Coroner's Finding: Le, Tu Loan

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 14th day of December 2023 and the 19th day of January 2024, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Tu Loan Le.

The said Court finds that Tu Loan Le aged 54 years, late of 4 Days Road, Croydon Park, South Australia died at The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, South Australia on the 9th day of May 2020 as a result of metastatic squamous cell carcinoma of the lung. The said Court finds that the circumstances of her death were as follows:

1. Introduction and reason for Inquest 1.1. Tu Loan Le was born on 19 January 1966, and died on 9 May 2020 at The Queen Elizabeth Hospital.1 She was 54 years of age.

1.2. This was a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 20032 as Ms Le was on home detention release from the Adelaide Women’s Prison3 at the time of her death. This rendered Ms Le’s death a death in custody as defined by section 3 of the Act.

2. Cause of death 2.1. A cause of death was determined by a pathology review conducted by Forensic Science SA. Dr Jane Alderman opined in that review that the cause of Ms Le’s death can be

1 TQEH 2 the Act

3 AWP

determined to be metastatic squamous cell carcinoma of the lung.4 I accept Dr Alderman’s opinion and make a finding about Ms Le’s cause of death accordingly.

3. Ms Le’s home detention 3.1. Ms Le was remanded in custody on 9 May 2013 for offences of participation in a criminal organisation, trafficking offences, money laundering offences, and dishonest dealing with documents.5

3.2. On 15 May 2015 she was sentenced to imprisonment for 10 years and 7 months, with a non-parole period of 7 years, backdated to 9 May 2013 to allow for time spent in custody. Her non-parole period was due to expire on 8 May 2020.6 She appealed the length of her sentence, however the appeal was dismissed on 20 October 2015.

3.3. On 14 November 2018, Ms Le was released from AWP on a home detention order. The Parole Board resolved to release her onto parole on 14 May 2020, subject to her continued good behaviour and several conditions.7 However, she passed away less than a week before her parole date.

4. Background 4.1. Prior to her admission to the Royal Adelaide Hospital8 in April 2020, Ms Le was residing with her daughter.

4.2. Ms Le had been born in Vietnam, where she had been raised with seven brothers and sisters. Her family lived in poverty and, accordingly, she left school at 10 years of age to work and earn money for her family.

4.3. Ms Le first attempted to emigrate to Australia when she was 13 years of age. However, this attempt was unsuccessful. She was returned to a re-education camp for a year before she was released to the care of her parents. Twelve months later Ms Le travelled on an oil ship to Indonesia, where she spent time in a refugee camp. She was subjected to sexual abuse both on the journey and at the camp.

4 Exhibit C2a 5 Exhibit C9a 6 Exhibit C9b 7 Exhibit C9b

8 RAH

4.4. Ms Le eventually arrived in Australia when she was 16 years of age. She took English classes and obtained employment, first in a plastics factory and then in a fish processing factory, where she met her first husband. They went on to have three children together, before separating.

4.5. Following the end of her first marriage, Ms Le resorted to gambling and became involved in the drug trade. She later remarried, with that relationship ending in 2007.

Following that separation, Ms Le again fell into gambling. Her participation in the offences leading to her incarceration commenced in November 2012 and continued until her arrest on 10 May 2013.9

4.6. Ms Le has been described as a skilled cook. On release to home detention, she became connected to the Vietnamese Community Centre. She was also dedicated to her Buddhist faith.

5. Circumstances leading to death 5.1. Ms Le was diagnosed with stage 4 lung cancer on 26 June 2019 at the RAH. She had been released to continue serving her sentence on home detention on 14 November

6. She was subject to supervision on home detention which included electronic monitoring. However, after her diagnosis, Ms Le was monitored through home visits and telephone calls to relieve her of the obligation to attend a Community Corrections office.10

5.2. Her treatment plan commenced at the RAH after her diagnosis, which included daily chemotherapy for a period of three weeks.11

5.3. Dr Rachel Johns was a palliative care registrar at TQEH at the time of Ms Le’s death.

She provided an affidavit which was tendered to the Court.12

5.4. Dr Johns reported the death of Ms Le to the Coroner and attached to the medical deposition a detailed summary of Ms Le’s treatment from the time of her admission to the RAH on 30 March 2020, where she presented with dyspnoea for investigation. CT scans were performed which indicated that the cause of the dyspnoea was anaemia and 9 Exhibit C5c, page 3 10 Exhibit C5a, page 11 11 Exhibit C5d, page 2 12 Exhibit C3

bilateral pleural effusions. The scans also revealed new liver metastasis which caused Ms Le considerable pain.

5.5. In the context of her progressive decline, it was determined that further chemotherapy would be futile. She was advised that her life expectancy was two to three weeks. Her electronic monitoring device was removed on 3 April 2020 for compassionate reasons.13

5.6. Ms Le was transferred to TQEH awaiting a palliative care bed, which became available on 8 April 2020.

5.7. Ms Le was reported to be distressed about her prognosis and the inability to have visitors at the RAH at that time. After her transfer, and before her passing, Ms Le was able to spend considerable time with her son, who had been released from prison on 14 April 2020, together with other family members.

5.8. Plans for Ms Le to return home for a period of time were explored but considered unfeasible due to her symptoms at that time and family concerns about managing care at home.

5.9. Ms Le’s respirations ceased on 8 May 2020 at approximately 6pm. However, formal pronouncement and certification of death could not occur for some eight hours in accordance with Ms Le’s religious wishes. Ms Le was therefore formally pronounced deceased at 4:30am on 9 May 2020.14

5.10. Dr Johns opined that the care of Ms Le at the RAH was very appropriate, and her comfort needs and medication adjustments were adequately addressed15.

6. Coronial investigation 6.1. As Ms Le passed away whilst subject to serving a sentence on home detention, a postincident analysis was conducted by Rachel McKay of the Department for Correctional Services.16 She concluded that the case management of Ms Le was appropriate, with targeted referrals. Further she found there were no acts or omissions of the DCS that directly caused or impacted upon the death of Ms Le.17 She also found that the case 13 Exhibit C5a, page 8 14 Exhibit C3, page 2 15 Exhibit C3, page 7 16 DCS; Exhibit C5a, MD3 17 Exhibit C5a, page 12

management of Ms Le was empathetic and supportive. Executive Director Hayley Mills agreed and noted that the case management was excellent with appropriate consideration of Ms Le’s cultural and physical status.18

6.2. Detective Brevet Sergeant Clark reviewed the DCS records and noted that Ms Le was never declined a pass by her case manager.19 She was granted permission to attend religious services, medical appointments, and to work part time at a local Vietnamese café.20

6.3. Detective Brevet Sergeant Clark provided a report in relation to the death of Ms Le. He considered the supervision and care provided to Ms Le by DCS to be more than adequate and described it as compassionate.21 Further, after her lung cancer diagnosis and while on home detention, Ms Le appeared to have been afforded every opportunity without significant impediment to attend and receive any and all health care.22 His opinion was that the medical care provided to Ms Le was as good as it could be in the circumstances.23

6.4. He confirmed that Ms Le was lawfully imprisoned, having pleaded guilty to the offences for which she had been sentenced, noting her appeal against the length of her sentence had been dismissed.24

6.5. The South Australian Prison Health Service25 was responsible for the management of Ms Le’s health care whilst she was in the Adelaide Women’s Prison.26 The adequacy of that care was considered by Kate Wilson, Principal Investigator for DCS.

6.6. Ms Wilson stated in her affidavit27 that SAPHS facilitated access to medical treatment for Ms Le in relation to her high cholesterol, asthma, a reported heart condition, gastrooesophageal reflux disease, hypertension and plantar fasciitis.

6.7. Ms Wilson opined that Ms Le was provided with appropriate access to medical professionals and facilities whilst incarcerated.28 She concluded that there appeared to 18 Exhibit C5d, page 5 19 Exhibit C5a, page 15 20 Exhibit C5d, page 2 21 Exhibit C5a, page 4 22 Exhibit C5a, page 5 23 Exhibit C5a, page 5 24 Exhibit C5a, page 10

25 SAPHS 26 Exhibit C4, page 2 27 Exhibit C5 28 Exhibit C4, page 4

be nothing in her access to relevant services or treatments before or after her release that prevented or limited her access or had a hand in her death.29 Medical adviser to the Coroners Court, Dr Peter White, also reviewed the medical records and did not identify any issues with the medical treatment of Ms Le.

7. Conclusions 7.1. I find Ms Le was in lawful custody at the time of her death.

7.2. I find the treatment and care provided to her for her cancer was exemplary whilst under the care of DCS.

7.3. I have no recommendations to make in this matter.

Key Words: Death in custody; Home Detention; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 19th day of January, 2024.

Deputy State Coroner Inquest Number 12/2023 (0932/2020) 29 Exhibit C4, page 6