Finding into death of Dennis Alfred Goudge

IN THE CORONERS COURT COR 2021 004013 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Leveasque Peterson Deceased: Dennis Alfred Goudge Date of birth: 02 July 1953 Date of death: 30 July 2021 Cause of death: 1(a) COMPLICATIONS OF METASTATIC

CHOLANGIOCARCINOMA Place of death: Port Phillip Prison 451 Dohertys Road, Truganina, Victoria, 3029

INTRODUCTION

1. On 30 July 2021, Dennis Alfred Goudge was 68 years old when he died of natural causes at St Vincent’s ward in Port Phillip Prison. Mr Goudge had been transferred to the hospital ward at Port Phillip Prison where he had been serving a period of imprisonment.

THE CORONIAL INVESTIGATION

2. Dennis’s death was reported to the Coroner as he was serving a term of imprisonment and it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury. The death of a person in care or custody is a mandatory report to the Coroner, even if the death appears to have been from natural causes.

3. 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.

4. 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.

5. Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Dennis’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

6. This finding draws on the totality of the coronial investigation into the death of Dennis Alfred Goudge including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1 1 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

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

7. Mr Goudge had a complex medical history including depression, angina, and most significantly, carcinoma of the prostate and metastatic bile duct cancer (metastatic chlolangicarcinoma).

8. Throughout the previous four weeks Mr Goudge had been admitted onto the hospital ward due to issues with his heart and complications arising from his cancers.

9. On 30 July 2021 one of Mr Goudge’s nurses performed an observation on him at approximately 3.00 am and saw his chest rise and fall indicating he was sleeping.

10. At 5.00 am that same day he was observed in bed groaning, the nurse manager was notified and at 5.05 am nurses attended Mr Goudge and noticed he was now non-responsive. The nursing team commenced CPR and called an ambulance.

11. Paramedics responded to the call and examined Mr Goudge and at 5.45 am declared him deceased.

Identity of the deceased

12. On 6 August 2021, Dennis Alfred Goudge, born 02 July 1953, identified via fingerprint identification.

13. Identity is not in dispute and requires no further investigation.

Medical cause of death

14. Forensic Pathologist Dr Sarah Parsons from the Victorian Institute of Forensic Medicine (VIFM), conducted an external examination on 2 August 2021 and provided a written report of her findings dated 11 August 2021.

15. The post-mortem examination revealed ascites (a fluid build-up), lung masses and fractured ribs (as a result of CPR).

evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

16. Toxicological analysis of post-mortem samples identified the presence of drugs consistent with therapeutic use.

17. Dr Parsons provided an opinion that the medical cause of death was due to natural causes, namely, 1 (a) COMPLICATIONS OF METASTATIC CHOLANGIOCARCINOMA.

18. I accept Dr Parson’s opinion.

FINDINGS AND CONCLUSION

19. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Dennis Alfred Goudge, born 02 July 1953; b) the death occurred on 30 July 2021 at Port Phillip Prison 451 Dohertys Road, Truganina, Victoria, 3029, from Complications of Metastatic Cholangiocarcinoma; and c) the death occurred in the circumstances described above.

I convey my sincere condolences to Mr Goudge’s family for their loss.

Pursuant to section 73(1B) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I direct that a copy of this finding be provided to the following: Mark Goudge, Senior Next of Kin Senior Constable Melanie McNamara, Coroner’s Investigator Signature: __________________________________

CORONER LEVEASQUE PETERSON Date : 16 June 2022

NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.