Finding into death of Allan Richard Hodson

IN THE CORONERS COURT Court Reference: COR 2018 4750

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: AUDREY JAMIESON, CORONER Deceased: ALLAN RICHARD HODSON Date of birth: 21 August 1945 Date of death: 21 September 2018 Cause of death: Metastatic rectal carcinoma St Vincent’s Hospital, 41 Victoria Parade Place of death: Fitzroy Victoria 3065 1 of 5

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

1. Allan Richard Hodson was a 73-year-old man who was, at the time of his death, serving an 11-year term of imprisonment at Port Phillip Prison, 451 Dohertys Road, Truganina Victoria 3029.

2. On 16 September 2018, Mr Hodson was transferred to St Vincent’s Hospital, 41 Victoria Parade, Fitzroy Victoria 3065. He was admitted for end of life care, where his health deteriorated over the following days.

3. On 21 September 2018, Mr Hodson died from his longstanding illness.

4. Mr Hodson’s death was reportable pursuant to section 4(2)(c) of the Coroners Act 2008 (Vic) (the Act) because it occurred in Victoria and, immediately prior to his death, Mr Hodson was a person placed in custody.

5. Pursuant to section 52(2)(b) of the Act, subject to section (3) and 3(A), a coroner must hold an inquest into a death, if the death or cause of death occurred in Victoria and the deceased was, immediately before death, a person placed in custody or care.

6. Pursuant to section 52(3A), the coroner is not required to hold an inquest if the coroner considers that the death was due to natural causes.

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INVESTIGATIONS Forensic pathology investigation

7. Dr Michael Burke, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM), performed an external examination upon the body of Mr Hodson, reviewed a post mortem computed tomography (CT) scan, St Vincent’s Hospital E-Medical Deposition Form and referred to the Victoria Police Report of Death, Form 83.

8. Dr Burke commented that the post mortem CT scan showed increased lung markings and ascites. The external examination was otherwise unremarkable.

9. There was no evidence to suggest that Mr Hodson’s death was due to anything other than natural causes.

10. Dr Burke ascribed the cause of death to metastatic rectal carcinoma.

Police investigation

11. Senior Constable (SC) Nathan Emms was the nominated Coroner’s Investigator.1 At my direction, SC Emms investigated the circumstances surrounding Mr Hodson’s death, including the preparation of the coronial brief. The coronial brief contained, inter alia, statements made by treating clinician and investigating officers and Mr Hodson’s medical file.

12. During the investigation, police learned that Mr Hodson was serving an 11-year term of imprisonment for the offences of rape, recklessly cause serious injury and threat to inflict serious injury, committed on 27 January 2011. Mr Hodson’s term of imprisonment commenced on 8 August 2011.

13. Mr Hodson was estranged from his family at the time of his death.

14. In April of 2018, Mr Hodson was diagnosed with rectal cancer metastatic to liver, lung and bone. He had a history of alcohol related liver cirrhosis, type 2 diabetes and basal 1 A Coroner’s Investigator is a police officer nominated by the Chief Commissioner of Police or any other person nominated by the Coroner to assist the coroner with his/her investigation into a reportable death. The Coroner’s Investigator receives directions from a Coroner and carries out the role subject to those directions.

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carcinoma of the neck. “He had been treated with chemo-radiotherapy through SVHM2 in May/June 2018 but when his disease progressed on first line therapy a decision was made not to pursue further anti-cancer treatments due to his advanced liver cirrhosis.”

15. Mr Hodson received treatment through St John’s at Port Philip Prison, where his health gradually declined.

16. On 16 September 2018, Mr Hodson’s health deteriorated, resulting in melaena, fever and confusion. His condition exceeded the nursing capabilities of St John’s, resulting in his transfer to St Vincent’s Hospital Emergency Department via Ambulance Victoria.

17. As there were no available beds in the St Augustine Ward3 upon his admission, Mr Hodson was admitted to the Inpatient Palliative Care Unit and monitored by a corrections officer. Mr Hodson was conscious and comfortable but confused, drowsy and was unable to have any oral intake. His symptoms were managed with small doses of morphine and midazolam when required for pain and agitation.

18. On 19 September 2018, Dr Bethany Russel consulted on Mr Hodson. Dr Russel observed that Mr Hodson’s condition had deteriorated and that his pain had increased.

Mr Hodson had developed a skin tear on his left shin as a result of wearing ankle shackles. Given Mr Hodson posed no risk of absconding, his shackles were removed in consultation with St Augustine Ward’s management.

19. On 20 September 2018, treating clinicians observed Mr Hodson’s condition to decline further and provided him with appropriate comfort measures and treatment.

20. On 21 September 2018 at approximately 10.00am, Dr Russel observed that Mr Hodson was completely unconscious. She suspected that his death was imminent and commenced the ‘Care Plan for the Dying Person- Victoria’.

21. At approximately 11.15am, Mr Hodson was noted as having died by the supervising corrections officer.

22. Mr Hodson was formally pronounced dead at 11.20am.

2 St Vincent’s Hospital Melbourne.

3 The acute correctional health ward at St Vincent's Hospital.

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FINDINGS

1. I find that Allan Richard Hodson, born 21 August 1945, died on 21 September 2018 at St Vincent’s Hospital, 41 Victoria Parade, Fitzroy Victoria 3065.

2. The investigation did not identify any relevant issues associated with Allan Richard Hodson’s custody. Accordingly, I find that there is no relationship between the cause of Allan Richard Hodson’s death and the fact that immediately before his death, he was a person placed in custody or care.

3. I accept and adopt the medical cause of death ascribed by Dr Michael Burke and I find that Allan Richard Hodson died from natural causes, being metastatic rectal carcinoma and accordingly, section 52(3A) of the Act was deemed appropriate in this matter.

Pursuant to section 73(1B) of the Act, I order that this Finding be published on the internet.

I direct that a copy of this finding be provided to the following: Brett Hodson Donna Filippich, St Vincent’s Hospital Melbourne Michelle Gavin, Justice Assurance and Review Office Senior Constable Nathan Emms Signature:

AUDREY JAMIESON CORONER Date: 10 September 2020 5 of 5