Coroner's Finding: Freeman, Keith Vivian

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INQUEST INTO THE DEATH OF KEITH VIVIAN FREEMAN [2025] SACC 11 Inquest Findings of her Honour Coroner Giles 20 May 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of Keith Freeman, who died whilst in lawful custody at the age of 71 years as a result of longstanding cardiac issues.

Held:

1. Keith Vivian Freeman, aged 71 years of Yatala Labour Prison, died at the Lyell McEwin Hospital on 7 June 2022 as a result of end-stage cardiac failure on a background of ischaemic heart disease with dilated cardiomyopathy.

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MR M KIRBY Hearing Date/s: 01/04/2025 Inquest No: 08/2025 File No/s: 1341/2022

INQUEST INTO THE DEATH OF KEITH VIVIAN FREEMAN [2025] SACC 11 Introduction and cause of death Mr Keith Vivian Freeman was born on 20 January 1951 and died at the Lyell McEwin Hospital on the evening of 6 June 2022. He was 71 years old.

A pathology review informed by Mr Freeman’s medical records was undertaken by Dr Alexandra Yuill, medical practitioner, and discussed with Associate Professor Neil Langlois, forensic pathologist, of Forensic Science South Australia. The cause of death was determined to be ‘end-stage cardiac failure on a background of ischaemic heart disease with dilated cardiomyopathy’.1 I find accordingly.

Reason for inquest At the time of his death, Mr Freeman was serving a sentence of imprisonment that was imposed on 24 September 2019.2 His death therefore constituted a death in custody, and an inquest into his death was mandatory pursuant to section 21(1)(a) of the Coroners Act 2003.

Background Mr Keith Vivian Freeman was born in Exeter in the south of England. At six weeks of age, he and his older brother were adopted by a family who provided them with a stable and happy upbringing.3 When he was about eight years old, he met his uncle, Michael David Connell, with whom he continued to have a strong relationship. In about 1969 or 1970 Mr Freeman emigrated to Australia. Michael Connell had emigrated with his wife in 1965 and that was partly the reason for Mr Freeman’s move.4 During a period in which he returned to England to be with his sick father, Mr Freeman met and married his wife Leantay, who was studying in Exeter. They had a daughter who was born in England, but he and his family later returned to live in South Australia, where they stayed initially with Mr Connell in Semaphore South.

Mr Freeman’s marriage ended, but he and Leantay remained in contact after they separated. Leantay and their daughter moved to Mount Gambier, and Mr Freeman lived with Mr Connell. Mr Freeman maintained a good relationship with his daughter initially following the separation. However, Mr Freeman’s relationship with his daughter became fractured in later years after allegations of criminal offending were made against Mr Freeman.

1 Exhibit C2a 2 Exhibits C8c 3 Exhibit C8, page 9 4 Exhibit C3, pages 1-2

[2025] SACC 11 Coroner Giles Throughout his life Mr Freeman worked in various roles, with the majority of his employment being as a security guard.5 Medical history Mr Freeman had complex health issues including: Ventricular tachycardia; • Impaired glucose tolerance; • Prostate cancer; • Ischaemic heart disease; • Hypercholesterolemia; • Coronary artery bypass graft in 2006; • Congestive cardiac failure; • Aortic valve replacement in 2006; • Pulmonary embolism in 2006; • Macrocytic anaemia; • Colonic polyps; • Chronic kidney disease; • Chronic airways disease; and • • Automatic internal cardiac defibrillator inserted in 2018.6 Mr Freeman was a heavy drinker and smoker.7 Admission to custody Mr Freeman was convicted at trial and sentenced to a period of imprisonment of eight years, with a non-parole period of three and a half years. His sentence was backdated to commence on 27 August 2019 which was the date on which his bail had been revoked and he had been remanded in custody.8 Mr Freeman was initially admitted to the Adelaide Remand Centre on 27 August 2019 and then transferred to the Yatala Labor Prison (Yatala) on 29 August 2019.

Upon admission to custody, Mr Freeman was placed in the care of the South Australian Prison Health Service (SAPHS). His medical history was recorded during an admission nursing assessment. A specialist letter from his cardiologist, Dr Cameron Brigman, dated 18 February 2019 is contained within his SAPHS records. The letter details Mr Freeman’s end-stage congestive cardiac failure and the limited therapeutic options available to him at this time.9 5 Exhibit C3, page 2 6 Exhibit C5 at [8] 7 Exhibit C3 at [10] 8 Exhibit C8c 9 Exhibit C9

[2025] SACC 11 Coroner Giles Dr Thomas Turnbull, the Medical Director of SAPHS at the time of Mr Freeman’s death, provided an affidavit summarising Mr Freeman’s medical treatment during his time in custody.10 Mr Freeman’s medical issues were monitored and regularly assessed during his incarceration.

On 2 September 2019 Mr Freeman was transferred from Yatala to the Mount Gambier Prison.

After a brief return to Yatala in October 2019, Mr Freeman was transferred to the Port Augusta Prison in March 2020 where he remained until shortly before his death.11 Events leading to death In the months leading up to Mr Freeman’s death, he began to experience issues with increased shortness of breath, initially suspected to be caused by a viral infection, which exacerbated his cardiac issues. He was commenced on furosemide12 medication.

In February 2022, Mr Freeman consulted with a doctor reporting that his shortness of breath was not improving. He was prescribed a different inhaler as an alternative treatment.

In March 2022, Mr Freeman consulted again with the doctor advising there was no change in his shortness of breath. Dr Dolgopol of SAPHS concluded that the shortness of breath was a worsening symptom of Mr Freeman’s congestive cardiac failure and chronic obstructive airway disease. He prescribed an alternative inhaler and increased the furosemide dosage.13 Following further consultations in March 2022, Mr Freeman had X-rays conducted which showed worsening congestive cardiac failure. He was referred to cardiology.

Noting Mr Freeman’s symptoms were continuing to worsen and that a cardiology appointment had not yet been scheduled, Dr Dolgopol arranged for Mr Freeman to be transferred to the Port Augusta Hospital Emergency Department on 6 April 2022.14 He was diagnosed with decompensated heart failure and hyperthyroidism. He was admitted to the Port Augusta Hospital until 13 April 2022, at which point he was transferred to the Flinders Medical Centre Coronary Care Unit where he remained until 29 April 2022. He was diagnosed with heart failure with reduced ejection fraction15 and thyroiditis. Whilst at the Flinders Medical Centre a transthoracic echocardiogram was undertaken with an estimated ejection fraction of less than 20%, indicating his heart was pumping at less than one-third of its capacity. He was discharged back to Yatala with a plan for GP follow-up and a review.16 However, only two days later on 1 May 2022 he was admitted to the Lyell McEwin Hospital experiencing chest pain. He was medically 10 Exhibit C5 11 Exhibit C8c, pages 2-5 12 A medication used to treat swelling and fluid retention caused by congestive heart failure and other diseases 13 Exhibit C5 at [23] 14 Exhibit C5 at [26] 15 An issue where the left ventricle cannot pump blood effectively leading to a low ejection fraction of less than 40% 16 Exhibit C8d

[2025] SACC 11 Coroner Giles managed for ischaemic heart disease and decompensated heart failure and discharged back to Yatala.

On 6 June 2022 Mr Freeman experienced difficulty swallowing and was admitted to the Modbury Hospital on the advice of the Central Adelaide Palliative Care Team. The next day, he was transferred to the Lyell McEwin Hospital with end-stage heart failure for ward-based measures only.

He deteriorated despite treatment and died on 7 June 2022.

Conclusion Consistent with the view expressed by the SAPOL investigating officer, Detective Brevet Sergeant Amanda Pyle, I find that Mr Freeman’s custody was lawful.

I further find that his medical treatment while in custody, both by SAPHS and SA Health, was appropriate.17 Recommendations I do not make any recommendations in this matter.

Keywords: Death in Custody; Prisoner; Natural causes 17 Exhibit C8, page 13