Finding into death of Bede Levi Davies

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2017 6605

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: MR PHILLIP BYRNE, CORONER Deceased: BEDE LEVI DAVIES Date of birth: 2 NOVEMBER 1988 Date of death: 30 DECEMBER 2017 Cause of death: I (a) ACUTE BRONCHOPNEUMONIA IN A

MAN WITH CARDIOMEGALY CONTRIBUTING FACTORS CLASS I OBESITY Place of death: PORT PHILLIP PRISON, 280 PALMERS

ROAD, TRUGANINA, VICTORIA, 3029

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2017 6605

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 BEDE LEVI DAVIES without holding an inquest:

find that the identity of the deceased was BEDE LEVI DAVIES

born on 2 November 1988

and the death occurred on 30 December 2017

at the Port Phillip Prison, 280 Palmers Road, Truganina, Victoria, 3029

from: 1 (a) ACUTE BRONCHOPNEUMONIA IN A MAN WITH CARDIOMEGALY

CONTRIBUTING FACTORS CLASS III OBESITY

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

circumstances: Background

1. Bede Davies, an aboriginal man, 29 years of age at the time of his death, was an inmate at Port Phillip Prison in Truganina.

Circumstances of the death

2. On 30 December 2017 at approximately 5.20pm, an inmate entered Mr Davies cell who was in bed. The inmate shook Mr Davics however could not illicit a tesponse. The inmate indicated Mr Davies felt cold. The inmate presumably concluding Mr Davies was asleep, went to get his dinner, after which he retumed to his cell, and then to Mr Davies cell, Sensing something was not right, the inmate pressed the buzzer to Mr Davies cell which has

alerted prison staff.

Prison staff who attended Mr Davies cell found him unresponsive and moved him.to the common area where they commenced cardio pulmonary resuscitation. Despite their efforts Mr Davies could not be revived and was formally declared deceased by ambulance officers

at approximately 6.11pm.

Post-mortem examination and report

Mr Davies’s death was reported to the coroner. Having considered the circumstances and having conferred with a forensic pathologist, and being advised the Senior Next of Kin

consented to autopsy, I directed an autopsy and ancillary tests be conducted.

Subsequently Forensic Pathologist Dr Heinrich Bouwer provided an Autopsy Report advising Mr. Davies died due to

(a) Acute Bronchopneumonia in a man with cardiomegaly Contributing Factors Class III obesity Dr Bouwer commented:

“At autopsy, was significant natural disease affecting the cardiorespiratory systems. The heart was significantly enlarged, floppy and dilated.

Histological examination showed pericellular fibrosis, but no evidence of specific cardiomyopathy, valve pathology, myocarditis or infarction. There was no significant coronary artery atherosclerosis. The cause of the cardiac enlargement is not known, but could be complication of obesity, stimulating drug use or hypertension. In addition there was bilateral acute

bronchopneumonia”.

Further investigation

As Mr Davies was in custody at the time of his death, following established protocols, both

the Justice Assurance and Review Office (JARO) and Justice Health respectively reviewed

Mr Davies’s correctional management and delivery of health care while in custody.

JARO in its report dated 27 September 2018 concluded:

“Port Phillip’s response to Mr Davies death was appropriate and that Port Phillip

staff should be commended in their efforts to preserve Mr Davies life”

Justice Health in its report dated 20 February 2018 found:

“Based on a file review of Mr Davies medical record there is nothing to suggest that the healthcare provided to Mr Davies was not in accordance with the Justice Health

Quality Framework 2014”.

Having examined both reports provided to the Court, I am satisfied Mr Davies’ correctional management was in accordance with the standards prescribed by Corrections Victoria. I am further satisfied that the healthcare provided to Mr Davies while in custody was in accordance with the Justice Health Quality Framework 2014.

Following a relatively recent amendment to the Coroners Act 2008, I am able to make a formal finding without recourse to the forensic judicial process (inquest) in circumstances where the cause of death of a person in custody is due to natural cause. I am entirely satisfied Mr Davies” death was due to natural causes. I finalise my coronial investigation by

way of this Finding without Inquest.

Finding

I formally find Bede Levi Davies died at Port Phillip Prison on 30 December 2017 due to acute bronchopneumonia in a man with cardiomegaly. I am satisfied his untimely death was

due to natural causes.

Pursuant to section 73 (1) (B) of the Coroners Act 2008 (Vic), I direct that this finding be

published on the Coroners Court of Victoria website.

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

Mr Glen and Mrs Derinda Davies, Senior Next of Kin;

Ms Michelle Gavin, Director, Justice Assurance and Review Office; Mr Scott Swanwick, Justice Health;

Ms Ingrid Nunnink, Marsh & Maher Richmond Bennison Lawyers for G4S Custodial Services Pty Ltd:

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

Senior Constable Sophie Templeton, Victoria Police Reporting Officer.

ro December 2018