Coroner's Finding: Foster, Clive Anthony

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 18th day of December 2020 and the 29th day of March 2022, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Clive Anthony Foster.

The said Court finds that Clive Anthony Foster aged 76 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 16th day of June 2019 as a result of end-stage renal failure. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for inquest 1.1. Clive Anthony Foster was 76 years of age when he died at the Royal Adelaide Hospital (RAH) on 16 June 2019. At the time of his death he was a prisoner serving a sentence.

His death was a death in custody for which an inquest was mandatory. These are the findings of that inquest.

1.2. A post-mortem examination of Mr Foster’s remains was not necessary. A pathology review dated 19 June 2019 performed by Dr Iain McIntyre of Forensic Science South Australia (FSSA) describes the cause of Mr Foster’s death as end stage renal failure.1 I accept that opinion and find that this was the cause of Mr Foster’s death.

1.3. On 20 June 2017, Mr Foster was sentenced to 11 years and 5 months in prison with a non-parole period of 4 years and 6 months. At the time of his sentence Mr Foster was 1 Exhibit C2a

74 years of age.2 He died while that sentence was still being served. I find that Mr Foster’s custody was at all times lawful.

2. Background 2.1. Mr Foster was born in the United Kingdom. After leaving school he joined the merchant navy. He moved to Australia when he was 22 years of age.

2.2. Mr Foster had been married with three biological children, two of whom are now deceased. He and his wife had also fostered a number of children. Mr Foster separated from his wife in 2017, shortly before being imprisoned.

3. Mr Foster’s medical history 3.1. In 1999 Mr Foster was diagnosed with hypertension. In 2001 he was diagnosed with diabetes. In 2009 he was diagnosed with stage three renal failure. In 2014 he was diagnosed with an abdominal aortic aneurysm. In 2015 he was diagnosed with prostatism.

4. Mr Foster’s health and medical care in prison 4.1. While serving his sentence, Mr Foster was transferred between Adelaide, Port Lincoln and Port Augusta prisons. During his time in custody he was medicated for blood pressure issues, high cholesterol, reflux and diabetes and was given pain relief medication. He also had ongoing physiotherapy to manage back pain.

4.2. On 16 March 2018, Mr Foster fell on bitumen and fractured his upper right humerus.

He was placed in a collar and cuff and did not require surgery.

4.3. On 15 November 2018 Mr Foster was identified as having low haemoglobin. A medical officer reviewed his condition at that time. It was established that his kidney function was worsening and that he had anaemia.

4.4. On 23 December 2018 Mr Foster presented with abdominal pain and was admitted to the RAH the following day. He was found to have choledocholithiasis which is a gallstone lodged in the duct system of the gallbladder. He underwent an endoscopic retrograde cholangiopancreatography (ERC) procedure to remove the gallstone. The 2 Exhibit C11b, sentencing remarks

discharge summary from 3 January 2019 indicates that during this episode of illness, Mr Foster suffered an acute kidney injury superimposed on his chronic kidney disease.

On 3 January 2019 an ultrasound revealed that Mr Foster also had a swollen prostate gland.

4.5. In early February 2019, Mr Foster was booked in to have his gallbladder removed and an MRI scan performed on his prostate gland. On 26 February 2019 the MRI took place. It was noted that the appearance of his prostate was highly suspicious of malignancy with a urology referral made for a specialist opinion and further investigation and management.

4.6. On 1 April 2019 Mr Foster was again admitted to the RAH with abdominal pain. He remained in hospital until 18 April 2019. During this time a series of investigations were conducted with Mr Foster's pain suspected to be related to gallstones. He was given antibiotics to assist with what was thought to be an infection in his gallbladder.

During this admission, Mr Foster’s hypertension medication was changed in order to achieve better control of his high blood pressure. During this period his renal function was noted to have further deteriorated.

4.7. Between 30 April 2019 and 3 June 2019, Mr Foster was again admitted to the RAH for uncontrolled hypertension. During this time he developed hospital acquired pneumonia, urinary incontinence, blood in his bowel actions, worsening cardiac function and chronic kidney failure. A CT scan on his brain revealed that he had suffered a small stroke. He was commenced on antibiotics for pneumonia.

4.8. Discussions commenced regarding dialysis for his ongoing and worsening kidney function. A decision was made that he was not a suitable candidate for dialysis at this time. I was satisfied that this decision was appropriate.

4.9. On 3 June 2019 Mr Foster was returned to the Health Centre at YLP for ongoing care.

4.10. On 4 June 2019 a medical officer at YLP noted that Mr Foster was having intermittent chest pains, increasing confusion with decreasing oxygen saturations and decreasing conscious state. A decision was made to return Mr Foster to hospital.

4.11. On 5 June 2019 Mr Foster was readmitted to the RAH. He was discharged on 14 June

2019. Prior to this discharge, a discussion with Mr Foster regarding his wishes was

undertaken. The RAH clinical notes indicate that he understood that his prognosis was poor. He stated that his desire was to focus on maintaining his quality of life. Following this he was palliated, his 7 step pathway was updated and end of life medications were prescribed. Mr Foster was returned to YLP for end of life care. However, on 15 June 2019 he was again returned to the RAH as YLP did not have the appropriate resources to provide adequate care for him. Mr Foster died the following day, approximately 26 hours after his final admission to the RAH.

5. Conclusions 5.1. The circumstances of Mr Foster’s death were comprehensively investigated by Brevet Sergeant Jeremy Byers of the SAPOL Major Crime Investigation Branch. Brevet Sergeant Byers reached the conclusions that Mr Foster, whilst lawfully detained, received adequate care while incarcerated at the YLP. Similarly, he concluded that Mr Foster received adequate care while in the RAH.

5.2. I agree with those assessments and find that Mr Foster died of natural causes after receiving adequate treatment both at the YLP and the RAH. His custodial circumstances did not contribute to his death.

5.3. 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 29th day of March, 2022.

Deputy State Coroner Inquest Number 90/2020 (1211/2019)