Coroner's Finding: Wallace, Peter John

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INQUEST INTO THE DEATH OF PETER JOHN WALLACE [2025] SACC 29 Inquest Findings of her Honour Deputy State Coroner Kereru 14 November 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of a prisoner who developed pneumonia after being treated for liver cancer. The Inquest explored the level of care provided and whether there were any opportunities to prevent the death.

Held:

1. Peter John Wallace, aged 67 years of Yatala Labour Prison, died at the Lyell McEwin Hospital on 7 January 2023 as a result of hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and multifocal hepatocellular carcinoma.

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

No recommendations made.

Counsel Assisting: MR D EVANS Hearing Date/s: 23/10/2025 Inquest No: 23/2025 File No/s: 0065/2023

INQUEST INTO THE DEATH OF PETER JOHN WALLACE [2025] SACC 29 Introduction Peter Wallace was born on 1 January 1956 and given the name Daryl Scott Kelley.1 He changed his name a number of times in his life. He lived in Adelaide until the age of 12 when the family moved to Perth. He married and had two sons.

Throughout his life he had a number of medical conditions including hypothyroidism, polysubstance use, Hepatitis C (contracted in 1993, but not treated until years later), gastro-oesophageal reflux disease, chronic obstructive pulmonary disease (COPD), anaemia, depression and a personality disorder.2 He had experienced instances of pneumonia and human metapneumovirus.

Mr Wallace served significant terms of imprisonment in Western Australia and South Australia.3 He had a conviction for escaping custody.

Imprisonment in South Australia In November 2004, Mr Wallace was arrested in relation to five counts of rape and three counts of false imprisonment, and a prosecution was initiated. He was later found guilty by a jury in the District Court and in 2008 he was sentenced to imprisonment for 14 years and 10 months with a non-parole period of 11 years and 10 months, taking into account the time he had already spent in custody. An appeal against his conviction was dismissed by the Court of Criminal Appeal4 and permission to appeal against his sentence was refused.5 Throughout the years between 2004 and 2023, Mr Wallace was housed at Yatala Labour Prison, the Adelaide Remand Centre, Port Augusta Prison, Port Lincoln Prison and Mount Gambier Prison.6 Mr Wallace had a great deal of involvement with the health services in prison, accumulating eight volumes of medical notes over his time. Mr Wallace received health care related to general ailments, infectious diseases, dental, eyesight, hearing and mental health. He was prescribed a number of medications, including antidepressants.7 He experienced long-standing nausea for which he was prescribed various medications.

Liver cancer In August 2021, Mr Wallace was at the Port Lincoln Prison when he raised symptoms which led to his transfer to the Royal Adelaide Hospital for investigation of COPD.

While at the Royal Adelaide Hospital, Mr Wallace had a CT pulmonary angiogram scan which incidentally revealed that he had liver cancer with a large lesion of about 10cm in length found.

1 Exhibit C5, page 8 2 Exhibit C2 at [7] 3 Exhibit C5, page 6 4 See R v Wallace [2008] SASC 47 5 See R v Wallace [2010] SASC 30 6 Exhibit C2 at [9] 7 Exhibit C2 at [8] and [12]

[2025] SACC 29 Deputy State Coroner Kereru Upon his return to Port Lincoln Prison, Mr Wallace was reviewed by a doctor. He told a nurse that he had to go to a liver clinic to discuss the results of his CT scan and that he did not think things were good.8 An appointment was booked with the hepatobiliary clinic, but Mr Wallace expressed hesitation about going, telling a nurse that he did not want to travel to Adelaide unless it was for treatment.9 A few days later he agreed to go to his hepatobiliary review. He was transferred to Yatala Labour Prison on 1 September 2021 with a direction that he should be kept in Adelaide for treatment following his review.

In the meantime, a multi-disciplinary meeting was held on 16 August 2021 and Mr Wallace’s case was discussed. It was determined that the lesions were not resectable due to poor exercise tolerance as a result of his severe COPD.10 Instead fluoroscopyguided transarterial chemoembolisations (or TACE procedures) were recommended. The plan was to then have palliative chemotherapy. His general prognosis was poor.

The first TACE procedure was conducted on 30 September 2021 and had good uptake but resulted in an incomplete response by the cancer.

On 13 January 2022, the second TACE procedure was performed which was also uncomplicated.11 The following day, a medical emergency was called as a result of wheezing, dysphonia, angioedema, urticaria and transient chest pain. The immunology unit reviewed Mr Wallace and concluded that he had a delayed allergic reaction to the TACE formula.12 The specific agent that caused the reaction could not be identified as this response had not been scientifically studied.

Mr Wallace’s case was again discussed at another multi-disciplinary meeting on 21 March 2022.13 It was agreed that Mr Wallace would be offered a third TACE procedure with precautions to be taken to address any potential allergic reaction. Notes by prison health nurses record that Mr Wallace had declined further chemotherapy.

On 11 May 2022, an endoscopy was performed which found a small 5mm angiodysplastic lesion in Mr Wallace’s duodenum. An argon plasma coagulation was conducted during the endoscopy to ablate the lesion.14 Following that procedure, Mr Wallace asked to be discharged from the Yatala Health Service and returned to his regular accommodation.

This was considered in light of his chemotherapy. Given there were no ongoing sideeffects noted from the chemotherapy, this was approved.15 In late June through early July 2022, Mr Wallace underwent ablation radiotherapy in relation to the liver cancer, spread across six fractions.16 This was managed by a radiation oncologist from the Royal Adelaide Hospital, Dr Hien Le.

8 Exhibit C7, nursing note 15 August 2021 9 Exhibit C7, nursing note 24 August 2021 10 Exhibit C9, RAH Medical Notes 11 Exhibit C9, page 320 12 Exhibit C9, page 341 13 Exhibit C9, page 569 14 Exhibit C9, page 61 15 Exhibit C2 at [13]; Exhibit C7, nursing note dated 12 May 2022 16 Exhibit C2 at [17]

[2025] SACC 29 Deputy State Coroner Kereru On 3 August 2022, Mr Wallace had a consultation at Yatala Labour Prison with Dr Le.17 Mr Wallace reported abdominal pain, but only on deep palpation, memory issues and long-standing nausea. Dr Le arranged routine a CT scan to assess the effect of the radiotherapy. This was conducted on 18 October 2022 and showed a recurrence of the previously treated liver lesion which had now extended to occlude the right hepatic vein and partially occlude the inferior vena cava. At a clinic review on 26 October 2022, Mr Wallace continued to report feeling well.18 On 9 November 2022, an application for parole was refused by the Parole Board.

Mr Wallace had a discussion with a social worker. He said that while he did not agree with the Parole Board’s decision, he understood it.19 On 7 December 2022, Mr Wallace was examined in relation to ongoing nausea.20 At that time he indicated that there had been an improvement since recently starting a new antinausea medication, metoclopramide. A doctor examined him, added medications, took blood samples and ordered another medical follow-up.

Mr Wallace’s decline On 21 December 2022, Mr Wallace reported to a nurse that he had been experiencing chest pain for two days.21 The nurse told him to go to the Health Centre, but Mr Wallace said that he was comfortable and would visit the Centre the following day. Asking Mr Wallace to attend the Health Centre was in keeping with the Chest Pain Protocol in place.22 Policies allow a prisoner the right to attend, or choose not to attend, for healthcare as would occur in the community.

The following day, 22 December 2022, Mr Wallace saw the doctor and advised that he had experienced three days of chest pain that was radiating to his back and was worse on deep inspiration.23 Physical examination at this time was normal, but oxygen saturation levels were low. An ECG showed premature ventricular complexes. Mr Wallace was noted to be dyspnoeic and pale. An ambulance was called.

Mr Wallace was taken to the Lyell McEwin Hospital where he was held under guard. He was not physically restrained but was in the company of guards at all times. An x-ray revealed pneumonia, and targeted intravenous antibiotics were commenced. After a CT pulmonary angiogram two days later, he was diagnosed with left upper lobe pulmonary embolism and hyponatremia, with likely hypovolaemia which was thought to be medication-induced.24 Doctors took advice from haematology about the appropriateness of anticoagulation to treat the embolism. Following a discussion with Mr Wallace about the risks and benefits, he was commenced on enoxaparin at a middling dose. Mr Wallace continued to require supplemental oxygen to achieve normal saturations.

Scans at this time showed that Mr Wallace’s liver cancer had extended beyond the boundaries of the chemoembolisations, suggesting that his cancer was progressing despite 17 Exhibit C2 at [17] 18 Exhibit C9, Letter dated 26 October 2022 19 Exhibit C7, Entry dated 2 December 2022 20 Exhibit C2 at [24] 21 Exhibit C2 at [25] 22 Exhibit C2 at [25.1] and Annexure TT1 23 Exhibit C2 at [26] 24 Exhibit C7

[2025] SACC 29 Deputy State Coroner Kereru his extensive treatments. On 26 December 2022, Mr Wallace went into Type 1 respiratory failure, as well as being diagnosed with a syndrome of inappropriate antidiuretic hormone secretion. Over time, his oxygen levels deteriorated, and he was taken to the Intensive Care Unit on 27 December 2022 after a fever developed.25 He was given high-flow oxygen therapy but continued to worsen.26 On 4 January 2023, a CT scan was conducted which found Mr Wallace’s liver cancer had extended further. Doctors at the Lyell McEwin Hospital spoke to Dr Le at the Royal Adelaide Hospital who advised that this was a significant advancement of Mr Wallace’s cancer and meant that his prognosis was now poor.27 Dr Le expressed that Mr Wallace would have less than two months to live at best.28 Doctors also contacted the oncology team at the Lyell McEwin Hospital for a second opinion which was in keeping with Dr Le’s view.

A family meeting was held on 5 January 2023 with Mr Wallace’s brother and sister-in22 law contributing over the phone from Western Australia.29 Mr Wallace was also awake and involved in the discussion himself.30 A decision was made to transition him to comfort care, with end-of-life medications commencing on 7 January 2023. In the meantime, Mr Wallace’s brother travelled over from Western Australia. At 9:30pm on 7 January 2023, Mr Wallace was noted to have ceased breathing and a doctor declared him life extinct at 9:35pm.31 He was 67 years old.

Cause of death Mr Wallace’s death was reported to the State Coroner by a doctor from the Lyell McEwin Hospital with advice that his death was as a result of hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and multifocal hepatocellular carcinoma.

This is well supported by the evidence and I find that that was his cause of death.

Lawfulness of detainment At the time of Mr Wallace’s death he was serving a sentence of imprisonment for serious offences. He was therefore lawfully held in custody at the time of his death.

Notwithstanding his death occurring at the Lyell McEwin Hospital, he was under constant guard of the Department of Correctional Services, making his death a death in custody for which a mandatory inquest was required.

Care afforded to Mr Wallace in custody During his time in prison Mr Wallace had a great deal of involvement with the South Australian Prison Health Service and the medical services at non-government operated prisons where he was housed. Mr Wallace had appointments with doctors, nurse practitioners, an optometrist and an audiologist. Upon review of his medical file, it is 25 Exhibit C2 at [27] 26 Exhibit C7 27 Exhibit C7 28 Exhibit C7, page 190 29 Exhibit C7, page 200 30 Exhibit C7, page 206 31 Exhibit C1a at [8]; Exhibit C4 at [8]; Exhibit C5a

[2025] SACC 29 Deputy State Coroner Kereru clear that when health issues were identified, they were treated and where they could not be, transfer to hospital was arranged.

Mr Wallace’s cancer did not cause him any discomfort and was only found incidentally upon scanning his abdomen to assess his lungs. Given it had not presented any specific symptoms, I consider that it was not able to be found earlier. As soon as it was found, significant treatment was undertaken in order to address it. A difficulty Mr Wallace faced was his COPD which limited his treatment options. His allergic response to the second TACE procedure, while able to be managed if it happened again, was enough for Mr Wallace to decline a further round. In light of all of the evidence, I consider that there are no criticisms to be made of the care provided to Mr Wallace. He received a standard of care that was at least as high as is available to the general community.

In respect of Mr Wallace’s end-of-life care, this was managed appropriately and similarly, I do not make any criticism of the level of care provided to him at the Lyell McEwin Hospital.

I make no recommendations.

Keywords: Death in Custody; Prison; Natural Causes