Finding into death of Keanne Liza Whittam

IN THE CORONERS COURT COR 2022 000539 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Paresa Antoniadis Spanos Deceased: Keanne Liza Whittam Date of birth: 24 December 1978 Date of death: 27 January 2022 Cause of death: 1(a) Hypoxic ischaemic encephalopathy 1(b) Out of hospital cardiac arrest due to ischaemic heart disease Place of death: The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, 3004 Keywords: Death in Custody; Dame Phyllis Frost Centre; Natural Causes

INTRODUCTION

1. On 27 January 2022, Keanne Liza Whittam was 43 years old when she died at the Alfred Hospital following a heart attack on 21 January 2021 while in custody at the Dame Phyllis Frost Centre. Prior to being placed in custody, Ms Whittam lived in Rowville.

2. Ms Whittam was born in 1978 in Box Hill to parents Keith and Anne Whittam. She had one older brother and at the time, the family lived in Forest Hill, Victoria.

3. Ms Whittam went to primary school in Forest Hill and commenced high school there before transferring to study in Knoxfield when the family moved to Ferntree Gully. Although she was capable at school, Ms Whittam did not enjoy the school environment and left school at the end of year eight to join the workforce. Ms Whittam began work at a local ceramic business. When she was about 18 to 19 years old, Ms Whittam moved out of the family home to live with the son of her employer.

4. In her early twenties, Ms Whittam first began to use heroin. Her parents remained in contact with her during this period and as far as they were aware she was doing okay despite her drug use. In 2006, Ms Whittam married her then partner Bruce Campbell with whom she already had a daughter. Not long after marrying the couple also shared a son together. After several years of marriage, the couple separated, and Mr Campbell took primary care of the children and raised them.

5. Following the separation, Ms Whittam continued to abuse drugs and was first incarcerated in 2013 for two weeks. She had another short stay in prison in November 2015.

6. In August 2021, Ms Whittam presented to the Monash Hospital Emergency Department (ED) with multiple lower leg ulcers. She was reviewed by the vascular team and at the time it was recorded that Ms Whittam did not have any known cardiac issues. No heart murmur was observed on examination. Follow-up appointments were made on three separate occasions for further review of Ms Whittam’s leg ulcers, but she failed to attend each appointment. Monash Health medical records from that episode of care indicate that Ms Whittam did not have a known regular treating General Practitioner (GP), nor did she have any known health issues apart from being a smoker and an intravenous drug user.

THE CORONIAL INVESTIGATION

7. Ms Whittam’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Generally, reportable deaths include deaths that are unexpected, unnatural or violent, or result from accident or injury. However, if a person satisfies the definition of a person placed in custody or care immediately before death, their death is reportable even if it appears to have been from natural causes.1 Ms Whittam’s death is such a death.

8. 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.

9. 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.

10. Victoria Police assigned Detective Leading Senior Constable Paul Barrow to be the Coroner’s Investigator for the investigation of Ms Whittam’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.

11. This finding draws on the totality of the coronial investigation into the death of Keanne Liza Whittam 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.2 1 See the definition of “reportable death” in section 4 of the Coroners Act 2008 (the Act), especially section 4(2)(c) and the definition of “person placed in custody or care” in section 3 of the Act.

2 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.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased

12. On 28 January 2022, Keanne Liza Whittam, born 24 December 1978, was visually identified by her brother, Ryan Whittam, who signed a formal Statement of Identification to this effect.

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

Medical cause of death

14. Forensic Pathologist Dr Melanie Archer, from the Victorian Institute of Forensic Medicine (VIFM), conducted an autopsy of Ms Whittam’s body on 1 February 2022 and provided a written report of her findings dated 10 June 2022. In preparation of her report, Dr Archer was assisted by medical records from Alfred Health and the Sunshine Hospital, as well as the initial police report of Ms Whittam’s death to the coroner.

15. The autopsy showed severe coronary artery atherosclerosis (blockage of the coronary arteries) well in excess of that expected in a 43-year- old woman, resulting in ischaemic heart disease.

Dr Archer commented that coronary artery atherosclerosis causes reduced oxygenation of the heart muscle and is associated with sudden cardiac death.

16. Dr Archer noted that Ms Whittam was recorded to be withdrawing from heroin while at prison and that steps had been taken to manage this. Opiate withdrawal can be life threatening, or at least has the potential to act as a stressor in synergy with underlying natural disease.

Symptoms of opiate withdrawal included sleeplessness, yawning, nausea, vomiting and diarrhoea. If not sufficiently treated, vomiting and diarrhoea can result in dehydration, or derangement of biochemistry. Dr Archer stated there is no evidence in the materials received to suggest that heroin withdrawal played a part in Ms Whittam’s death.

17. Routine toxicological analysis of ante-mortem samples collected on 25 January 2022 at the Alfred Hospital detected fentanyl3, diazepam4 and its metabolite, lignocaine5, laudanosine6, prazosin7, and metoclopramide8.

18. Dr Archer commented that the substances detected in toxicological samples were in keeping with emergency medical intervention. No drug screening was performed on admission to the Sunshine Hospital and it is unclear what substances may have been in her system at the relevant time on 21 January 2022.

19. Dr Archer provided an opinion that the medical cause of death was 1(a) hypoxic ischaemic encephalopathy secondary to 1(b) out of hospital cardiac arrest due to ischaemic heart disease.

20. Dr Archer considered that Ms Whittam’s death was due to natural causes.

21. I accept Dr Archer’s opinion.

Circumstances in which the death occurred

22. On 20 January 2022, Victoria Police members from the Croydon Divisional Tasking Unit planned to execute a warrant under the Drugs, Poisons and Controlled Substances Act 1981 (Vic) for suspected offences related to trafficking heroin. The listed address for the warrant was 213/1165 Stud Road, Rowville (Rowville property), and the persons of interest there where a Mr Lim and Ms Whittam.

23. At about 5.00pm that afternoon, police attended the Rowville property for surveillance. At around 5.45pm, a grey Mazda 6 driven by Ms Whittam arrived in the underground carpark at the Rowville property. Police intercepted Ms Whittam while she was still in the carpark, and she was subsequently arrested. Small amounts of heroin were found in Ms Whittam’s dress pocket and in her car. Police conducted a search of the Rowville property and located a further 50 grams of heroin, scales, deal bags, tasers, laser pointers, 8 grams of marijuana, firearm 3 Fentanyl is a synthetic opioid with 50-100 times the analgesic potency of morphine, rapid onset (2-3 min) and short duration of action (0.5-1 h). It is used in surgical anaesthesia, chronic pain and breakthrough cancer pain.

4 Diazepam is a benzodiazepine derivative indicated for anxiety, muscle relaxation and seizures.

5 Lignocaine (lidocaine) is an amide local anaesthetic and antiarrhythmic drug.

6 Atracurium is a non-depolarising neuromuscular blocker indicated for general anaesthesia to aid tracheal intubation, muscle relaxation for surgery and mechanical ventilation. Atracurium undergoes spontaneous degradation to become laudanosine.

7 Prazosin is an alpha-adrenergic blocking agent specific for alpha-1 (or post-synaptic) receptors used in the treatment of high blood pressure and other conditions.

8 Metoclopramide is an anti-emetic drug used for the treatment of nausea and vomiting.

ammunition, and approximately $10,000 worth of alcohol suspected to be the proceeds of crime. Throughout Ms Whittam’s arrest and the subsequent search of the Rowville property, Mr Lim was not present.

24. At about 9.30pm, Ms Whittam was transferred to the Croydon Police Station where she was interviewed in relation to the events of the day and other outstanding police matters. During her police interview, Ms Whittam disclosed she had multiple ulcers on her legs that she believed to be from spider bites, and that she was receiving medical treatment for the ulcers.

Police noted her legs were “very swollen and the bite sites were inflamed.”9

25. Ms Whittam also informed police that she used an average of 1-2 points10 of heroin a day and that she last consumed heroin at around 10.00am that morning. Ms Whittam reported to police that she was feeling a little sick but was mostly tired. The interview concluded at 12.50am on 21 January 2022 and Ms Whittam was remanded in custody.

26. Following her police interview, police called the Custodial Health Advice Line (CHAL) and reported Ms Whittam’s reported spider bites and heroin consumption. Registered Nurse Ms Bernadette Carey from the CHAL answered the call and provided a statement to the court. Ms Carey noted Ms Whittam had nil complaints of vomiting, diarrhoea, excessive sweating (diaphoresis), or body aches. Plans were made for a custodial nurse to review Ms Whittam and police were advised to recontact the CHAL if she experienced any new symptoms.

27. While still at the Croydon Police Station, police conducted a welfare check on Ms Whittam at 1.40am and at 2.03am. On both occasions, Ms Whittam reported she was “ok” and wanted to sleep.

28. At some point on 21 January 2022, Ms Whittam was transported to the Ringwood Police station where she was initially kept in the police cells. When she appeared at the Ringwood Magistrates Court later that day, she made no application for bail and was remanded in custody on charges including trafficking heroin, possessing heroin and cannabis, possessing the proceeds of crime and possessing cartridge ammunition. The further hearing of those charges was adjourned to 24 January 2022.

29. After appearing at the Ringwood Magistrates Court, Ms Whittam was transported to the Dame Phyllis Frost Centre (DPFC), a maximum-security women’s prison in Ravenhall, arriving at 9 Coronial Brief, Statement of Senior Constable Ryan Bradbury dated 29 September 2022.

10 A ‘point’ of heroin typically refers to 1/10th of a gram.

about 5.30pm. Prison Officer Ms Amanda Keesmaat who initiated Ms Whittam through prison reception and believed she appeared to be substance effected. Shortly after arriving at the DPFC, Ms Whittam was reviewed by a nurse through a cell trap door who performed a COVID-19 screening. Ms Whittam’s temperature was recorded at 36.5 degrees Celsius, and she denied any flu like symptoms. She was able to follow the nurse’s instructions including being able to lift her head.

30. At 6.09pm, Ms Whittam was assessed by Medical Officer Dr Nath who assessed her as withdrawing from heroin. At the time, Ms Whittam presented as tired, sweaty, and jittery with no nausea or vomiting. Dr Nath prescribed a non-buprenorphine withdrawal pack as well as diazepam, ibuprofen, paracetamol, hyoscine-n-butyl bromide and metoclopramide. Another review by a medical officer was planned for the following day.

31. After the assessments by the nurse and medical officer, Ms Whittam was escorted by prison officers to the Yarra Unit which at time was being used as a quarantine unit. Throughout the transfer, Ms Whittam appeared drowsy and slow with her thoughts. She was compliant with the instructions of prison officers and despite her presentation, was able to walk without assistance albeit slowly. Ms Whittam was placed on hourly observations, in part due to the fact she had yet to be assessed by a psychiatric nurse.

32. Prison Officer Ms Christine McLeod was assigned to perform the hourly observations of Ms Whittam. According to Ms McLeod, she was not provided with a handover of any sort to suggest that there were any health concerns for Ms Whittam. Observations are conducted by a prison officer, in this instance Ms McLeod, shining a torch though the cell window and looking for a rise and fall of the chest. Mr McLeod stated there is no need for a prisoner to be awake during the observations.

33. A total of five observations performed by Ms Mcleod and recorded in the DPFC observation register: i. 7.00pm: Ms Whittam was awake and stood for count.

ii. 8.00pm: Ms Whittam appeared asleep on her left side on her bed.

iii. 9.00pm: Ms Whittam appeared asleep on her left side on her bed.

iv. 10.00pm: Ms Whittam appeared asleep on her back on her bed.

v. 11.00pm: Ms Whittam appeared asleep on her back on her bed.

34. Ms Mcleod stated that to her Ms Whittam appeared alive and asleep throughout the final four observations.

35. At about 11.40pm on 21 January 2022, three prison officers and a Correct Care Australia nurse attended Ms Whittam’s cell for a medication round. The medication round was running late due to a previous incident involving another prisoner. Prison Officer Clare Watson looked into Ms Whittam’s cell via the trap door and saw Ms Whittam on her back, on the floor, with her feet on her bed. Efforts made to elicit a response from Ms Whittam were unsuccessful. Ms Clare and the others in attendance were unable to see any discernible movement of Ms Whittam’s chest.

36. Prison officers unlocked the cell door and initiated a ‘Code Black: Prisoner Death/ Serious Medical Incident’ and called for emergency services to be contacted. Prison officers attended to Ms Whittam and were unable to detect a pulse. The nurse was summoned into the cell and confirmed Ms Whittam had no pulse and no detectable blood pressure. Cardiopulmonary Resuscitation (CPR) was commenced and additional staff, including a second nurse, arrived and provided assistance. A defibrillator was applied, and two shocks were administered.

37. Fire Rescue Victoria (FRV) were the first to respond to the call and arrived at around 12.05am on 22 January 2022 and took over CPR. A short time later, Ambulance Victoria paramedics arrived and assumed primary responsibility of resuscitation efforts. Paramedics administered one dose of adrenaline and at about 12.28am achieved a return of spontaneous circulation. Ms Whittam was intubated, sedated and transferred via ambulance to the Sunshine Hospital.

38. On arrival at the Sunshine Hospital Ms Whittam’s heart rate was 105 beats per minute and her blood pressure 110/63, with both measurements being supported by adrenaline. Her Glasgow Coma Scale (GCS)11 was three. Blood tests indicated Ms Whittam was in a state of mixed respiratory and metabolic acidosis. She also underwent a CT brain scan which showed a loss of grey-white matter differentiation. Ms Whittam was believed to have suffered hypoxic ischaemic encephalopathy (a brain injury caused by low oxygenation while she was in cardiac arrest).

11 The Glasgow Coma Scale (GCS) is a neurological scoring system used to assess conscious level. The GCS is comprised of three categories; best eye response, best vocal response and best motor response. The GCS is scored out of 15, with a score of 15 indicating a normal level of consciousness and three being the lowest possible score.

39. Sunshine Hospital ED staff planned for Ms Whittam to be discharged to the Intensive Care Unit (ICU) but there were no available beds. Subsequently, Ms Whittam was intubated, sedated and transferred to the Alfred Hospital at around 11.30am.

40. While sedated at the Alfred Hospital, Ms Whittam’s clinical course was uncomplicated.

Sedation was ceased on 27 January 2022. A neurological examination was performed when she was no longer sedated and the results were grossly abnormal. Ms Whittam was assessed by a series of specialists as who concluded there was no chance of recovery. At 6.45pm on 28 January 2022, Ms Whittam was pronounced brain dead.

FINDINGS AND CONCLUSION

41. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: vi. the identity of the deceased was Keanne Liza Whittam, born 24 December 1978; vii. the death occurred on 27 January 2022 at The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, 3004; viii. the cause of Ms Whittam’s death was hypoxic ischaemic encephalopathy secondary to out of hospital cardiac arrest due to ischaemic heart disease; and ix. the death occurred in the circumstances described above.

42. Having reviewed the available evidence, I am satisfied that the custodial management by staff at the Dame Phyllis Frost Centre during Ms Whittam’s brief period of incarceration was reasonable and appropriate.

43. Further, the available evidence does not support a finding that there was any want of clinical management or care on the part of the clinical staff at either the Sunshine or Alfred Hospitals that caused or contributed to Ms Whittam’s death.

44. Ms Whittam’s death was reportable by virtue of section 4(2)(c) of the Act because, immediately before her death, she was a person placed in custody. Section 52 of the Act requires an inquest to be held, except in circumstances where the death was due to natural causes. I am satisfied that Ms Whittam died from natural causes and that no further investigation is required. Accordingly, I have exercised my discretion under section 52(3A) of the Act not to hold an inquest into her death and to finalise the investigation of her death on the papers.

I convey my sincere condolences to Ms Whittam’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: Bruce Campbell, senior next of kin Keith Whittam Justice Assurance and Review Office Western Health Alfred Health Detective Leading Senior Constable Paul Barrow, Victoria Police, Coroner’s Investigator Signature: ___________________________________ Coroner Paresa Antoniadis Spanos Date : 20 March 2023 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.