Coroner's Finding: Hohol, Peter

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 4th day of August 2021 and the 30th 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 Peter Hohol.

The said Court finds that Peter Hohol aged 68 years, late of Yatala Labour Prison, Peter Brown Drive, Northfield, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 23rd day of August 2019 as a result of decompensated heart failure with pulmonary hypertensive crisis, complicated by pneumonia on a background of ischaemic and dilated cardiomyopathy. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for inquest 1.1. Peter Hohol was 68 years of age when he died at the Royal Adelaide Hospital (RAH) on 23 August 2019. At the time of his death Mr Hohol was a prisoner serving a sentence. His death was a death in custody in respect of which an inquest into the cause and circumstances of his death was mandatory. These are the findings of that inquest.

1.2. A post-mortem examination of Mr Hohol’s remains was not necessary. A pathology review was undertaken by Dr Alexandra Yuill of Forensic Science South Australia (FSSA). Her report states that Mr Hohol's cause of death was ‘decompensated heart failure with pulmonary hypertensive crisis complicated by pneumonia in a person with known ischaemic and dilated cardiomyopathy’.1 I accept that opinion and find that the cause of Mr Hohol’s death was decompensated heart failure with pulmonary 1 Exhibit C2

hypertensive crisis complicated by pneumonia on a background of ischaemic and dilated cardiomyopathy.

2. Background 2.1. Mr Hohol was born on 24 September 1950 at Woodside in South Australia. He was born to immigrant parents who emigrated from the Ukraine after being displaced in the second world war. He resided with his parents in a family home in Royal Park where he remained after their deaths and until his incarceration in 2019. He did not have any siblings or any other family in Australia.

2.2. Mr Hohol never married or fathered any children. His closest friend was Sofia Kelly who first met him in 1979 when she was seven or eight years old at the Ukrainian Camp in the Adelaide Hills. She was his next of kin and his only known friend. Ms Kelly provided an affidavit to the Court.2

2.3. Mr Hohol was a bottle collector when he left school and then obtained employment as a spray painter for a number of years. He drove buses for tour groups, community groups and school groups for about eight years. He purchased a courier van and subcontracted as a courier for nine years. He drove buses in his early life for children on Ukrainian camps.

2.4. Mr Hohol was also involved in Ukrainian community radio and theatre and attended the Ukrainian Church. He had a fascination with trains to the extent that he would log all of the trains that he would see.

2.5. On 21 June 2019 Mr Hohol was sentenced in the Port Adelaide Magistrates Court to a term of imprisonment of nine months and three weeks with a non parole period of three months and three weeks. On the same day, Mr Hohol was admitted into the Yatala Labour Prison (YLP) and was placed into E Division. I find that Mr Hohol’s custody was at all times lawful. He died before the expiration of his non parole period.

3. Mr Hohol’s medical history 3.1. Mr Hohol had experienced significant health issues in the years preceding his admission into YLP including ischaemic cardiomyopathy, moderate renal impairment 2 Exhibit C3

due to diabetes, heart failure leading to the insertion of an automated implanted cardioverter defibrillator, significant obesity, hypertension, difficulty in walking and chronic obstructive airways disease. A relatively recent diagnosis of obstructive sleep apnoea with the use of a continuous positive airway pressure machine (CPAP) was documented. These health issues were identified in the initial nursing assessment conducted by the South Australia Prison Health Service (SAPHS) and were confirmed by his cardiologist Dr Devan Mahadavan in a letter provided to SAPHS on 26 June 2019.

3.2. During a comprehensive medical review of Mr Hohol by a SAPHS medical officer on 11 July 2019, it was noted that he reported occasional shocks from his implanted cardiac defibrillator. Dr Daniel Pronk, the Medical Director of the South Australian Prison Health Service (SAPHS), who has provided an overview of Mr Hohol's health during his time in custody, asserts in his statement: 'The fact that Mr Hohol reported periodic shocks from the device implies to me that his heart was showing indicators of significant deterioration at this stage.' 3

3.3. Mr Hohol received regular monitoring and treatment from the YLP Health Centre within the prison. Mr Hohol required weekly injections to support his kidney failure and an inability to produce sufficient red blood cells. It was assessed that due to the requirement that Department for Correctional Services (DCS) restrict external prisoner medical appointments to secure sites, ongoing review by Dr Mahadavan was impractical. Mr Hohol was therefore referred to the Cardiology Department at the RAH for ongoing treatment while incarcerated. Records indicate that a cardiology appointment was booked for 26 August 2019.

3.4. On 22 July 2019 Mr Hohol was reviewed by a locum medical officer. The officer completed a thorough clinical examination and requested an updated chest X-ray to check Mr Hohol’s lungs for any sign of infection or worsening heart failure that might be compounding his shortness of breath. A referral was faxed for a chest X-ray on this same date. However, a clinical note of 31 July 2019 recorded that the appointment with medical imaging was cancelled as Mr Hohol was unable to alight the van and required an access cab for transport. On this issue, Dr Pronk stated: 'It is impossible for me to comment as to whether a chest X ray at that time would have had any bearing on his subsequent management and eventual health decline. From my 3 Exhibit C4

review of the notes at around that time, it would appear that his observations were at his baseline level and not showing any concerning signs of significant decompensation.' 4

3.5. On 6 August 2019 it is noted in the progress notes that Mr Hohol did not attend the medical centre.

4. Mr Hohol’s decline in health 4.1. On 10 August 2019 nursing staff were notified that Mr Hohol was experiencing shortness of breath. Nursing staff attended E Division and assessed him in his cell.

The observations on this occasion showed him to be at baseline despite feeling subjectively shorter of breath than usual. The main complaint made by Mr Hohol to medical staff included his inability to walk distances as it caused him shortness of breath. As well, he complained of leg and calf pain. His inability to walk distances impacted on his ability to access the medical centre at YLP.

4.2. A clinical note of 12 August 2019 suggested that Mr Hohol remained in the medical centre overnight at the request of the medical officer so he could be reviewed in the Complex Needs Clinic on the following day.

4.3. On 13 August 2019 Mr Hohol underwent another comprehensive medical officer review during which a 7 step pathway was documented relating to his end of life care wishes. At that stage the pathway involved full measures including intensive care. At this review it was again documented that Mr Hohol had a diagnosis of obstructive sleep apnoea and that he had been using a CPAP machine prior to incarceration. Mr Hohol stated that he had been unable to have the machine brought in for use in prison due to not having anyone in the community to bring it in for him. The reviewing medical officer documented a request for DCS social work input to resolve the situation and to have Mr Hohol's CPAP machine brought in.

4.4. At 9:30am on 21 August 2019, Mr Hohol complained of feeling unwell to medical staff.

Health checks indicated that his blood pressure was low. As a result, his midday medications were withheld to prevent any further reduction in blood pressure. The clinical notes indicate that at 7:15pm on the same day, Mr Hohol was alert and orientated and that his blood pressure had returned to baseline level. He had his usual 4 Exhibit C4, paragraph 13

medications. Nursing staff noted that he needed a shower. However, Mr Hohol indicated he was reluctant to do so as he felt dizzy and lightheaded.

4.5. Nursing notes indicate that at 2:30am on 22 August 2019 Mr Hohol was discovered yelling for help. Staff located him sitting upright on the toilet floor after he had fallen while attempting to get to the toilet. It was noted that he had an expiratory wheeze and he became distressed as a result of his breathing difficulties. His respiratory rate was concerningly high. His blood glucose level was low. This prompted staff to give him repeated Glucogel in an attempt to bring his blood sugar level up. An ambulance was called which arrived at 3:25am. Mr Hohol was transported to the RAH for further treatment. He was admitted to the RAH. However, he deteriorated and died on 23 August 2019.

5. The issues at inquest 5.1. Two issues regarding Mr Hohol’s treatment were identified by counsel assisting, Ms Sally Giles, at inquest.

5.2. Firstly, it appears that Mr Hohol did not have the use of the CPAP machine despite it being noted during his admission that he had used one in the community.

5.3. Secondly, it was documented that Mr Hohol’s poor mobility, the requirement for him to walk slowly with the assistance of a walker and the distance between E Division and the YLP Health Centre created difficulty in facilitating Mr Hohol being medically reviewed. On several occasions Mr Hohol declined a health review on account of his compromised mobility. Requests were made by the SAPHS medical officer for DCS to use a wheelchair where possible to facilitate transfer for health review. However, there are notations in the records documenting occasions where DCS were not able to facilitate that.

6. Conclusions 6.1. It is said correctly that medical services provided to prisoners serving a sentence should be no less of a standard and should be no less accessible than the medical services that can be provided by the public health system to any person who resides in the community. It has been unable for this Court to determine why it was that Mr Hohol was not provided with his CPAP machine which he had reportedly been using in the

community. There is a notation that the DCS social work service were to be involved in an attempt to secure the machine for his use in prison. The statement of Mr Hohol’s friend, Ms Sophia Kelly, reveals only a limited amount of contact that she had with Mr Hohol after he was incarcerated on 21 June 2019. On that date she received a phone call from YLP in which she had a conversation with Mr Hohol. He told her that he was going to be in prison for about three months and asked her to look after his property.

She asserts in her statement that she also received a letter from him in prison. The letter said that he was doing ‘okay’ and that he was being treated well. On 23 August 2019 Ms Kelly received a phone call from an officer at the YLP informing her that Mr Hohol had been taken to the RAH ICU and that staff had suggested that she should go to the hospital quickly. Enroute to the hospital ward where Mr Hohol was being treated, Ms Kelly was informed that Mr Hohol had died. Ms Kelly indicates that she had not seen Mr Hohol since about 23 February 2019. There is nothing in Ms Kelly’s statement which appears to be a comprehensive account of all and any communication she had with or about Mr Hohol since he was incarcerated, about any request for his CPAP machine to be brought to the prison.

6.2. Manifestly, if Mr Hohol had been using a CPAP machine for sleep apnoea in the community, it should have been available for his use in prison.

6.3. I turn to the second issue regarding Mr Hohol’s occasional inability to go to the YLP Health Centre due to mobility issues. If the occasional lack of a wheelchair was the reason he could not be moved, this does seem to be a rather poor explanation. However, I do note that he was seen on quite a number of occasions during the period of his incarceration and was reviewed by a medical officer from time to time. In addition, nursing staff attended to him and assessed him in his cell. Mr Hohol also appears to have been a patient within the Health Centre on an ongoing basis.

6.4. Mr Hohol was clearly an unwell man, even at the time of the commencement of his prison sentence. As stated above, he had a number of serious comorbidities. His acute unwellness and deterioration seems to have been identified in a timely manner. On 22 August 2019, when Mr Hohol was discovered in a distressed state, he was attended to and transferred to the RAH by ambulance. In all of the circumstances it is not possible to say whether the absence of a CPAP machine, or his inability to occasionally attend the Health Centre due to immobility issues, had any adverse impact on his health or on his medical treatment.

6.5. The circumstances of Mr Hohol’s death were comprehensively investigated by Detective Brevet Sergeant Britta Rivett of SAPOL. Regarding the adequacy of Mr Hohol’s care and treatment, Detective Rivett has stated that in her opinion the DCS could improve their practices concerning management of invalid prisoners and in particular those with mobility issues. She points to the fact that the prison population of South Australia is an ageing one. However, she states that her investigation established no direct link between Mr Hohol’s inability to easily access the Health Centre and his death. I agree with Detective Rivett’s assessment in this regard.

6.6. Detective Rivett also expresses the view that DCS could have taken further steps to ensure that Mr Hohol had his CPAP machine available to him in the YLP. It is difficult to determine the validity of this observation. However, it seems apparent that DCS were aware of Ms Kelly’s relationship with Mr Hohol. It would not have taken much to establish that she may have had some possible means of securing the machine for Mr Hohol. However, I am unable to make any finding about that.

6.7. Finally, Detective Rivett has concluded that she believes that Mr Hohol obtained adequate medical care by SAPHS and the RAH for his numerous health issues and that his level of care, once admitted to the YLP Health Centre, probably surpassed a level of care that he would have received in the community. I agree that there appears to be no deficit in care within the SAPHS Health Centre nor in the RAH. It is impossible to conclude that Mr Hohol’s custodial circumstances contributed to his death.

6.8. 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 30th day of March, 2022.

Deputy State Coroner Inquest Number 1740/2019 (14/2021)