Finding into death of Jason Leslie Spradbury

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2017 1034

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

Findings of: MR PHILLIP BYRNE, CORONER

Deceased: JASON LESLIE SPRADBURY

Date of birth: 18 OCTOBER 1973

Date of death: 2 MARCH 2017

Cause of death: I (a) METASTATIC COLO-RECTAL

CARCINOMA Place of death: ST VINCENT’S HOSPITAL, 41 VICTORIA

PARADE, FITZROY, VICTORIA, 3065

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2017 1034

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, PHILLIP BYRNE, Coroner having investigated the death of JASON LESLIE SPRADBURY

without holding an inquest:

find that the identity of the deceased was JASON LESLIE SPRADBURY born on 18 October 1973

and the death occurred on 2 March 2017

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

from: l(a) METASTATIC COLO-RECTAL CARCINOMA

Pursuant to section 67(1) of the Coroners Act 2008 I make findings with respect to the following

circumstances: Background

1. Mr Jason Spradbury, 43 years old at the time of his death, was an inmate detained at Port

Phillip Prison in Truganina.

2. Mr Spradbury’s past medical history included asthma, colon cancer resulting in a partial bowel resection, anxiety, depression and polysubstance abuse.

3. Mr Spradbury’s death constituted a ‘reportable death’ under the Coroners Act 2008 (Vic), as immediately before death, he was in the legal custody of the Secretary to the Department of Justice and Regulation (formerly the Department of Justice) as an inmate detained at Port Phillip Prison.’ Ordinarily, a coroner must hold an inquest into a death if the death or cause

of death occurred in Victoria and the deceased person was immediately before death a

' Section 4, definition of ‘Reportable death’, Coroners Act 2008; Section 4, definition of ‘Person placed in custody or care’, Coroners Act 2008.

person placed in custody or care.” However, a coroner is not required to hold an inquest if the coroner considers that the death was due to natural causes.?

4. On 28 February 2016 Mr Spradbury claimed to be experiencing severe abdominal and back pain. On 4 March 2016 he was transferred to St Vincent’s Hospital and diagnosed with metastatic colorectal cancer. Mr Spradbury underwent a partial bowel resection.

5. On 7 March 2016 Mr Spradbury was discharged from hospital and transferred back to Port Phillip Prison, with a plan in place to commence chemotherapy intermittently as an outpatient at St Vincent’s Hospital.

6. On 5 April 2016 Mr Spradbury commenced chemotherapy treatment at St Vincent’s Hospital. The chemotherapy treatment continued on a fortnightly basis until November 2016.

7. During the course of his treatment, regular tests revealed the cancer continued to spread and Mr Spradbury’s life expectancy was limitéd, however it was reported Mr Spradbury remained “future focused”.

8. On 15 November 2016, Mr Spradbury attended a review at the St Vincent’s Hospital.

Chemotherapy was not administered on this occasion given the rapid progression of the cancer. Mr Spradbury, in consultation with the treating medical team, made the decision to

cease further chemotherapy and active treatment.

Circumstances of the death

9. On 16 January 2017, Mr Spradbury’s condition had deteriorated and his pain increasing, even though he was prescribed high doses of pain relief. He was subsequently transferred by ambulance to the Emergency Department of St Vincent’s Hospital for further assessment.

As a result of this assessment, Mr Spradbury was admitted to the secure inpatient unit at St

Vincent’s Hospital, where he remained until 25 February 2017.

10. Mr Spradbury’s condition continued to deteriorate and he was transferred to the Palliative Care unit of St Vincent’s Hospital, where he received pain relief and comfort until his death

on 2 March 2017.

POST-MORTEM INSPECTION AND REPORT

11. The matter was appropriately referred to the Coroner. Having regard to the circumstances and having conferred with a forensic pathologist, I directed an externalonly post-mortem examination and ancillary tests be conducted. A post-mortem

examination was performed by Forensic Pathologist Dr Michael Burke of the Victorian

? Section 52(2) (b) Coroners Act 2008.

3 Section 52(3A), Coroners Act 2008.

Institute of Forensic Medicine. Dr Burke advised that the immediate cause of Mr

Spradbury’s death was: I (a) Metastatic colo-rectal carcinoma Further investigation

12. The Office of Correctional Services Review (OCSR) have provided the Court with their formal report, which provides an overview of the management of Mr Spradbury during

his time in custody from 5 May 2010 until his death on 2 March 2017.

13. Having reviewed the OCSR report, I agree that there is nothing to suggest the healthcare provided to Mr Spradbury while in custody was not in keeping with the Justice Health

Quality Framework 2014.

14.1 am satisfied, having considered all of the evidence before me, that no further

investigation is required.

FINDING

15. I formally find Mr Jason Leslie Spradbury died at St Vincent’s Hospital Fitzroy on 2 March

2017 as a result of metastatic colo-rectal carcinoma. I am satisfied Mr Spradbury died due

to natural causes.

16. I direct that a copy of this finding be provided to the following: Ms Frances Spradbury, Senior Next of Kin; Ms Emma Catford, Office of Correctional Services Review; Ms Melanie Kyezor, St Vincent’s Health; and Sergeant David Barlow, Coroner’s Investigator, Victoria Police.

17. Pursuant to section 73(1B) of the Coroners Act 2008, I also direct the finding be

published on the Coroners Court of Victoria website in accordance with the rules of the

Coroners Court.

me ;

Date: 20 September 2017