Finding into death of David John Scott

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 5908

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of: DAVID JOHN SCOTT

Delivered On: 7 November 2014 Delivered At: Coroners Court of Victoria

65 Kavanagh Street

Southbank 3006 Hearing Date: 7 November 2014 Finding Of: AUDREY JAMIESON, CORONER

Counsel Assisting Ms Amira Kafka

I, AUDREY JAMIESON, Coroner having investigated the death of DAVID JOHN

SCOTT

AND having held an inquest in relation to this death on 7 November 2014

at MELBOURNE

find that the identity of the deceased was DAVID JOHN SCOTT

born on 27 July 1962

and the death occurred on 22 December 2013

at St Vincent’s Hospital, 41 Victoria Parade, Fitzroy, 3065

from: 1(a) METASTATIC SMALL CELL LUNG CANCER

in the following circumstances:

1. On 7 November 2014, a mandatory inquest under section 52(2)(b) of the Coroners Act 2008 (Vic) (the Act) was held into the death of Mr David John Scott, because immediately before his death, Mr Scott was “a person placed in....custody” as it is defined in the Act. Mr Scott had been an inmate at Port Phillip Prison (PPP) serving a 12-year minimum sentence relating to a murder

he committed in 1999.

BACKGROUND AND CIRCUMSTANCES

2s Mr Scott was 51 years of age at the time of his death. He had a past medical history that included asthma and smoking.

3. Mr Scott was born in Brisbane and grew up in Queensland with his two sisters. He partly completed secondary school and was considered functionally

illiterate. Both of Mr Scott’s parents died during his early years.

4. Mr Scott developed a transient lifestyle, performing labouring work across

both Queensland and the Northern Territory.

5: Records indicate that Mr Scott became involved with the criminal justice system as early as 1981, with 24 recorded convictions largely related to sexual

offences. He received a prison term of six years in Queensland in 1991.

tds

On 14 June 2000, Mr Scott was sentenced to 17 years imprisonment with a 12-

year non-parole period for a murder he had committed on 28 March 1999.

Mr Scott resided at the maximum security PPP from May 1999 until May 2001, at medium security Fulham Correctional Centre from May 2001 until February 2009, at Ararat Prison from February until November 2009, and at minimum security Langi Kal Kal Prison from November 2009 until he escaped from custody on 15 April 2010. He was re-apprehended within a few days and returned to PPP on 27 April 2010.

Mr Scott had been approved for parole following his 12-year non-parole

period by the Adult Parole Board whilst at the Fulham Correction Centre,

On 10 August 2010, Mr Scott was sentenced to an additional one-month’s

imprisonment.

Mr Scott was released on parole on 20 June 2011 with transitional support provided through the Stepping Up Standing Tall program. A report to the Adult Parole Board dated 26 September 2011 outlined several issues that had developed regarding Mr Scott’s conduct in the program, including bullying behaviour and inappropriate disclosures. Despite a formal warning on 15 September 2011, Mr Scott was unable to moderate his behaviours and was returned to custody on 28 September 2011, first to Loddon Prison and then to PPP in April 2013.

Mr Scott was in good health for the majority of his imprisonment.

Mr Scott presented to the PPP Nurse on 3 April 2013 with complaints of leftsided chest pain and was referred to the Emergency Department at Bendigo Healthcare. Preliminary test results prompted Mr Scott’s transfer to the St Augustine secure ward at St Vincent’s Hospital on 6 April 2013. Mr Scott was diagnosed with small cell lung cancer on 9 April 2013.

Mr Scott underwent chemotherapy and radiotherapy at the Peter MacCallum Cancer Centre and St Vincent’s Hospital, with an initial positive response with

almost complete shrinkage of his primary tumour.

Mr Scott was managed by Nursing staff at PPP between August and

November 2013, where it was clear that his condition continued to deteriorate.

Mr Scott was admitted to St Vincent’s Hospital on 6 December 2013 with functional decline, weight loss and back pain. Investigations determined that Mr Scott had bony metastases and metastatic lung, adrenal and abdominal soft

tissue tumours.

Mr Scott received a short course of palliative radiotherapy and returned to

PPP.

On 19 December 2013, Mr Scott appeared disorientated and was observed to have an audible respiratory wheeze. He was assessed by a Medical Officer who advised that a hospital admission was appropriate however Mr Scott

refused treatment.

On 21 December 2013, Mr Scott presented to prison staff with complaints of abdominal pain and was observed to be tachycardic and hypertensive. He was admitted to St Vincent’s Hospital where investigations identified that Mr Scott was suffering from acute pancreatitis and a suspected chest infection. His renal function deteriorated and his general condition continued to decline. He died at approximately 8:55pm on 22 December 2013 in the presence of his partner,

Ms Jeanette Dunn.

FORENSIC PATHOLOGIST EXAMINATION AND EVIDENCE

19, Dr Paul Bedford, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an external examination upon the body of Mr Scott, reviewed a post mortem CT scan and reviewed the Victorian Police Report of Death, Form 83.

20. Dr Bedford ascribed the cause of Mr Scott’s death to natural causes, being metastatic small cell lung cancer.

POLICE INVESTIGATION

21. The circumstances of Mr Scott’s death have been the subject of investigation

by Victoria Police. Police obtained statements from Acting Clinical Director of St Vincent’s Correctional Health Service at Port Phillip Prison Dr Bruce McLaren and St Vincent’s Hospital Director of Oncology Dr Raymond Snyder. Reports from Justice Health and the Office of Correctional Services

Review were also obtained.

FACTORS CAUSING OR CONTRIBUTING TO DEATH

22. The evidence supports a conclusion that Mr Scott died on 22 December 2013 and that the cause of his death was metastatic small cell lung cancer. The circumstances under which Mr Scott died were, according to the Forensic Pathologist, consistent with Mr Scott’s relevant past medical history. There was no evidence to suggest any other cause or contribution to his death. Mr

Scott died from natural causes related to metastatic small cell lung cancer.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following

comment(s) connected with the death:

In all the circumstances, I am satisfied that there would be no benefit from conducting a full inquest into Mr Scott’s death or obtaining any further medical or other evidence, as neither would assist me to further understand the medical issues before me or the cause of Mr Scott’s death which resulted from natural causes in the context of

metastatic small cell lung cancer.

FINDINGS

I accept and adopt the medical cause of death as ascribed by Dr Paul Bedford and I find that David John Scott died from natural causes being metastatic small cell lung

cancer.

AND | find that there is no relationship between the cause of Mr Scott’s death and the

fact that he was “a person placed in custody”.

Pursuant to section 73(1) of the Coroners Act 2008, I order that the following be

published on the internet.

I direct that a copy of this finding be provided to the following: Ms Jeanette Dunn

Dr Bruce McLaren Acting Clinical Director of St Vincent’s Correctional Health

Service, Port Phillip Prison Dr Raymond Snyder, Director of Oncology, St Vincent’s Hospital

Ms Melanie Kyezor, Clinical Risk Manager, St Vincent’s Health

Mr Jonathan Kaplan, Director, Office of Correctional Services Review

Constable Mark Henley

Signature:

AUDREY JAMIESON CORONER Date: 7 November