Coroner's Finding: Clark, Murray Eric

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 14th 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 Murray Eric Clark.

The said Court finds that Murray Eric Clark aged 81 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at Northfield, South Australia on the 20th day of September 2019 as a result of valvular heart disease with cardiac amyloidosis. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for Inquest 1.1. Murray Eric Clark was born on 28 December 1937. He was a prisoner in lawful custody at the Yatala Labour Prison when he died on 20 September 2019 in the infirmary. He was 81 years old. This is a mandatory Inquest pursuant to Section 21 of the Coroners Act 2003, as Mr Clark was in lawful custody at the time of his death.

1.2. On 25 September 2019 an autopsy was conducted on Mr Clark by forensic pathologist Dr Stephen Wills from Forensic Science South Australia. He concluded in his post-mortem report that the cause of death was valvular heart disease with cardiac amyloidosis and I so find.1

1.3. Dr Wills noted in his post-mortem report that Mr Clark’s heart was mildly enlarged and left ventricular hypotropia was observed. Dr Wills noted that individuals with enlargement of the heart, left ventricular hypotrophy and cardiac amyloid deposition are at an increased risk of cardiac dysfunction. He did not identify any other cause of 1 Exhibit C2A

death. Significantly, no complication was identified related to the aortic valve implant or the pacemaker of Mr Clark.

2. Background 2.1. Mr Clark was born and raised in Port Pirie. He was the eldest of four children and worked for much of his life in the tyre industry. He commenced working at the Port Pirie smelters and completed 29 years of service before retiring at 55 years of age.

He married his wife Anne in 2005. Whilst they had no children together, Mrs Clark had four children from a previous relationship. Unfortunately Mrs Clark developed dementia and moved into an aged care facility in April 2013.

2.2. On 24 August 2013, Mr Clark was arrested for sexual offences against a 12-year-old girl who lived nearby. He was remanded in custody. Mr Clark was found guilty of the offences following a trial in the Supreme Court but maintained his innocence.

2.3. On 20 July 2016 Mr Clark was sentenced to imprisonment. The sentence imposed by the Supreme Court was seven years and six months imprisonment with a non-parole period of three years and nine months, commencing from 24 August 2013. Mr Clark's non-parole period expired on 23 May 2017. Despite being eligible at the time of his death, Mr Clark had not been released on parole as there had been some difficulty locating suitable housing for him.

3. Mr Clark’s medical history 3.1. At the time of Mr Clark's death, Dr Daniel Pronk was the medical director at the South Australian Prison Service. Dr Pronk has provided a summary of Mr Clark's past medical history and an affidavit to this Court.2

3.2. Mr Clark’s medical history on admission indicated that he suffered from gout, high blood pressure and possibly Type 2 diabetes mellitus.

3.3. Mr Clark suffered from a degree of cognitive impairment. This was likely the result of a traumatic brain injury he suffered in 1965 when he was struck by a car driven by an intoxicated driver. He was eventually diagnosed with bilateral encephalomalacia in the 2 Exhibit C7

frontal lobes in 2014. This caused some impairment in Mr Clark's executive functioning.

3.4. The first indication of any difficulties with Mr Clark's heart arose on 22 October 2014 when he was diagnosed with a first degree heart block. While this finding was of little concern at the time, it marked the beginning of the deterioration of Mr Clark's heart. In November 2015 he had an episode of chest pain and attended the Emergency Department of the Royal Adelaide Hospital. A series of tests were conducted that excluded a diagnosis of a heart attack.

3.5. Mr Clark's health was relatively stable for the remainder of 2016 until July 2017 when he reported shortness of breath on exertion. Cardiac investigations followed and a diagnosis of atrial fibrillation was made. This led to the commencement of blood-thinning medication.

3.6. On 20 July 2017 Mr Clark attended the Port Augusta Hospital Emergency Department with an episode of breathlessness. Again, it was established that Mr Clark had not had a heart attack but he did have some pulmonary effusions. A heart murmur was detected on this occasion and this was thought to be valvular disease.

3.7. Further cardiac investigations ensued to determine why Mr Clark's heart was not functioning as it should. Blood tests also showed mild anaemia.

3.8. Mr Clark was reviewed by the Cardiology Clinic in December 2017. It was noted on this occasion that the previously identified heart block was worsening. An ultrasound of his heart also revealed aortic stenosis, a condition where the main valve of the heart that allows blood out when the heart pumps, was starting to get stiff and was not opening as it should. This was thought to account for the murmur identified in July 2017.

4. Mr Clark’s decline in health between 2018 and 2019 4.1. In February 2018 Mr Clark was presented to the Emergency Department of the Royal Adelaide Hospital reporting increased shortness of breath. It was determined that his shortness of breath related to a combination of anaemia and his heart failure. The heart block was also noted. There was a suspicion that Mr Clark was also losing blood into

his intestinal tract. This, combined with the fact that he was not in atrial fibrillation at the time, led to the anticoagulants being ceased.

4.2. Mr Clark had two further hospital presentations in January 2018 but he was not admitted on those occasions.

4.3. On 12 March 2018 Mr Clark had a fall. He was assessed at hospital and returned to prison. He was reviewed by the prison health officer on 15 March 2018 who noted that he had postural hypotension. Mr Clark had another fall on 16 March 2018 and attended the Modbury Hospital Emergency Department.3 On that occasion he was prescribed fludrocortisone, a medication designed to help bolster the blood pressure and minimise his symptoms of postural hypotension. He returned to prison the following day.

4.4. On 18 March 2018 he returned to the MHED and was diagnosed with sick sinus syndrome. This relates to the electrical activity of the heart starting to fail critically and causing the heart not to pump effectively. As a consequence, a pacemaker was inserted to regulate the function of his heart. A follow-up at the cardiac clinic on 9 May 2018 indicated that the pacemaker was operating effectively. Mr Clark had a specialist cardiology review on 19 October 2018. A repeat ultrasound of his heart did not indicate any deterioration from the previous ultrasound 12 months prior.

4.5. On 27 March 2019 Mr Clark had another fall. On this occasion he was fasting in preparation for an endoscopy and colonoscopy and it was thought that dehydration may have resulted causing the fall. However, the following day Mr Clark fell again. This time he hit his head and was taken to hospital. A small skull fracture was identified.

There was no indication of bleeding on the brain.

4.6. Whilst hospitalised, Mr Clark had a further ultrasound which showed severe aortic stenosis. At that point consideration was given to replacing the aortic valve using a procedure known as a TAVI.4 This procedure was booked for 9 September 2019.

However, prior to the TAVI procedure being performed, Mr Clark was admitted to the Royal Adelaide Hospital on 20 July 2019 complaining of chest pain. He underwent an angiogram on 26 July 2019 which found a series of blockages in the blood vessels

3 MHED 4 Transcatheter Aortic Valve Implantation

supplying his heart muscle. Five stents were placed to open the blockages and help the blood flow into the heart.

4.7. On 9 September 2019 the TAVI was performed on him. There were no complications.

Mr Clark returned to the prison infirmary on 10 September 2019 where he was subject to regular monitoring by nursing staff. It is noted that at 7:30pm on 12 September 2019 he refused vital sign observations. He also expressed and demonstrated a reluctance to use the walker. The risks of his refusal were explained to him.

4.8. Just after midnight on 13 September 2019, Mr Clark collapsed after passing urine and used the prison cell bell to alert staff. He was admitted to the Lyell McEwin Emergency Department. He sustained a serious laceration to the back of his head requiring staples.

4.9. Mr Clark remained in hospital until 16 September 2019, during which time his heart was constantly monitored. It was determined that Mr Clark's collapse was not likely to be a complication of the TAVI procedure, and most likely was a post-micturition syncope5 episode.

4.10. He returned to the prison infirmary on 16 September 2019 and was regularly monitored by nursing staff. On 17 September, Mr Clark was reviewed by the prison health medical officer and reported that he was feeling well and was not dizzy. However, the nursing note from 3:20pm that day records that Mr Clark had low blood pressure and was slightly dizzy.

5. 20 September 2019 5.1. I turn now to a brief account of the circumstances of the death of Mr Clark.

5.2. On 20 September 2019, Mr Clark was observed by nursing staff at 5am and it was noted that he had been well-settled overnight. At 6:30am Correctional Services Officer Ben Drummond was conducting a headcount of prisoners in the E Division infirmary. When he arrived at Mr Clark's cell he noticed he was not in his bed. Mr Clark's cellmate was asleep in bed. Mr Drummond could see Mr Clark sitting on the toilet. Due to the frosted glass shower panel he could only see his outline. He was sitting upright and there were no signs of distress.

5 Fainting after urination due to a severe drop in blood pressure

5.3. A few minutes later Mr Clark's cellmate, Johnny Walters, got out of bed and went to use the toilet. In his affidavit he stated he ‘found Murray lying on the ground next to the toilet’, unresponsive.6 Mr Walters pressed the buzzer and notified nursing staff. A Code Black was called at about 6:34am.

5.4. In accordance with Mr Clark's wishes, as recorded in the Seven Step Path documentation he signed on 4 February 2018, there was no attempt to perform CPR.

He was declared life extinct by registered nurse Damien Storten at 6:50am.

6. Conclusion and Recommendation 6.1. I find Mr Clark was in lawful custody at the time of this death.7 This is consistent with the conclusions of the investigating officer, Detective Brevet Sergeant Andrew Bull.

The circumstances surrounding his death are not suspicious and did not indicate the involvement of any third party, or concerns relating to his care. Detective Bull’s opinion is that Mr Clark's care, treatment, and supervision by the Department of Correctional Services was appropriate. I agree with his findings and opinions.

6.2. I make no recommendations.

Key Words: Death in Custody; Prison; Natural Causes 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 13/2021 (1964/2019) 6 Exhibit C4 7 Exhibit C10