Coroner's Finding: Hancott, Duncan John

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 Duncan John Hancott.

The said Court finds that Duncan John Hancott aged 56 years, late of Mount Gambier Prison, Benara Road, Moorak, South Australia died at Moorak, South Australia on the 17th day of February 2019. His cause of death was attributed to urosepsis.

The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for Inquest 1.1. Duncan John Hancott was born on 12 July 1962. He was a prisoner at the Mount Gambier Gaol when he died on 17 February 2019. He was 56 years old.

1.2. Forensic pathologist, Dr John Gilbert from Forensic Science South Australia, conducted a post-mortem examination on Mr Hancott on 20 February 2019. He stated the cause of death was ‘attributed to urosepsis’.1 I make a finding accordingly.

1.3. This sepsis was caused by infections of the urinary tract. Sepsis occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body. This can cause a cascade of changes that damage the multiple organ systems, leading them to fail.

1 See also comments in paragraph 8.5

1.4. This is a mandatory Inquest pursuant to Section 21 of the Coroners Act 2003 as Mr Hancott had been a prisoner in the custody of the Department for Correctional Services at the time of his death.

2. Background 2.1. Mr Hancott’s sister, Debra Blagrove, provided an affidavit to the Court detailing her brother’s personal life.2

2.2. Mr Hancott was born in the United Kingdom and emigrated to Australia in 1975 with his mother, stepfather and sister. They lived for a short period of time in New South Wales and then moved to Moana in South Australia. Mr Hancott attended Willunga High School until the age of 15 before working as an apprentice carpenter and then as a painter.

2.3. Throughout the late 1970s and early 1980s, Mr Hancott had a successful painting business. He had a child, Matthew, with a woman named Jan in about 1985 and a daughter, Bianca, with a woman named Jody Brumby in 1996.

2.4. Later he had a relationship with a woman named Collette Nickson, who died in 2015.

They lived together in a transportable home at the Sturt Caravan Park.

2.5. It was noted that Mr Hancott had abused alcohol from an early age and started using illicit drugs in the mid 1990s.

2.6. In 2015 Mr Hancott suffered a head injury. This was the result from a fall during a seizure whilst in the Noarlunga Hospital Emergency Department. Mr Hancott was being seen for benzodiazepine withdrawal. There was also a hospitalisation in 2018 for mild hepatic encephalopathy.

2.7. At a psychiatric assessment with psychiatrist, Dr Singhin in 2018, Mr Hancott admitted to the use of cannabis, heroin, cocaine and methamphetamine.3 2 Exhibit C1a 3 Exhibit C19d

3. Medical history 3.1. Mr Hancott had a history of smoking, depression, intravenous drug use and alcohol abuse. His medical history included previous hepatitis C with cirrhosis of the liver complicated by portal hypertension.4

3.2. In 2009 Mr Hancott had many health issues including ascites5, bleeding oesophageal varices6, spontaneous bacterial peritonitis7 and episodes of hepatic encephalopathy.8 In 2014 he was diagnosed with hepatocellular carcinoma.9 Mr Hancott underwent chemotherapy for the cancer, which was ultimately successful.

4. Reason for incarceration 4.1. At the time of his death, Mr Hancott was serving a sentence for the offence of robbery.

The offending involved Mr Hancott entering the BankSA Branch in Victor Harbor and handing the teller a note, demanding money and claiming to have a weapon. He was handed $1,075 and then left the bank.

4.2. He was sentenced for that offence on 21 January 2016 in the South Australian District Court. Mr Hancott plead guilty and was sentenced to a term of imprisonment of three years and seven months with a non-parole period of two years.

4.3. The sentence commenced on 14 August 2015 which was the date he was taken into custody.

4.4. Mr Hancott was released on parole on 26 September 2017. On 22 November 2018 the Parole Board issued a warrant for his arrest due to him breaching a condition of his parole by not reporting to his Community Corrections Officer. He was arrested on that warrant on 23 November 2018 and then remained in custody until his death.

4 Elevated pressure in the major vein that lead to the liver 5 Fluid in the abdomen 6 Enlarged veins 7 Swelling of the tissue that lines the abdomen 8 Caused by severe liver disease that affects brain function 9 Liver cancer

5. Issues while in prison from 23 November 2018 5.1. On 20 December 2018, Mr Hancott was taken from Mobilong Prison to the Bridge Clinic at Murray Bridge. He was seen by Dr David Butler and sent to the Flinders Medical Centre10 to receive a medical assessment.

5.2. He was noted during that assessment as being faecally incontinent despite the medical records referring to Mr Hancott as not having opened his bowels for the previous two days.

5.3. He was experiencing increasing dizziness and confusion. Mr Hancott was seen on that occasion by his own specialist, Dr Alex Rodgers. Dr Rodgers assessed Mr Hancott as likely having grade 1 encephalopathy, precipitated by constipation.

5.4. A CT of Mr Hancott's head showed some white matter changes but no acute intracranial pathology. Upon his release from FMC, Mr Hancott was transferred to Yatala Labour Prison due to there being more appropriate facilities than at Mobilong Prison.

5.5. On 27 January 2019, Mr Hancott declined a medical assessment of his liver function that was scheduled for 28 February 2019.11 The reason for declining, according to the records signed by Mr Hancott, were that he said that he would follow-up himself when released from prison and was pretty sure he would be okay.

5.6. Mr Hancott was transferred to Mount Gambier Prison on 12 February 2019. Whilst at Mount Gambier Prison he was housed in D block of Waa Wor unit in cell D04.

5.7. Mr Hancott shared his cell with another inmate, Jermaine Coppini. Mr Hancott’s bed was the top bunk of that cell. Mr Coppini has provided an affidavit to the Court.12

5.8. In that affidavit Mr Coppini referred to Mr Hancott as seeming quite weak and stated that he spent a lot of time lying in bed. He also stated that Mr Hancott would only eat half his meal and he did not drink any water.

10 FMC 11 Exhibit C19f and C19g 12 C19j

6. Circumstances concerning Mr Hancott’s death 6.1. At approximately 3:50am on 17 February 2019, Mr Hancott slipped on a bunk step whilst going to the toilet. He fell and sustained a small laceration to his left forehead, laceration to his left elbow and bruising, including to his right wrist. He was faecally incontinent.

6.2. Mr Coppini alerted staff, including Correctional Services Officers13 Andrew Stevens and Michael Egan, using the intercom system. Both officers attended the cell and found Mr Hancott standing fully clothed with faeces all over his clothing and spread throughout the cell. He was offered a shower, clean bedding, clean clothing and first aid treatment. He declined them all and went back to bed. Mr Coppini was moved into another cell.

6.3. Mr Hancott was reviewed by prison nurse Roseline Kessell at about 11:45am and she noted he seemed to be well.14 Mr Hancott denied a loss of consciousness from the head injury. He admitted to having issues with incontinence but did not seem alarmed by this condition. It was noted during that assessment that he appeared to be slightly jaundiced.

6.4. At about 6:30pm CSOs Stuart Harvey and Jeremy Hammond checked on Mr Hancott and noticed that he appeared unwell. He was lying on his back and struggling to breathe.

6.5. He had slurred speech, shallow breathing, and was gasping for breath. He was attended to by a supervisor, Wendy Lunsmann, and a prison nurse. Mr Hancott was placed on the cell floor and an oxygen mask was applied. An ambulance was called at 6:34pm and arrived on scene at about 6:46pm. Resuscitation continued throughout this time until life was certified extinct by the ambulance paramedic, Sandra Jones, at 7:28pm.

7. Next of kin concerns 7.1. I have received a comprehensive note from Ms Blagrove outlining her three concerns regarding the treatment of her brother in custody.

7.2. Issue one She criticised the assessment and treatment at Mount Gambier Prison by prison nurse

13 CSO 14 Exhibit C9

Roseline Kessell. She believed her assessment that Mr Hancott seemed well at about 11:45am on 17 February 2019, nearly eight hours after his fall from the bunk, could not be reliable or credible.

7.3. Nurse Kessell in her affidavit15 spoke about seeing him on Sunday, 17 February 2019 at about midday and presenting normally despite a little jaundice which is consistent with the liver disease he was suffering from. She attended to his minor wounds on his left elbow, left eyebrow and right wrist and spoke to him regarding his faecal incontinence. He reported to her that he thought it was simply a case of not making it in time to the toilet and was unconcerned by the event. He denied any loss of consciousness.

7.4. Issue two Ms Blagrove complained that her brother’s incontinence problem was not being assessed properly by SAPHS. She criticised the frequency in which her brother was moved between prisons and did not promote a consistent medical support and treatment regime.

7.5. Issue three It was suggested by Ms Blagrove that Mr Hancott’s health issues did not seem to be taken seriously and that focus was on his incontinence and resulting moves to various prisons.

7.6. I have considered these three issues together with the conclusion and recommendation of the SAPOL investigation into Mr Hancott’s death.

8. Post-mortem examination 8.1. As stated, Dr Gilbert performed a post-mortem on Mr Hancott on 20 February 2019.

8.2. In his autopsy report16, Dr Gilbert refers to the neuropathological examination of the brain. Dr Gilbert noted an old plaque jaune17, which may correlate with a 2015 head injury. Importantly, in the neuropathological examination of the brain, it is noted that there were no signs of a recent head injury to correlate with the fall overnight prior to his death. That finding by Dr Gilbert is referring specifically to a macroscopic brain 15 Exhibit C9 16 Exhibit C2a 17 Bruise of the brain tissue

analysis that was performed by Professor Blumbergs.18 Professor Blumbergs is an expert in brain analysis. He performs macro and micro brain analyses in circumstances such as these.

8.3. Another matter of interest Dr Gilbert referred to was a greater than therapeutic level of amitriptyline, an antidepressant. It is also referred to or known as ‘endep’. He also referred to a non-toxic level of its metabolite, nortriptyline. Mr Hancott was prescribed amitriptyline, or ‘endep’ whilst he was in custody, including at the time of his death.

That prescription was for 100mg daily.

8.4. Dr Gilbert noted, that in normal circumstances, the blood levels of amitriptyline and nortriptyline are usually roughly equivalent, however in this case the amitriptyline was substantially higher. Dr Gilbert made the point that it might be seen in circumstances of an overdose of amitriptyline, which he noted would be unlikely in a prison setting.

The alternative hypothesis is that it is due to the impaired metabolism of the chronic liver disease Mr Hancott suffered for many years, as noted earlier in this finding. I find this to be the more likely explanation for the situation.

8.5. Additionally, in the post-mortem report, Dr Gilbert stated that the cause of death is not entirely clear but appears to have resulted from a urinary tract infection, as indicated by the pure growth of ecoli from the urine, and the presence of focal acute pyelonephritis.19

9. Conclusion and recommendations 9.1. In my view the medical evidence concluded that Mr Hancott was a very sick man with a probable deteriorating liver function.

9.2. Having reviewed all the evidence and the three issues raised by Ms Blagrove, I have concluded that I agree with the investigating officer, Detective Brevet Sergeant Andrew Bull in his thorough report20, namely that:

• Mr Hancott was in lawful detention at the time of his death;

• He was provided with appropriate medical assistance throughout his imprisonment; 18 Exhibit C4a 19 Acute kidney infection 20 Exhibit C19a

• In the months before his death, he was actively and appropriately managed for his medical conditions;

• I have no concerns arising from his final specialist appointment with Dr Rodgers, or his subsequent treatment by SAPHS.

10. Recommendations 10.1. 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 21/2021 (0326/2019)