Coroner's Finding: Schlaefer, Norbert

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INQUEST INTO THE DEATH OF NORBERT SCHLAEFER [2026] SACC 5 Inquest Findings of her Honour Deputy State Coroner Roper 13 March 2026

CORONIAL INQUEST Examination of the cause and circumstances of the death of a man who died of natural causes while serving a sentence of imprisonment.

Held:

1. Norbert Schlaefer, aged 69 years of Yatala Labour Prison, died at the Modbury Hospital on 4 February 2023 as a result of disseminated urothelial carcinoma of the bladder (palliated), bilateral lung adenocarcinoma and severe emphysema.

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

No recommendations made.

Counsel Assisting: MR G DUDZINSKI Hearing Date/s: 13/02/2026 Inquest No: 0003/2026 File No/s: 0311/2023

INQUEST INTO THE DEATH OF NORBERT SCHLAEFER [2026] SACC 5 Introduction Norbert Schlaefer was 69 years old when he died on 4 February 2023 at the Modbury Hospital from natural causes.

Mr Schlaefer had been lawfully incarcerated since 17 May 2010, when he was remanded in custody at Port Augusta Prison in relation to serious criminal offences. He pleaded guilty and on 22 July 2010 was sentenced to imprisonment for 26 years, with a non-parole period of 17 years. Following a successful appeal, Mr Schlaefer’s sentence was reduced to 21 years imprisonment with a non-parole period of 14 years.

As Mr Schlaefer died in custody, an inquest into the cause and circumstances of his death was mandatory.1 Who was Mr Schlaefer?

Mr Schlaefer was born on 2 August 1953 at the Woodside Barracks, which operated at that time as a camp for migrants and displaced persons. Mr Schlaefer’s parents emigrated from Germany following the end of the second world war. His German heritage reportedly gave rise to difficulties during his schooling.

Mr Schlaefer met his wife in around 1975, and they had one biological son together.

Mr Schlaefer remained married to his wife for 41 years and they exchanged letters and spoke on the telephone frequently during his incarceration, up until her death in 2015.

Over the course of his working life Mr Schlaefer was employed in a variety of capacities, including by the Australian National Railways for 15 years, as a fencer on cattle farms and as a salesperson for Gateway Batteries. In 1997 he was involved in a motor vehicle accident and subsequently stopped working.

During his time in custody Mr Schlaefer was noted to be a quiet and compliant prisoner who mixed well with others.

What was Mr Schlaefer’s medical condition prior to incarceration?

Prior to his incarceration, Mr Schlaefer had been diagnosed with bilateral emphysema and left upper lobe adenocarcinoma, for which he underwent surgery and chemotherapy.

He completed his cancer treatment in March 2010, shortly before his incarceration.

By way of background, Mr Schlaefer had been a heavy smoker of cigarettes for over 50 years and continued to smoke in prison. He ceased smoking in 2019 when the Port Lincoln Prison became smoke-free. He was also apparently exposed to asbestos during his employment.

1 Coroners Act 2003, section 21(1)(a)

[2026] SACC 5 Deputy State Coroner Roper How was Mr Schlaefer’s health managed while he was in custody?

The South Australian Prison Health Service (SAPHS) is responsible for the provision of health care services to people in custody within the public prisons of South Australia.

Between 2010 and 2022, Mr Schlaefer was accommodated at the Yatala Labour Prison, Port Augusta Prison, Mount Gambier Prison and, from 6 March 2019, Port Lincoln Prison. These are all public prisons, with the exception of the Mount Gambier Prison. The records available to the Court do not document any significant medical events between 2010 and 2018.

In September 2018, however, Mr Schlaefer was diagnosed with right upper lobe adenocarcinoma. A left upper lobe lesion was also identified. Mr Schlaefer was considered a poor candidate for surgery due to his frailty, and he was treated with stereotactic ablative radiotherapy.

Mr Schlaefer was monitored regularly by the Royal Adelaide Hospital outpatient oncology team following his lung cancer diagnosis. A CT scan in January 2020 indicated that his emphysema had progressed and was now severe, but that his lung nodules were stable. A CT scan in July 2020 showed a new right lower lobe lesion. While this resolved in September 2020, by that time, a new left lower lobe lesion had been identified.

Throughout 2021 Mr Schlaefer contracted numerous chest infections resulting in a hospital transfer for bronchitis-induced exacerbation of chronic obstructive pulmonary disease.

Radiological surveillance of his lungs continued, and by July 2021 there was no evidence of any cancer within the lung nodes or other sites. The plan was to review Mr Schlaefer again in six months for re-staging.

During August 2022, however, Mr Schlaefer’s health began to deteriorate. His blood pressure and oxygen saturations were low, and he was experiencing shortness of breath on minimal exertion. He was frail and now mobilised in a wheelchair. Mr Schlaefer experienced unintentional weight loss of seven kilograms over approximately five months.

Urgent investigations were commenced, and a booking was made for a CT scan of his chest, abdomen and pelvis on 19 August 2022. The results of that scan were called through to the prison the same day, as a new mass had been detected within the bladder, with concerns for transitional cell carcinoma.

That evening, Mr Schlaefer was admitted to the Port Lincoln Hospital until his transfer to the Royal Adelaide Hospital by the Royal Flying Doctor Service on 23 August 2022.

On 6 September 2022, Mr Schlaefer underwent a transurethral resection of bladder tumour (TURBT), a surgical procedure by which bladder tissue is removed through the urethra. Approximately 90% of the mass was removed. A biopsy of the excised tissue demonstrated muscle invasive urothelial carcinoma of the bladder.

[2026] SACC 5 Deputy State Coroner Roper Mr Schlaefer was reviewed by the medical oncology team who deemed him unsuitable for chemotherapy due to his frailty. He commenced palliative radiotherapy while at Yatala Labour Prison.

On 30 December 2022, Mr Schlaefer was reviewed by prison nursing staff. He was noted to be shaking, pale and grey in colour. He complained of abdominal pain and severe shortness of breath at rest. Oxygen therapy was commenced. However, due to his high temperature and continuing respiratory distress, an ambulance was called. Mr Schlaefer was conveyed via ambulance to the Lyell McEwin Hospital Emergency Department.

Radiological imaging was performed, which demonstrated: A left lower lobe lung lesion with central necrosis; • A left seventh rib destructive bone lesion; • Bilateral pulmonary nodules; • Left pleural effusion; • Bony lesion of the sacrum; and • Pelvic lymphadenopathy.

• Mr Schlaefer was treated with intravenous antibiotics due to his high temperature and raised inflammatory markers. However, this did not result in improvement of his condition. He also received palliative chemotherapy for the destructive metastatic lesion of his seventh rib, which was considered likely to have arisen from his known urological primary malignancy.

Mr Schlaefer’s condition worsened throughout his admission and, following consultation with Mr Schlaefer, who indicated that he did not wish to have any treatment to prolong his life, a decision was made for comfort focussed care.

Consequently, on 1 February 2023, Mr Schlaefer was transferred to the Modbury Hospital Palliative Care Unit for ongoing symptom management and end of life care.

His condition gradually declined and he was declared life extinct at 6:31pm on 4 February 2023.

What was the cause of Mr Schlaefer’s death?

Dr Jane Alderman, a medical practitioner experienced in providing opinions as to cause of death, conducted an examination of Mr Schlaefer’s longitudinal medical history.

Dr Alderman opined that the cause of Mr Schlaefer’s death was the combined effects of disseminated urothelial carcinoma of the bladder (palliated), bilateral lung adenocarcinoma and severe emphysema, and I so find.

Family concerns Mr Schlaefer’s son provided an affidavit to the Court. He stated that his father complained about his treatment at the Lyell McEwin Hospital, and, in particular, that a nurse spoke to him in a sarcastic tone in response to a request for pain medication.

[2026] SACC 5 Deputy State Coroner Roper Mr Schlaefer’s son was also refused permission to see his father on several occasions while he was receiving treatment at the Lyell McEwin Hospital and the Modbury Hospital. However, this issue was resolved, and Mr Schlaefer was able to receive visits from his son.

I have carefully considered the concerns raised by Mr Schlaefer’s son. Overall, however, I am not satisfied that the evidence demonstrated any material deficiency in the healthcare provided to Mr Schlaefer during his incarceration. I recognise that the refusal of visits by Mr Schlaefer’s son would have caused him significant stress at an already difficult time.

I extend my condolences to him.

Conclusions Mr Schlaefer was lawfully in custody at the time of his death.

I find that Mr Schlaefer received adequate medical treatment during his incarceration.

I have no recommendations to make.

Keywords: Death in Custody; Natural Causes; Prison