Coroner's Finding: Papadopoulos, George

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 George Papadopoulos.

The said Court finds that George Papadopoulos aged 63 years, late of Yatala Labour Prison, Peter Brown Drive, Northfield, South Australia died at Northfield, South Australia on the 9th day of August 2019 as a result of disseminated carcinoma. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. George Papadopoulos was 63 years of age when he died on 9 August 2019 at Yatala Labour Prison (YLP). At the time of his death he was serving a term of imprisonment.

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

1.2. A post-mortem examination of Mr Papadopoulos was not necessary. A review of Mr Papadopoulos’ clinical circumstances was undertaken by Dr Jane Alderman of Forensic Science South Australia (FSSA). In her written pathology review Dr Alderman opines that Mr Papadopoulos' cause of death was disseminated carcinoma.1 I accept that opinion and so find.

1 Exhibit C2

2. Background 2.1. Mr Papadopoulos was born in Greece in 1956 and his family migrated to South Australia when he was 18 years of age. He gained a Bachelor of Electrical Engineering in 1980 and then a Bachelor of Health Science and Complementary Medicines in

3. He went on to operate a natural health practice and provide naturopathic services from a clinic at his home address. He married in 1996 and had a daughter and a son.

That relationship ended in divorce in 2009.

2.2. On 8 June 2018 Mr Papadopoulos was sentenced by the District Court to 12 years imprisonment with a non-parole period of 6 years. He had been convicted of certain offences after a trial by jury. His sentence was backdated to 9 November 2017 which was the date on which he had been convicted and his bail had been revoked. I find that Mr Papadopoulos’ custody was lawful. He died while still undergoing his prison sentence.

3. Mr Papadopoulos’ medical history 3.1. Dr Daniel Pronk is the medical director of South Australia Prison Health Service (SAPHS). He provided an affidavit to the inquest.2 Dr Pronk states that during Mr Papadopoulos’ admission to custody on 9 November 2017, Mr Papadopoulos reported that he had previously had kidney cancer and that in 2014 he had undergone a kidney removal in Serbia. There is a suggestion in the evidence that he had undergone this procedure in Serbia because doctors elsewhere had not been prepared to operate.

Mr Papadopoulos stated that he had chronic back pain and reported a lump on his testicle. He also reported some blood in his urine and indicated that he had an allergy to morphine. There are recurrent themes throughout the SAPHS notes that during his incarceration, Mr Papadopoulos refused imaging tests due to concerns surrounding radiation from CT scanning. As will be seen, it is possible that this irrational aversion contributed to a delayed diagnosis of the condition that would ultimately cause his death.

3.2. Mr Papadopoulos repeatedly asserted that he required doses of magnesium and vitamin D well in excess of mainstream medically acceptable levels. He reported that he had been taking fifty different supplements in the community. He was quite insistent 2 Exhibit C5

that he required oil of oregano which Dr Pronk states has no known medical purpose.

Mr Papadopoulos regularly refused blood tests. Doctors noted that he was exceptionally difficult to work with and was fixed in his beliefs.

3.3. By 14 November 2017 Mr Papadopoulos was in Mount Gambier Prison. On that date he presented with some bruises after an alleged assault. He was reviewed by the prison medical officer at Mount Gambier Prison who noted the left testicular mass of which he had complained. The doctor suggested that a testicular ultrasound or an abdominal CT scan would be appropriate.

3.4. On 24 November 2017 Mr Papadopoulos agreed to an ultrasound as he did not want a CT scan of his abdomen. The testicular lump was found to be a varicose vein in the scrotum. Dr Pronk states that this was not a concerning finding. An ultrasound of the abdominal wall revealed an uncomplicated umbilical hernia.

3.5. In his statement, Dr Pronk comments upon Mr Papadopoulos not having the abdominal CT scan at this time. From the fact that Mr Papadopoulos’ pancreatic cancer involved numerous metastasis in the liver and also probably in his lung, and that for those reasons the pancreatic cancer had spread significantly and was relatively advanced, it would seem reasonable to assume that had the CT scan been performed it would likely have picked up the pancreatic cancer given that it was found not too much later in June

2019. However, Dr Pronk goes on to suggest that even if the subsequently discovered cancer had been picked up by ultrasound in November 2017, there are too many variables to speculate whether surgical intervention would have been plausible. What Dr Pronk does say is that he could only speculate whether the cancer could have been treated if it had been found at that earlier point in time. He goes on to say that if the cancer was subject of earlier detection and had been isolated to the pancreas at that point in time, or perhaps in the immediate surrounding region, it is his understanding that surgery may have been an option although it would have been a complicated procedure.3

3.6. Mr Papadopoulos did not have much contact with the prison health system throughout

2018. During the early part of that year, attempts were made to perform blood tests to check various vitamin levels relating to Mr Papadopoulos’ beliefs about the efficacy of the same. There was some resistance from him about that but ultimately the tests were 3 Exhibit C5, paragraph 11

undertaken on 1 February 2018. They revealed that the initial bloods were all largely within normal parameters. Mr Papadopoulos rejected these results as he had repeatedly asserted that he required doses of magnesium and vitamin D well in excess of accepted levels. He was also quite insistent that he required oil of oregano which is understood to be used as a naturopathic supplement but, as seen above, it does not appear to have any evidence based medical use. On several occasions during 2018 Mr Papadopoulos requested copies of his results.

4. Mr Papadopoulos’ health in 2019 4.1. On 19 February 2019 Dr Kavanagh, a medical practitioner in the South-East who provides medical services to the Mount Gambier Prison, noted that Mr Papadopoulos' blood tests revealed low levels of vitamin D which she noted were not uncommon in prisoners due to the relative lack of sun exposure. Mr Papadopoulos' magnesium levels were normal but his iron levels were low. An entry in the notes indicates a plan to discuss potentially supplementing iron and vitamin D for Mr Papadopoulos. Hepatitis, HIV and haemoglobin tests at that time were unremarkable and his urine did not reveal any malignant cells.

4.2. On 25 March 2019 Mr Papadopoulos was seen by nursing staff. A family member had contacted the Department for Correctional Services (DCS) claiming that Mr Papadopoulos' legs were turning black. Mr Papadopoulos insisted that he would not take the vitamins that were prescribed for him as he was convinced that the doses were too low. He reported that he had peripheral vascular disease and that he required a certain type of olive oil. He became argumentative during this consult and was ultimately asked to leave the clinic.

4.3. The following day Mr Papadopoulos was seen by Dr Kavanagh who confirmed that Mr Papadopoulos had prominent veins in his leg but otherwise there was no clinical concern. Dr Kavanagh noted a raised C-Reactive Protein (CRP) and indicated that this would be a flag that required some investigation as to its cause. Dr Kavanagh indicated that she offered Mr Papadopoulos scans but he is documented to have replied to the effect that if he had a tumour on his kidney they would not be able to remove it and so there was no point in having a scan. This appears to have been an indirect reference to his previous experience in relation to the lesion on his other kidney in respect of which had reportedly been successfully operated on in Serbia.

4.4. Dr Pronk states in his affidavit that potentially the pancreatic cancer was the cause of the CRP increase at that point in time. Dr Kavanagh proposed further imaging via MRI scan as it does not utilise the radiation associated with CT scanning. While it was understood that this was not the gold standard imaging to investigate the intra-abdominal pathology, it was offered as a compromise to further investigate Mr Papadopoulos’ condition given the refusal of a CT scan. A malignancy was suspected in his abdomen or genital area.

4.5. On 4 June 2019 Mr Papadopoulos was again seen by Dr Kavanagh. He reported pain around his sternum and kidney region after eating. He also reported a sensation of consistently feeling cold with shortness of breath. He agreed to further blood tests at that point. The doctor again recommended the MRI scan and he agreed to have that scan which was performed on 6 June 2019.

4.6. A casenote dated 11 June 2019 relates to Dr Kavanagh receiving the results of the scan.

Those results showed a presumed pancreatic primary tumour with para-aortic pre-aortocaval crural and subcarinal nodal disease. Additionally, Mr Papadopoulos had numerous metastases in the liver with presumed metastases in the left lower lobe of his lung and a small amount of fluid in his abdomen. Dr Pronk states that the MRI scan suggested a pancreatic cancer that had spread significantly and was relatively advanced.

4.7. Dr Kavanagh noted that treatment had been significantly delayed due to Mr Papadopoulos' refusal of scans; it had reportedly taken three hours to convince him to undergo the MRI scan. It is also noted that the radiology department that had performed the scan had done so as a compromise outside of clinical protocols that dictated that a CT scan would have been the most appropriate modality of investigation.

Mr Papadopoulos was offered chemotherapy. He declined this with the clinical notes indicating that he felt that he had been neglected. He expressed a desire to return to Serbia for further surgery. Dr Pronk states in his affidavit that in his opinion any treatment offered at this time would not have been aimed at being curative but rather would have been palliative to prolong his life and improve his quality of life.

4.8. Mount Gambier Prison was considered not the best place to accommodate Mr Papadopoulos as there was no in-patient health capability nor 24-hour nursing staff.

A plan was therefore initiated to transfer him to the infirmary at YLP once he was too ill to be accommodated at Mount Gambier Prison.

4.9. On 18 June 2019 Mr Papadopoulos was again reviewed by Dr Kavanagh. She noted that having regard to his fixation on supplements, he could benefit from a psychiatric review to exclude the possibility of an underlying mental health pathology that might be influencing his treatment decisions. Dr Kavanagh also suggested that given the advanced nature of his condition, a palliative approach to management would be most appropriate.

4.10. Dr Kavanagh had a discussion with forensic mental health psychiatrist Owen Heaney in which she described Mr Papadopoulos' symptoms. The psychiatric assessment based on the information provided was that Mr Papadopoulos had a fixed belief system rather than a psychotic illness and that he did not pose a danger to himself or to others due to an underlying psychiatric illness. It was acknowledged that he was unlikely to accept or do well on medication, the conclusion being that there was likely little benefit from a psychiatric review. Mr Papadopoulos was reviewed regularly by the doctor at Mount Gambier Prison. On 1 July 2019 he refused blood tests.

4.11. On 10 July 2019 Mr Papadopoulos was seen by Dr Ryan who assessed that he had a small amount of dullness at the bottom of his lungs likely caused by fluid. He had a fall that day after he mechanically overbalanced and was too weak to right himself. He sustained minor injuries.

5. Mr Papadopoulos’ decline in health 5.1. On 15 July 2019 Mr Papadopoulos was moved from Mount Gambier Prison to YLP where he was accommodated in the Health Centre on his arrival. On 16 July 2019 the medical officer Dr Noakes, reviewed him. Dr Noakes also sought a psychiatric review, again to investigate whether Mr Papadopoulos was competent to make decisions about his treatment.

5.2. On 19 July 2019 a comprehensive psychiatric review was performed by Dr Williams.4 The review concluded that the deceased had no history of mental illness but that he held a number of overvalued ideas in relation to naturopathy, a number of which were held at a delusional level. Dr Williams reported that from a psychiatric perspective it was deemed that there was no evidence of psychiatric illness that was contributing to 4 Exhibit C9

Mr Papadopoulos’ refusal of treatment. It was assessed that he was capable of making informed decisions about his treatment.

5.3. Over the next period of approximately one week, Mr Papadopoulos reported ongoing abdominal pain and nausea. There were themes of him not wanting to take the medication he was being offered for pain and nausea.

5.4. In late July another review of Mr Papadopoulos was conducted by a medical officer who commenced discussion about end of life wishes. The practitioner ascertained that Mr Papadopoulos did not want heroic measures to sustain his life. Mr Papadopoulos stated that he did not want to go to hospital but would prefer to remain in prison-based care. It was decided that measures such as reversing an infection or assisting him with pain control were within his wishes but nothing more should be done to resuscitate him or prolong his life. A 7 Step Pathway document was completed. From that point Mr Papadopoulos was on a palliative trajectory of care.

5.5. On 2 August 2019 it was documented that Mr Papadopoulos was beginning to become confused and was reporting an increase in pain which required increased use of pain medication.

5.6. On 4 August 2019 there was discussion about a need for a carer to be involved in Mr Papadopoulos’ ongoing care. At that time a carer was allocated to assist him with the activities of daily living.

5.7. On 5 August 2019 Mr Papadopoulos was again seen by Dr Noakes. A significant deterioration was noted since Dr Noakes had last seen him. Dr Noakes noted increased lethargy, decreasing oxygen saturations and low oral intake. The notes on 7 August 2019 suggest that Mr Papadopoulos had deteriorated relatively quickly over the previous few days. There was further contact with palliative care specialists at the Queen Elizabeth Hospital (QEH) who provided advice regarding the initiation of another series of medications.

5.8. On 8 August 2019 Manjinder Arora, who has provided an affidavit to the inquest, was the personal care worker assigned to Mr Papadopoulos from 9pm.5 He was informed at the start of his shift that Mr Papadopoulos was unwell and that he may die during the night. Mr Arora states that earlier in his shift he could quite clearly hear 5 Exhibit C4

Mr Papadopoulos breathing but that by around 4am he had to stand and look very closely to check on his breathing. By then the breathing was very shallow. At about 5:05am Mr Arora was certain that Mr Papadopoulos was no longer breathing. He summoned the registered nurse on duty, Mr Staunton, who confirmed life extinct and completed the necessary declaration to that effect.

5.9. In his affidavit, Dr Pronk proports to summarise Mr Papadopoulos’ clinical course as follows: 'In summary we were dealing with a person who had an unconventional set of beliefs centred around his background in naturopathy. Additionally he had the history of a tumour in his kidney that he didn't have follow up for in our system and that he eventually had removed in Serbia, which I suspect exacerbated his mistrust of our Australian conventional medical system. There is no doubt these factors delayed the diagnosis of his pancreatic tumour based on his reluctance to engage with us.' 6

6. Conclusions 6.1. The circumstances of Mr Papadopoulos’ death were comprehensively investigated by Detective Brevet Sergeant Jason Olsen of the Police Corrections team. Mr Olsen has expressed a number of conclusions. The first is that the deceased was in lawful custody at the time of his death. I indicate that I agree with that assessment and so find.

6.2. Regarding the principal issue investigated in this case, namely whether appropriate medical care had been provided to Mr Papadopoulos, Mr Olsen has expressed the view that the evidence suggests that Mr Papadopoulos was a difficult prisoner to manage in terms of his health care. He had an unconventional set of beliefs centred around his background of naturopathy and that his mistrust in the South Australian medical system and in conventional medicine appears to have been reinforced by his earlier successful surgery in Serbia in relation to a kidney tumour that the local medical system here had suggested was inoperable. Mr Olsen points out the significance of Dr Kavanagh having to spend several hours with Mr Papadopoulos in an endeavour to convince him to accept an MRI scan which ultimately led to the diagnosis of his cancer. Mr Olsen states that there is no evidence of a deficit in the standard of care or attention afforded to Mr Papadopoulos. I agree with that assessment and so find.

6 Exhibit C5, paragraph 48

6.3. Mr Papadopoulos’ resistance to the more appropriate CT scan does not appear to have helped him. I accept Dr Pronk’s evidence that it is possible that if Mr Papadopoulos had undergone a CT scan as early as November 2017, his diagnosis of pancreatic cancer may have been made at that time. However, it is not possible to express a definitive view about that issue. It is not possible to make any finding as to whether earlier more conventional diagnostic procedures may have led to a diagnosis and course of treatment that could have prevented Mr Papadopoulos’ death or have prolonged his life.

6.4. In any event, it is the Court’s finding that Mr Papadopoulos’ medical care while in custody was in all of the circumstances appropriate. His custodial circumstances did not contribute to his death.

6.5. I have no recommendations to make 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 11/2021 (1626/2019)