Finding into death of Peter Swanston

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2014 001247

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: PETER SWANSTON

Delivered on: 14 JULY 2014 Delivered at: MELBOURNE Hearing dates: 14 JULY 2014 Findings of: CORONER ROSEMARY CARLIN

Place of death/Suspected death: ST AUGUSTINE’S WARD, ST VINCENTS HOSPITAL,

41 VICTORIA PARADE, FITZROY, VICTORIA

Counsel Assisting SENIOR CONSTABLE PAUL COLLINS

I, ROSEMARY CARLIN, Coroner

having investigated the death of PETER SWANSTON

AND having held an inquest in relation to this death on 14 JULY 2014 at MELBOURNE

find that the identity of the deceased was PETER SWANSTON

born on 13 AUGUST 1950

and the death occurred on 7 MARCH 2014

at ST AUGUSTINE’S WARD, ST VINCENTS HOSPITAL, 41 VICTORIA PARADE, FITZROY,

VICTORIA

from: 1(a) COMPLICATIONS OF METASTATIC NON SMALL CELL LUNG CANCER .

in the following circumstances:

1. A summary inquest was held in relation to the death of Mr Swanston in circumstances where he was in custody, The holding of an inquest was mandatory due to his “in custody”

status.

2. Mr Swanston was born on 13 August 1950 and was 63 years of age at the time of his death.

At the time of his death he was receiving treatment at the St Augustine’s Ward at St

Vincent’s Hospital in Fitzroy, Victoria.

3, On 7 April 2009, Mr Swanston was sentenced to a term of imprisonment of twelve years and six months with a non parole period of ten years for various offences. He served this sentence at the Melbourne Assessment Prison, Metropolitan Remand Centre, Barwon

Prison, Hopkins Correctional Centre and Port Phillip Prison (PPP).

4. Mr Swanston’s medical history included chronic obstructive airway disease, basal cell carcinoma, emphysema and asthma. He was a chronic smoker and had suffered from depression and anxiety. He was taking a range of medication by way of treatment for his

conditions, including anti-depressant medication.

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Throughout his time in custody, Mr Swanston was reviewed by prison nursing and medical staff for various conditions, He had an extensive history of medical consultations and would

be referred to practitioners for specialised treatment where appropriate.

On 14 November 2012, Mr Swanston underwent a CT scan that showed a subpleural masslike lesion suspicious of bronchogenic carcinoma in the upper lobe of his right lung. The CT scan was conducted to investigate symptoms of ongoing discomfort in Mr Swanston’s right chest wall, decreased air entry, loss of weight and because the results of an earlier chest

x-ray showed mild pleural scarring in the right upper lobe of his lung.

Mr Swanston was diagnosed with Non Squamous Cell Carcinoma (lung cancer) following a review of his results and on 28 November 2012, he was transferred from his current accommodation at Hopkins Correctional Centre to PPP for further management of his

physical health with St Vincent’s Hospital, Melbourne.

The healthcare and treatment for Mr Swanston following this diagnosis was coordinated by St Vincent’s Correctional Health Service in collaboration with the hospital and the Peter

McCallum Cancer Centre (PMCC).

From 29 April - 19 September 2013, Mr Swanston was transferred on multiple occasions to the PMCC for prescribed cycles of chemotherapy and radiotherapy. He was also transferred to St. Vincent’s Hospital on multiple occasions for treatment of his physical health

complications.

. While accommodated at St John’s Ward at PPP, Mr Swanston was reviewed by multiple

clinicians to advise and manage his symptoms. He had a nursing care plan which included a

daily falls risk assessment chart and a care plan to assist him with his daily activities.

On 20 September 2013, Mr Swanston: was transferred to the St Augustine’s Ward at St Vincent’s Hospital for the management of complications of his illness. A CT scan

confirmed that his cancer had spread to his abdomen and bones in his lower back,

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On 3 October 2013, he underwent surgery for a fractured hip which was thought to have been caused by the cancer spreading to his hip, Following stabilisation of his symptoms he

was transferred back to St John’s Ward.

On 28 November 2013, Mr Swanston was transferred to St Augustine’s Ward with

increased pain at the site of his previously fractured hip. It was decided that surgery was not

an option due to his widespread cancer and his condition was treated conservatively,

On 6 December 2013, in consultation with Mr Swanston, a ‘Not for Resuscitation’ order was implemented, however full ward management which included intravenous antibiotics

and pain relief continued,

On 6 January 2014, Mr Swanston was reviewed by the Oncology team and in consultation with him, the decision was made to provide palliative care only. His condition continued to deteriorate and on 7 March 2014 he was found dead by nursing staff and pronounced

deceased by the medical officer at 3.20 a.m.

An inspection of Mr Swanston’s body was undertaken by Dr Jacqueline Lee, Forensic Pathologist at the Victorian Institute of Forensic Medicine. Following an external examination of the body and a review of Mr Swanston’s clinical records, Dr Lee formulated a reasonable cause of death as 1(a) Complications of Metastatic Non Small Cell Lung

Cancer.

I find that Peter Swanston died as a result of Complications of Metastic Non Small Cell

Lung Cancer,

. I direct that a copy of this finding be provided to the family of Mr Swanston, the Interested

Parties and to the Investigating Member, Victoria Police.

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Signature:

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ROSEMARY CARLIN CORONER 14 JULY 2014