Coroner's Finding: Adams, Geoffrey Gordon

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign King at Adelaide in the State of South Australia, on the 8th day of December 2022 and the 28th day of April 2023, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Geoffrey Gordon Adams.

The said Court finds that Geoffrey Gordon Adams aged 72 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 15th day of December 2020 as a result of cerebral malignancy. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Geoffrey Adams was born on 6 June 1948. He died at the Royal Adelaide Hospital1 on 15 December 2020, aged 72 years. A pathology review undertaken by Dr Jane Alderman, in conjunction with Dr Stephen Wills of Forensic Science South Australia,2 determined his cause of death to be cerebral malignancy, and I so find.

1.2. Mr Adams had been admitted to custody at the Yatala Labour Prison3 on 20 September

2018. He was arrested for the alleged murder of his wife, Colleen Adams, at Maitland in 1973. She had been killed then buried by him in their premises. Up to his arrest, he claimed she had left him and that he never had contact from her again. Mr Adams remained in custody until his death on 15 December 2020.

1 RAH 2 FSSA 3 YLP

1.3. As Mr Adams’ death was a death in custody, an Inquest is mandated pursuant to section 21(1)(a) of the Coroners Act 2003.

1.4. Mr Adams was tried before a jury in the Supreme Court of South Australia4 for the offence of murder. He pleaded guilty to manslaughter at the commencement of the trial. That plea was not accepted, and the trial proceeded. The jury acquitted him of murder.

1.5. Mr Adams did not receive a sentence for manslaughter following the trial. He was transferred to the Port Augusta Prison. Whilst awaiting sentencing he became ill and was taken to the RAH. He was unable to attend the Supreme Court as scheduled. The matter was adjourned, and he died during the period of the adjournment.

2. Mr Adams’ health whilst in custody 2.1. When Mr Adams was admitted into custody he suffered from hypertension and high cholesterol. He was medicated for those conditions. He also took the anticoagulant warfarin. Warfarin requires constant monitoring of the anticoagulation level of a particular individual. He was monitored regularly in custody.

2.2. Mr Adams suffered minor ailments whilst in custody. They were dealt with appropriately. A list of those minor ailments and events are detailed in the affidavit of Dr Pronk, Director of Prison Health.5

2.3. Mr Adams suffered a major mental health episode whilst in custody. In April 2020 a fellow prisoner and a relative advised the prison staff that Mr Adams was expressing thoughts of self-harm. He was placed on a mental health review program for a period of time, but later advised that he was no longer experiencing those thoughts. He then ceased the program.

3. Mr Adams’ decline in health 3.1. On 13 November 2020, Mr Adams had a routine appointment to check his anticoagulation levels. He was noticed to have rapid and slurred speech. He was examined and found to be hypertensive and tachycardic. He had a general left-sided 4 Supreme Court 5 Exhibit C7

weakness and left-facial droop. Mr Adams reported that he had fallen the previous evening.

3.2. The prison staff called an ambulance, and he was transferred to the Port Augusta Hospital where he underwent a CT scan of his brain. The results showed three separate intracerebral lesions. Due to their number, the lesions were thought to be metastatic.

Mr Adams was transferred the same day to the RAH where he was seen by the neurosurgical team. Given the results and his condition, operative intervention was not performed.

3.3. Mr Adams underwent various tests, including an MRI scan of his head and a whole-body PET6 scan in search for a primary cancer. No primary cancer was located.

He was reviewed by both the radiation oncology and the medical oncology teams.

Neither medical team felt Mr Adams would benefit from treatment given that there was no primary cancer detected.

3.4. A further review of Mr Adams' MRI was conducted by a neuroradiologist who was of the opinion that the three separate cerebral lesions were in fact linked with each other and were consistent with glioblastoma multiforme. In other words, Mr Adams had a cerebral tumour with a very poor prognosis.

3.5. The palliative care specialists assumed the care of Mr Adams. His condition deteriorated quickly. He was medicated appropriately to relieve the symptoms of his deterioration. The RAH decided that it was unsuitable to transfer him back to the prison hospital at YLP. Mr Adams remained at the RAH until his death on 15 December 2020.

4. Conclusion 4.1. Mr Adams had a twin brother who had remained in contact with him, both in custody and at the RAH. His affidavit evidence was that his brother never complained about his treatment in custody, nor about his treatment at the RAH.

4.2. Mr Adams’ death was investigated by Stephen Albon, an investigator from the Department for Correctional Services.7 Mr Albon formed the view that there were no acts or omissions by DCS that either caused or impacted upon Mr Adams’ death. I 6 Positron Emission Tomography

7 DCS

agree with that conclusion. The management of Mr Adams when he presented for a routine appointment was exemplary including how he was managed and transferred to the Port Augusta Hospital.

4.3. I find Mr Adams was appropriately managed within DCS when he presented on 13 November 2020 with slurred speech and unilateral deficits. He was both promptly assessed and transferred to the Port Augusta Hospital, where his intracerebral lesion was detected. He was then transferred to the RAH for neurosurgical opinion. The RAH acted swiftly to identify any primary cancer before various medical specialties were engaged to see whether treatment may benefit Mr Adams. Unfortunately, Mr Adams had a primary cerebral tumour with a very poor prognosis, and he succumbed to that.

5. Recommendations 5.1. 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 28th day of April, 2023.

Deputy State Coroner Inquest Number 27/2022 (2542/2020)