Finding into death of A B

IN THE CORONERS COURT COR 2021 004607 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Darren J. Bracken Deceased: AB 1 Date of birth: 12 January 1940 Date of death: 31 August 2021 Cause of death: 1(a) METASTATIC LUNG CARCINOMA Place of death: Port Phillip Prison 451 Dohertys Road, Truganina, Victoria, 3029 1 Pseudonyms have been used in this finding as a result of a request made by the deceased’s family

I, Darren J Bracken, Coroner having investigated the death of AB without holding an inquest find that : The identity of the deceased was AB born on 12 January 1940 AB’s death occurred on 31 August 2021in the Hospital Ward at Port Phillip Prison, 451 Doherty’s Road, Truganina, Victoria, 3029 And that The cause of his death was metastatic lung carcinoma.

Background

1. AB was aged 81 years at the time of his death and was serving a sentence of imprisonment at Port Phillip Prison 451 Doherty’s Road, Truganina, Victoria, 3029.

Post Mortem Examination

1. On 2 September 2021 Dr Sarah Parsons, a specialist forensic pathologist practising at the Victorian Institute of Forensic Medicine performed a medical examination, an external examination of AB’s body and provided a report dated 3 September 2021. In that report Dr Parsons opined that the cause of Ab’s death was ‘metastatic lung carcinoma’ and that his death was due to natural causes.

Relevant Legislative Provisions

2. Pursuant to section 4(2) Coroners Act (2008) (“the Act”) AB’s death was a ‘reportable death’ at least because he was in custody when he died.

3. Pursuant to section 15 of the Act and bearing in mind that AB’s death was a ‘reportable death’ I am obliged to investigate it.

4. Pursuant to section 17(1)(b) of the Act and bearing in mind Dr Parson’s opinions I am not required to continue my investigation.

Circumstances of the death

5. At the time of his death AB had an extensive medical history and was receiving palliative care for metastatic lung cancer in the hospital ward of Port Phillip Prison.

6. On Tuesday 31 August 2021 AB was provided with his usual dose of medication. At approximately 6.00pm a nurse noticed that AB was not breathing but had a slight pulse. The nurse called a ‘code black’, signifying a medical emergency but AB died shortly afterward.

Further investigation

7. I am satisfied, having considered all of the evidence before me, that no further investigation is required and pursuant to section 17(1)(b) of the Act I discontinue my investigation into AB’s death.

Publication

8. Section 73 (1B) of the Act requires this finding be published on the Internet in accordance with the rules.

I direct that a copy of this finding be provided to the following: CD who is AB’s Senior Next of Kin; and The Chief Executive Officer of Port Phillip Prison.

Signature: ___________________________________ Darren J. Bracken, Coroner Date: 25 February 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.