Finding into death of Kenneth Albert Hargreaves

IN THE CORONERS COURT OF VICTORIA

AT MELBOURNE Court Reference: COR 2017 1065

FINDING INTO DEATH WITHOUT INQUEST

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

I, JACQUI HAWKINS, Coroner having investigated the death of KENNETH ALBERT HARGREAVES without holding an inquest:

find that the identity of the deceased was KENNETH ALBERT HARGREAVES

born on 5 September 1946

and the death occurred on 5 March 2017

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

from:

1(a) METASTATIC TUMOUR IN THE SETTING OF KNOWN RENAL AND BOWEL

CANCER

1. Kenneth Albert Hargreaves was 70 years old at the time of his death. He was serving a nine-

year term of imprisonment at Port Phillip Prison.

2. Mr Hargreaves had an extensive medical history, including Parkinson’s disease, lymphoma, ischaemic heart disease, congestive cardiac failure, hypertension and high cholesterol, anaemia, an overactive thyroid, and bowel and renal cancer. He also had a history of depression, and

alcohol and prescription drug abuse.

3. | Mr Hargreaves’ death was reported to the Coroner as it fell within the definition of a reportable

death in the Coroners Act 2008.

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At the time of his death, Mr Hargreaves was ‘in care’ pursuant to section 3 of the Coroners Act.

A coroner must hold an inquest if the deceased was, immediately before death, a person placed in care, in accordance with section 52(2)(b) of the Coroners Act. Pursuant to section 52(3A) of the Coroners Act, I am not required to hold an inquest in these circumstances, if I consider that

the death was due to ‘natural causes’.

In accordance with section 52(3B) of the Coroners Act, a death may be considered to be due to ‘natural causes’ if the coroner has received a report from a medical investigator, in accordance with the rules, that includes an opinion that the death was due to ‘natural causes’. I have received such a report in this case. Therefore, I make my findings with respect to the circumstances and

exercise my discretion not to hold a public hearing through an inquest.

The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death and with some exceptions, surrounding circumstances.

Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The law is clear that coroners establish facts; they do not lay blame, or

determine criminal or civil liability. !

In writing this Finding, I do not purport to summarise all of the evidence, but refer to it only in

such detail as appears warranted by its forensic significance and the interests of narrative clarity.

Identity

Mr Hargreaves was visually identified by his son, Darren Hargreaves, on 10 March 2017.

Identity was not in issue and required no further investigation.

Medical cause of death

On 7 March 2017, Dr Michael Burke, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an external examination on the body of Mr Hargreaves and reviewed the Form 83 Victoria Police Report of Death, and the post mortem computed tomography (CT)

scan.

Dr Burke commented that the post mortem CT scan showed ascites and pleural effusions. The

external examination was otherwise unremarkable.

' In the coronial jurisdiction facts must be established on the balance of probabilities subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

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11. Dr Burke provided an opinion that the medical cause of death was 1(a) METASTATIC TUMOUR IN THE SETTING OF KNOWN RENAL AND BOWEL CANCER.

12. On the basis of the information available at the time of completing his report, Dr Burke provided

an opinion that Mr Hargreaves’ death was due to natural causes.

Circumstances in which the death occurred

13, On 21 February 2017, Mr Hargreaves suffered a fall while admitted to the St John’s Unit of Port Phillip Prison. Upon transfer to St Vincent’s Hospital, he was found to have a fractured hip, and was admitted to St Augustine’s Ward for further assessment. Given his multiple medical co-morbidities, including his renal and bowel cancer, it was considered not appropriate

for Mr Hargreaves to undergo surgery for his hip fracture.

14. On 3 March 2017, due to his rapidly deteriorating condition and poor prognosis, clinicians recommended that Mr Hargreaves be palliated. He was transferred to the palliative care ward

of St Vincent’s Hospital, and given comfort care and pain relief.

15. On 5 March 2017 at 7.25am, a custodial officer rostered on to sit with Mr Hargreaves noticed that he had stopped breathing. He immediately notified the registered nurse on duty. At 8.15am,

an attending doctor confirmed that Mr Hargreaves was deceased.

Findings

16. Iam satisfied that the medical care and management provided to Mr Hargreaves was reasonable and appropriate.

17. Having considered the evidence I am satisfied, that no further investigation is required.

18. Pursuant to section 67(1) of the Coroners Act 2008, | make the following findings connected

with the death:

19. I find that:

a. the identity of the deceased was Kenneth Albert Hargreaves, born 5 September 1946;

and

b. Mr Hargreaves died on 5 March 2017 from l(a) Metastatic Tumour in the Setting of

Known Renal and Bowel Cancer; c. in the circumstances described above.

20. Iam satisfied that Mr Hargreaves’ death was due to natural causes.

21. Pursuant to section 74(1B) of the Coroners Act, this finding must be published on the internet.

I direct that a copy of this finding be provided to the following: The family of Mr Hargreaves; Information recipients; and

Coroner’s Investigator, Victoria Police

Signature:

CQUI HAWKINS Coroner Date: 31 August 2017

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