stem the bleeding. Six bands were deployed for this purpose. He was also dialysed due to the failure of his kidneys.

Surgery was considered but was not performed as it was assessed to be unlikely to change the outcome. At that point Mr Cannell's brother, Matthew Cannell was spoken to and gave his permission for life support to be withdrawn and palliative measures were introduced.

5.9. A 10:22am on 5 September 2019 life was declared extinct.

6. Conclusion 6.1. Detective Clegg of SAPOL stated in his report of the investigation into Mr Cannells’s death that ‘In the process of collecting information relative to this investigation, I have not identified any deficiency in the care and attention afforded to the deceased whilst detained in DCS custody’.11 Detective Clegg took into consideration the reason for the two to three minute delay in opening the cell door and any impact that it may have had.

He stated that there was a mistaken belief that it would have been a breach of the operational guidelines to have opened that cell door, however the operational guidelines at the time were clear that where there is an immediate and obvious threat to life of a prisoner in a secure cell, the officer will unlock and enter the cell in order to render assistance and first aid. This has since further been clarified in an amendment to the Operational Instructions which state ‘Unless there is a medical emergency… Permission must be sought from the Duty Manager prior to entering a cell or cottage during nightshift’.12

6.2. I agree with the conclusions of Detective Clegg in his report. Mr Cannell was in lawful custody at the time of his death. No submissions or recommendations were made 10 Exhibit C7 11 Exhibit 12a, page 22 12 Exhibit C12a, page 17

relating to his care or treatment. I find his care and treatment was performed appropriately and professionally.

7. Recommendation 7.1. I make no recommendations in this matter.

Key Words: Death in Custody; Natural Causes; Prison In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 25th day of November, 2021.

Deputy State Coroner Inquest Number Inquest Number 22/2021 (1844/2019)