Inquest into the Death of Lincoln Arthur CAMPBELL

[2023] WACOR 34 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 5 SEPTEMBER 2023 DELIVERED : 6 SEPTEMBER 2023 FILE NO/S : CORC 1234 of 2020

DECEASED : CAMPBELL, LINCOLN ARTHUR Catchwords: Nil Legislation: Nil Counsel Appearing: Senior Constable C Robertson assisted the Coroner.

Case(s) referred to in decision(s): Nil

[2023] WACOR 34 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Lincoln Arthur CAMPBELL with an inquest held at Perth Coroners Court, Perth, Court 51, 501 Hay Street, Perth, on 5 September 2023, find that the identity of the deceased person was Lincoln Arthur CAMPBELL has been established beyond all reasonable doubt and that the identity of the deceased person was Lincoln Arthur CAMPBELL and that death occurred on or about 24 December 2005 at Kununurra as a result of end-stage throat cancer in the following circumstances:

TABLE OF CONTENTS

[2023] WACOR 34 INTRODUCTION

1. Lincoln Campbell was a 52 year old Aboriginal man who was last seen in the vicinity of Kununurra Hospital on 24 December 2005. Mr Campbell was in very poor health at that time. He had been diagnosed with terminal throat-cancer and was admitted as a patient at the hospital to receive end-stage palliative care in order to keep him comfortable at the end of his life.

2. Mr Campbell was last seen by nursing staff at around 4.00 am on 24 December 2005. A preliminary search of the hospital wards and grounds by hospital staff after that time found no sign of him. At 4.50 am, police were notified that Mr Campbell could not be found and the hospital staff were very concerned for Mr Campbell’s welfare. He had a feeding tube protruding from his stomach and required regular medication. Police were told that without medical care, he would not be expected to survive for longer than 48 hours.

3. A preliminary search of the land in the vicinity of the hospital was conducted by police, and later in the morning with the assistance of Mr Campbell’s relatives, but he was not located. At 7.50 pm that evening, hospital staff made a formal missing person report in relation to Mr Campbell. Further searches of the immediate area were conducted by police officers and local SES officers until midnight, and over a much broader area the following day. The only reported sighting of Mr Campbell was by a hospital domestic worker, who believed he had seen Mr Campbell in a vehicle in Kununurra at 10.30 am.

On 27 December 2005, police found some items of clothing and medicinal items in grassland to the west of the hospital, which nursing staff identified as belonging to Mr Campbell. There was no sign, however, of Mr Campbell.

4. Enquiries with nursing staff and Mr Campbell’s family and friends obtained information that he knew he was going to die soon and had been making preparations for his death.

He had reportedly expressed a desire to return to Halls Creek to die, or possibly had been searching for a secluded place closer to Kununurra where he could die in peace.1

5. In April 2020, an officer from the WA Police Homicide Squad Missing Persons Team prepared a report for the information of the State Coroner regarding the suspected death of Mr Campbell. Searches of state and federal data holdings had found no record of Mr Campbell since his reported disappearance in December 2005. It was suggested that, based on the evidence obtained in the police investigation, the most probable explanation for Mr Campbell’s disappearance was that he left the hospital of his own accord and perished in the remote terrain of Kununurra due to his terminal illness.2

6. On the basis of the information provided by the WA Police in relation to Mr Campbell’s disappearance, I determined that pursuant to s 23 of the Coroners Act 1996 (WA), there was reasonable cause to suspect that Mr Campbell had died and that his death was a reportable death. I therefore made a direction that a coroner hold an inquest into the circumstances of the suspected death.3 1 Exhibit 1.

2 Exhibit 1, Tab 2.

3 Section 23 Coroners Act Direction of Deputy State Coroner, dated 18 May 2023.

[2023] WACOR 34

7. I held an inquest at the Perth Coroner’s Court on 5 September 2023. The inquest consisted of the tendering of the documentary evidence compiled during the police investigation conducted into Mr Campbell’s disappearance, as well as hearing evidence from Sergeant Andrew Pelletier.

BRIEF BACKGROUND

8. There is limited information available about Mr Campbell’s family and background available to me. It is known that Mr Campbell was an Aboriginal man who was born in Wyndham on 1 April 1953 and he lived most of his life on country in the Kimberley.

Mr Campbell generally lived between the towns of Wyndham, Halls Creek and Kununurra. Medical records indicate Mr Campbell reported he had never married, was unemployed and was generally of no fixed place of address, although Mr Campbell’s last known place of address before he was hospitalised was Ranch Reserve, Kununurra.4

9. Due to the lapse of time since his disappearance, many of Mr Campbell’s family are sadly deceased or have not been able to be traced. Recent police enquiries found Mr Campbell’s closest identified next of kin is Wendy Chungula, who lives in Halls Creek. Wendy’s father and Mr Campbell’s mother were brother and sister, so Wendy and Mr Campbell were cousins. Another relative, Elizabeth Mandijerry, also lives in Halls Creek. Ms Mandijerry and Mr Campbell’s mothers shared the same father and Ms Mandijerry called Mr Campbell’s mother, Violet Campbell, ‘Auntie’.5 Both Ms Chungula and Ms Mandijerry were spoken to by Senior Constable Robertson prior to the inquest and they indicated to him that they believe Mr Campbell is deceased.

Ms Chungula confirmed that Mr Campbell was never married and had no children.

10. Mr Campbell was first diagnosed with throat cancer in early 2005. He had swelling on the side of his neck for about a month and had originally attributed it to a spider bite. He presented to Kununurra District Hospital on 23 January 2005 due to the ongoing swelling and pain to his neck. Mr Campbell reported a history of cigarette smoking.

Mr Campbell was given antibiotics for two weeks but there was little improvement and a carcinoma was suspected. He was eventually diagnosed with a cancerous tumour.

Mr Campbell was sent to Perth and underwent surgery at Fremantle Hospital in February 2005 and then radiotherapy treatment, which commenced in June 2005 and was completed in July 2005.6

11. Mr Campbell was reviewed in a Head and Neck Clinic on 8 September 2005 and appeared to be recovering well. However, on 23 September 2005, Mr Campbell presented to Kununurra Hospital with a report of difficulty swallowing and coughing up phlegm. It was noted that swelling around his neck was causing the swallowing difficulty. During his admission, he developed neuropathic type pain around his right eye and face and his weight dropped dramatically. On 6 October 2005, Mr Campbell was transferred to Perth and underwent surgery at Fremantle Hospital as it was established the tumour had spread and was affecting his ability to swallow. A PEG feeding tube was inserted on 17 October 2005. The Oncology opinion was that there 4 Exhibit 1, Tab 7; MFI 1.

5 Exhibit 1, Tab 11.

6 MFI 1.

[2023] WACOR 34 was nothing to be gained from chemotherapy or radiotherapy by that stage, and he was to pursue a palliative care plan. Mr Campbell was transferred back to Kununurra Hospital when his condition was known to be terminal, so he could receive palliative care closer to home.7

12. Mr Campbell had spent some time with extended family in Wyndham in December 2005, but it is said he “wore out his welcome with them and they brought him back”8 to hospital about ten days before Mr Campbell disappeared.

13. There is evidence that one of Mr Campbell’s family members had come to collect him again on 24 December 2005 and take him back to Wyndham for Christmas, but unfortunately he disappeared before their arrival at the hospital. They spent the day looking for him, unsuccessfully.9

14. According to Registered Nurse Janet Fearn, who was working at the Kununurra District Hospital and had come to know Mr Campbell, he was receiving palliative care for terminal throat cancer and it was extremely difficult for him to speak due to the cancer.

He was also hypoxic and undernourished as he could not eat. Mr Campbell was fed through a feeding tube inserted into his stomach, but he didn’t like it and had cut the feeding tube short. The last time Nurse Fearn saw Mr Campbell, he was wearing a blue coloured pyjama top and blue jeans. He had a piece of bandage around his jeans to hold them up as he had lost so much weight.10

15. Mr Campbell required regular pain medication in the form of morphine and a sedative, which he apparently often took with half a can of beer. He was supposed to have it every four to six hours but he didn’t always receive it as charted because sometimes he was not in the hospital when the medication was due and at other times Mr Campbell declined to take the medication as he did not like the effect that it had on him.11

16. Nurse Fearn told police that there were no restrictions on Mr Campbell’s movements at the hospital. He preferred to remain outside and often slept outdoors in the courtyard.

He would also come and go from the hospital grounds and walk into town. If he wandered too far and became exhausted, he would ask people to take him back to the hospital. This was apparently a regular occurrence. Usually, Mr Campbell would be brought back by family or police, although sometimes the local Art Gallery would ring and a hospital orderly would go there and collect him.12

17. Nurse Fearn stated that generally Mr Campbell’s “mind was wandering,”13 but she did remember him saying, amongst other things, “that he wanted to go back to Halls Creek to die.”14 Close to the day that he went missing, Mr Campbell told Nurse Fearn that he had about $200 that he wanted to give away to charity, apparently as part of winding up 7 Exhibit 1, Tab 2; MFI 1.

8 Exhibit 1, Tab 13.

9 Exhibit 1, Tab 4.

10 Exhibit 1, Tab 13.

11 Exhibit 1, Tab 13.

12 Exhibit 1, Tab 13.

13 Exhibit 1, Tab 13 [6].

14 Exhibit 1, Tab 13 [6].

[2023] WACOR 34 his affairs. There was documentation to indicate the money had been kept in the hospital safe after Mr Campbell withdrew it during the week.15

LAST KNOWN SIGHTING

18. The last person reported to see Mr Campbell alive was Registered Nurse Alicia Kerr, who was working the night shift on 23 December 2005, ending at about 7.30 am on 24 December 2005. Nurse Kerr had last seen Mr Campbell when he left the hospital at about 4.00 am.16

19. Later information from another nurse, Fiona Bohn, who was working with Nurse Kerr, indicated that Mr Campbell had been walking around that night saying that he wanted to go out. He never normally went out of the hospital at night when the doors were locked, and normally waited until daylight when the doors were opened. However, he appears on this occasion to have used the kitchen access door to get out into the hospital carpark. Cleaning staff were also contacted and they confirmed the clothes found in bush on 27 December 2005 were Mr Campbell’s clothes and that they had noticed Mr Campbell had become confused recently.17

20. Police had reportedly been keeping a lookout for Mr Campbell, at the hospital staff’s request, from about 4.50 am, but the Missing Person report indicates Mr Campbell’s disappearance was reported to police at 8.00 am on 24 December 2005. It was recorded that Mr Campbell was wearing blue jeans and a brown check shirt when he was last seen. Mr Campbell was said to be extremely ill and in need of hospital care.18

21. Nurse Fearn told police that on Saturday, 24 December 2005, she commenced duty on the afternoon shift at 1.00 pm. She was informed Mr Campbell had not been seen by nursing staff since 4.00 am that day. During Nurse Fearn’s shift, nurses rang several people to see if anyone had seen Mr Campbell, but nobody had seen him. Nurse Fearn personally looked around the wards and also asked the orderlies to look for Mr Campbell. Nurse Fearn rang the local Kununurra Police Station at 7.45 pm to advise that Mr Campbell still could not be found and she had serious concerns for his welfare.

A formal Missing Person report was then submitted.19

22. The Missing Person report was entered on the system at Kununurra Police Station at 9.12 pm on 24 December 2005 and noted that when Mr Campbell had first left the hospital at around 4.00 am it had not been considered unusual, as he often walks early in the morning. However, when he had not been seen around town and did not return to the hospital, concerns were raised. Mr Campbell’s family members, including Anne Trust who had come to collect him and take him to Wyndham for Christmas, had tried looking for Mr Campbell that day but had been unable to locate him. Ms Trust had told police that Mr Campbell had accepted that he would die and she believed he may have 15 Exhibit 1, Tab 3 and Tab 13.

16 Exhibit 1, Tab 3 and Tab 13.

17 Exhibit 1, Tab 4.

18 Exhibit 1, Tab 3.

19 Exhibit 1, Tab 4 and Tab 13.

[2023] WACOR 34 walked off into the bush to die. Some local addresses were provided to police that might be worth checking again, although Ms Trust said she had already tried them.20

THE SEARCH

23. The local SES office was notified that evening and land search options were discussed, before some SES officers began searching the rear of Kununurra Hospital that night.

After police and SES officers had searched all the possible areas in the general vicinity of the hospital, and checked the addresses suggested by Ms Trust, the search ceased at 12.01 am on 25 December 2005, with a plan to resume the next morning.21

24. The search recommenced the next morning, extending out into nearby national park, but no sign of Mr Campbell was found. Senior Sergeant Turner, who was part of the search team, went to Kununurra Hospital and spoke to hospital staff, who advised that Mr Campbell was likely to be suffering extreme dehydration given he had an intravenous feeding tube and he was probably already deceased unless someone had taken him into their care. A hospital domestic worker, Ms Gimble, was also reported to have claimed to see Mr Campbell in a white troop carrier outside the Tuckerbox Store at around 10.30 am on 24 December 2005. She was spoken to by police on 27 December 2005 and said she saw Mr Campbell nearly every day and was sure it was him sitting in the white car in the passenger seat parked in the Tuckerbox carpark facing the tourist centre at about 10.30 am, but could provide no other information.22

25. It was noted that all outlying Aboriginal communities had been contacted, as well as any local houses where Mr Campbell might have gone, but none of them had reported seeing him. The police running sheet records that it was time critical that Mr Campbell be found as he will likely be deceased if not receiving regular medical treatment.23

26. An entry at 8.00 am on 27 December 2005 recorded that a vehicle/foot search conducted on the town side surrounds of Kununurra Hospital located some items of medication, a blue hospital pyjama top and one jogger shoe in bush area. Hospital staff confirmed that one of the items, a specimen jar, had Mr Campbell’s name on it. It was noted that the timeframe for how long those items had been there was not known, as Mr Campbell walked daily, but there was a note that the items had apparently been first seen there by someone on the morning of Sunday, 25 December 2005.24

27. Some more information was provided to police on 27 December 2005 that Mr Campbell had been known to sometimes travel out of Kununurra by bus or truck. The local bus line was contacted and asked to provide details of any passengers leaving from Kununurra around the time Mr Campbell went missing. A response was provided on 29 December 2005 that no passengers matching Mr Campbell’s description had caught a bus around that time.25 20 Exhibit 1, Tab 3.

21 Exhibit 1, Tab 4.

22 Exhibit 1, Tab 4.

23 Exhibit 1, Tab 4.

24 Exhibit 1, Tab 4.

25 Exhibit 1, Tab 3 and Tab 8.

[2023] WACOR 34

28. Police continued to receive information from local Aboriginal Communities, Halls Creek and Wyndham police and other sources confirming that there had been no recent sightings of Mr Campbell.26

29. An aerial search was conducted by a helicopter on 27 December 2005 to look for any sign of Mr Campbell from the air. Nothing was located.27

30. On 29 December 2005, police officers spoke to a witness, Donna Engel, in Kununurra, who said she had spoken to Mr Campbell on 23 December 2005 and he had told her that he only had one week to live and wanted to go to ‘Doon Doon’ to die. Ms Engel also told police that a Charlene Raymond was living at Doon Doon and had been visiting in Kununurra on Christmas Eve and owned a white Troop carrier, so it was possible she gave Mr Campbell a lift. Ms Raymond was spoken to on 30 December 2005, and she confirmed that she was in Kununurra on Christmas Eve but said she did not see Mr Campbell, and she had not seen him for more than four years.

31. Police received some community reports of possible remains at different locations in Kununurra. They were all followed up but none were identified as human remains.28

32. Police received information from another family member of Mr Campbell, Frank Chulong, on 26 January 2006, advising that he and other family members were happy with the extent of the police search, but were going to continue to conduct their own private searches for Mr Campbell in the Kununurra area. He advised that Mr Campbell had been adamant that he wanted to return to Wyndham and be buried next to his parents and had nominated a family member to preside over his burial.29

33. In July 2006 when she signed her statement, Nurse Fearn expressed her personal opinion that Mr Campbell died somewhere within the first 24 hours that he went missing, because of the cold night and Mr Campbell’s weak condition. She noted at that stage he was very weak and short of breath and basically at the end of his life.30

34. In August 2006, after no further information was obtained about Mr Campbell’s whereabouts, the file was closed by the local Kununurra Police and transferred to the Missing Person Unit in Perth.31

RECENT POLICE REVIEW

35. In 2020, the investigation into Mr Campbell’s disappearance was reviewed. It was confirmed that there had been no trace of Mr Campbell interacting with any government agencies since his disappearance. During 2020, further proof of life checks with 26 Exhibit 1, Tab 4.

27 Exhibit 1, Tab 4.

28 Exhibit 1, Tab 4 and Tab 9 and Tab 10.

29 Exhibit 1, Tab 4.

30 Exhibit 1, Tab 13.

31 Exhibit 1, Tab 4.

[2023] WACOR 34 Australian policing jurisdictions and the Registry of Births, Deaths and Marriages were conducted with nil result.32

36. Some attempts were made to contact any living family members as part of the review.

This caused some initial confusion, as some family members were led to believe that Mr Campbell’s remains had been found. Eventually it was clarified that the Missing Persons Team were simply reviewing the case, given Mr Campbell’s longstanding disappearance. There was consideration given to obtaining DNA samples, in case any new remains were found that might correlate to Mr Campbell, and the closest next of kin indicated they were willing to provide it if required. Currently, no unidentified remains have been found that might relate to Mr Campbell.33

37. At the conclusion of his review of the materials on the file, Sergeant Andrew Pelletier of the Homicide Squad, Missing Persons Team, indicated that the most probable explanation of Mr Campbell’s disappearance and subsequent lack of interaction with family, government agencies or health providers was because he left the hospital of his own accord, wandered into the remote terrain outside the hospital and perished due to ill health.34

CONCLUSION

38. I am satisfied beyond all reasonable doubt that Mr Campbell died around the time of his disappearance from hospital on 24 December 2005. Given his terminal diagnosis and the indication from health staff that he was not expected to live more than 24 to 48 hours without medical treatment, on the balance of probabilities I am satisfied Mr Campbell died as a result of throat cancer and the manner of death was by way of natural causes. Mr Campbell had made it clear he was not comfortable in the hospital environment and did not want to die there, and I believe he exercised his right to die on country.

S H Linton Deputy State Coroner 6 September 2023 32 Exhibit 1, Tab 2.

33 Exhibit 1, Tab 11.

34 Exhibit 1, Tab 2.