Finding into death of Rodney Wayne Weise

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2019 1771

FINDING INTO DEATH WITHOUT INQUEST

Findings of:

Deceased:

Date of birth:

Date of death:

Cause of death:

Place of death:

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

Simon McGregor, Coroner

Rodney Wayne Weise

21 October 1970

8 April 2019

Complications of metastatic melanoma

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

INTRODUCTION

1. Rodney. Wayne Weise was a 48-year-old man who was in custody at the Port Phillip Prison located at 451 Dohertys Road, Truganina Victoria 3029 at the time of his death.

2. Mr Weise died following complications of metastatic melanoma at St Vincent’s Hospital

Melbourne located at 41 Victoria Parade, Fitzroy Victoria 3065 on 8 April 2019.

THE PURPOSE OF A CORONIAL INVESTIGATION

3. | Mr Weise’s death was reported to the Coroner as it occurred in custody, and was unexpected

and so fell within the definition of a reportable death in the Coroners Act 2008.

4. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame

or determine criminal or civil liability.

5. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death

under investigation.

6. The Department of Justice and Community Safety, Justice Assurance and Review Office (JARO) conducted a review into the healthcare afforded to Mr Weise.! I have used the

material produced from this review in coming to my findings.

7. In the coronial jurisdiction facts must be established on the balance of probabilities.” After considering all the material obtained during the coronial investigation, I determined that I had sufficient information to complete my task as coroner and that further investigation was not required. Whilst T have reviewed all the material, I will only refer to that which is

directly relevant to my findings or necessary for narrative clarity.

' Department of Justice and Community Safety, Justice Assurance Review letter to Coroners Court dated 15 July 2019, Coronial Brief. .

2 This is 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.

8. In considering the issues associated with this finding, I have been mindful of Mr Weise’s basic human rights to dignity and wellbeing, as espoused in the Charter of Human Rights and Responsibilities Act 2006, in particular sections 8, 9 and 10.

BACKGROUND

9. At the time of his death, Mr Weise was serving his first term of imprisonment. He was received into the custody of Corrections Victoria on 4 February 2015.

10. On 27 February 2015, Mr Weise was sentenced to nine years imprisonment with a nonparole period of five years and six months. His earliest date of release would have been 20 July 2020.

11. In 2016, Mr Weise developed a lesion on his left great toe. Biopsies identified the lesion as a malignant melanoma. Mr Weise’s toe was subsequently amputated.?

12. Jn November of 2018, Mr Weise reported that he had developed sharp acute pain. Scans conducted in January of 2019 confirmed metastases in the lungs as well as bony metastases in his vertebrae, right medial clavicle and right humeral neck.4

13. On31 January 2019, Mr Weise was discharged from St Vincent’s Hospital Melbourne to the

St John’s sub-acute inpatient unit at Port Phillip, where his condition continued to be

monitored.°

CIRCUMSTANCES IN WHICH THE DEATH OCCURRED

On 20 March 2019, Mr Weise reported experiencing crushing chest pain that increased when he lay down. Following a review by the medical officer, the decision was made to transfer Mr Weise to the Emergency Department at St Vincent’s Hospital Melbourne for further assessment. Due to his deteriorating condition, Mr Weise was admitted to the St

Augustines secure ward.°

On 8 April 2019, Mr Weise was transferred from the St Augustines secure ward to the Cardiac Ward. At approximately 8.06pm, a hospital Code Blue was called. Mr Weise was

3 Department of Justice and Community Safety, Justice Assurance Review letter to Coroners Court dated 15 July 2019, Coronial Brief.

• Ibid.

5 Tid.

§ Tbid.

stabilised however; a second Code Bluc was called and Mr Weise was pronounced deceased

at 8.10pm.

IDENTITY AND CAUSE OF DEATH

On 10 April 2019, Jean Lynette Giles visually identified the body of her brother, Rodney Wayne Weise, born 21 October 1970. Identity is not in dispute and requires no further

investigation.

On 9 April 2019, Dr Heinrich Bouwer, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an external examination of Mr Weise’s body and reviewed a post mortem computed tomography (CT scan), St Vincent’s Hospital medical deposition, St Vincent’s Hospital medical records and the Police Report of Death for the Coroner. Dr Bouwer provided a written report, dated 10 April 2019, in which he formulated

the cause of death as ‘/(a) Complications of metastatic melanoma’.

Toxicological analysis of post mortem samples taken from Mr Weise identified the presence of methadone and its metabolite EDDP’, morphinc®, 7-Aminoclonazepam’, pregabalin’,

sertraline!!, haloperidol!?, frusemide!?, domperidone™ and paracetamol.

Dr Bouwer commented that the post mortem CT scan showed multiple lung nodules (metastatic melanoma), spinal vertebral plates and a pathological fracture of the T11

vertebral body.

l accept Dr Bouwer opinion as to cause of death.

FINDINGS AND CONCLUSION

Having reviewed the material provided by JARO, I am satisfied that the healthcare afforded to Mr Weise was in accordance with the Justice Health Quality Framework 2004,

Pursuant to section 73(1B) of the Act, I direct that this finding be published on the Internet.

7 Methadone is a synthetic narcotic analgesic and is used for the treatment of opioid dependency or for the treatment of severe pain.

8 Morphine is a narcotic analgesic used for the treatment of moderate to severe pain.

° 7-Aminoclonazepam is a metabolite of clonazcpam. Clonazepam is clinically used for the treatment of seizures.

1° Pregabalin is clinically used for the treatment of partial seizures and neuropathic pain.

1! Sertraline is an anti-depressant drug for use in cases of major depression.

12 Haloperidol is an anti-psychotic agent.

3 Brusemide is a loop diuretic used to treat oedema and mild to moderate hypertension.

'4 Domperidone is used as an antiemetic.

15 Paracetamol is an analgesic is am analgesic drug available in many proprietary products either by itself or in combination with other drugs, such as codeine and propoxyphene.

23. express my sincere condolences to Mr Weise’s family for their loss.

24. Having investigated the death, without holding an inquest, I make the following findings pursuant to section 67(1) of the Coroners Act 2008:

(a) The identity of the deceased was Rodney Wayne Weise, born 21 October 1970,

(b) The death occurred on 8 April 2019 at St Vincent’s Hospital located at 41 Victoria

Parade, Fitzroy Victoria 3065 from complications of metastatic melanoma; and

(c) The death occurred in the circumstances described above.

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

(a) Mr Andrew Weise, senior next of kin

(b) Ms Michelle Gavin, Justice Assurance and Review Office, interested party

(c) Dr Alice Bergin, St Vincent’s Hospital Melbourne, interested party (ad) Mr Scott Swanwick, Justice Health, interested party

(e) First Constable Thomas Mills, Coroner’s Investigator

Signature:

\

P jae |

SIMON McGREGOR

CORONER Date: 3 September 2019