Coroner’s decision re death of peter clarke

the nt coroner, greg cavanagh, handed down his findings and decisions, via a deputy coroner, in alice springs on 13 february, 2014. following is a précis of his findings and decisions and the opinions arising from that report of isja and isja only.

peter clarke was in alice springs gaol when he became extremely ill and was admitted to alice springs hospital on 19 march, 2012 where he subsequently died on 3 april, 2012 arising from several health complications.

coroner cavanagh then lists the 11 witnesses called during the inquest and outlines the evidentiary material he relied on to reach his conclusions.

he begins his decision by backgrounding the history of peter clark’s time in the alice springs gaol since november, 2008 and specifically to the health care provided by the gaol clinic over that time. he closely looked at the medical care provided to peter by the clinic from thursday 15th march,2012 until his release to go to the alice springs hospital on the 19th march, 2012. dr. goodwin examined peter on the 15th march, 2012 but did not conclude that peter was as ill as he was. dr. goodwin provided some medication for his misdiagnosed ‘musculo-skeletal pain’ whilst advising him to return should the pain continue. four days later peter reported back to the clinic stating that he was unwell and ‘suffering continued pain.’ at 0700 that morning peter attended the clinic and the clinic nurse tested him but came to no firm conclusion to his actual illness but recognising the need for him to see dr. goodwin later that day.

when seen by dr. goodwin later that afternoon he appeared to him to be ‘substantially worse’ since he saw him on the 15th. whilst his vital signs appeared satisfactory he concluded that peter had an infection in his lung and therefore required hospitalisation. the ambulance was called at 1547 and arrived at the alice springs hospital at 1640. he was accompanied by gaol officers.

events at the alice springs hospital were then considered by the coroner. peter was seen by the emergency medical team and was assessed as ‘suffering from severe pneumonia’ and was sent to a ward. overnight his condition deteriorated and at 1100 on the 20th march, 2012 he was transferred to the intensive care unit. the gaol officer went with him. routine medical procedures were performed on peter who was awake during this process. his condition however again deteriorated and he was placed into a medically induced coma just before midnight on the 20th march, 2012.

peter’s condition worsened each day despite medical tests and antibiotics and a ct scan on the 23rd march, 2012 showed that peter had cancerous masses in his lungs, heart and abdomen. due consultations with medical experts determined that no surgical therapy or chemotherapy was viable. this was explained to family members on 24th march, 2012.

bronchial washings from peter were taken on 26th march, 2012 and returned on the 27th march, 2012. prof. maguire and dr. goud both gave evidence that the washings showed neither the type of infections peter had but did not show any cancer results either.

peter’s condition improved somewhat and it was decided to bring him out of his coma so he could spend time with his family members. this occurred on 30th march, 2012. however peter declined again on the 2nd april, 2012 and he passed away at 0610 on the 3rd april, 2012.

the coroner found the cause of death to be a consequence of bronchopneumonia and cancer of the right lung. this was complicated by longstanding emphysema, coronary atherosclerosis and chronic pancreatitis. he now raised the family concern to the presence of the mac bacterium found in the washings by prof. maguire. despite the concerns of peter’s family and their legal team to the presence of this bacterium being positively identified as being present in peter’s body and presumably present in the alice springs gaol environment the prof. downplayed any problems relevant to its existence. he dismissed any medical problems with contact to the bacterium whatsoever. no recommendation for tests of inmates and staff at alice springs gaol was forthcoming. i have posted previously on my misgivings on the presence of this bacterium.

four other concerns were raised with the coroner by the family legal team and he dealt with each separately.

the first was the nature and standard of the care given to peter during his gaol time. it was stated that though the health of peter was not good he did however attend the clinic as and when necessary. he was not seen as being a malingerer by medical staff and all his visits to the clinic were for legitimate medical reasons and treated as such. peter was a heavy smoker all of his life and continued to be so. there are no reports of peter making any complaints relative to the health treatment he received during his time in gaol. on the 19th march, 2012 when peter reported to the gaol clinic he was promptly seen by the on-duty nurse and referred to dr. goodwin.

the nurse said on evidence that she requested the dr. to see peter urgently but the dr. denied this message got to him. clinic notes support the dr. the coroner dismissed any relevance to the time lapse between nurse and dr. believing that the time frame was not relevant to the consequent demise of peter. in the opinion of the coroner peter received appropriate and satisfactory care during his gaol time.

the second concern related as to whether that care in the gaol had any impact upon peter’s death. the coroner found it to be unfortunate that peter’s cancer had not been discovered earlier during his gaol time. whilst the best of medical care was given to peter there was no diagnosis made of cancer being present. in fact the cancer was only discovered some days after his admittance to the alice springs hospital by state of the art medical equipment and procedures. he accepted the words and experience of both drs. goodwin and goud that there was nothing else they could have done to prevent peter’s death.

the third concern the coroner looked at was the nature of the custody and control of peter by gaol staff whilst at the hospital. peter was accompanied by gaol staff from the 19th march, 2012 until 21 march, 2012 when custody was signed to the hospital by the gaol. during the first two or three days however peter was shackled to his bed by an ankle bracelet and this caused the family much distress. whilst it was argued that the shackling was standard procedure. the shackle was finally removed about 2130 on 20th march, 2012 by a request to the gaol officer by hospital staff who were in the process of placing him in an induced coma. he then goes on to agree with the need for shackling in some cases, none relevant to peter’s circumstances. that the shackling procedures was an unlawful act between the gaol procedures and the act itself, as put by the family legal team, was not accepted by the coroner. he was however clearly distressed by the shackling process being used on dying inmates.

the fourth concern raised the major breakdown of peter’s death not being initially recognised as a reportable death in custody under the nt coroner’s act. it was this event that brought isja into contact with peter’s extended family. peter died at 0610 on 3rd april, 2012 and evidence was given that dr. goud contacted sc hosking and informed him of the death. hosking was the ‘coroner’s constable’ to whom such deaths are reported to. hosking attended the hospital and read the files relevant to peter among which was the transfer note from the gaol to the hospital. that letter set out that as from 26 march, 2012 peter was considered to be on parole and thus no longer a responsibility to the alice springs gaol. the coroner’s office was also contacted and they also accepted the wrong interpretation of hosking. it took several days before the correct interpretation was found which caused much distress to the family. the coroner’s opinion was that the death was eventually properly recognised and treated as such accordingly.

two other concerns were raised by family members when they addressed the coroner, the first being the cruel farce that was played out by the parole board during peter’s time in gaol. peter was knocked back for his parole because he had not signed up for the particular course that the parole board wanted him to do so he could then be approved for parole. whilst peter wanted to do the nominated course he was thwarted by the simple fact that this course was not available in the alice springs gaol. the coroner stated that whilst that fact was unfortunate he believed other issues were present but he had no interest in examining the boards’ decisions.

the second family concern was the lack of an x-ray machines in the nt gaol clinics that would allow quicker and better health diagnosis to be made on inmates and thus perhaps saving lives. the family wanted no other family to suffer as they had.

the coroner then gave his findings and two recommendations on the use of shackles and the introduction of the x-ray machines.

whilst the legal team, and i, believe that the outcome was as good as we could realistically have hoped for i also agree with the family comments that we did hope for more. we are all, however, caught between a rock and a hard place in this inquest. had better medical care been given or even possible, would it have made much difference to the outcome? had the parole board not been so obdurate to an inmate being released early to have the dignity of dying in the arms of his family surely would have been a more successful outcome for peter and his family. nt corrective services also has a role to play in this issue.

i personally find the ‘mix-up’ by professionals as to how peter should have been identified unbelievable. this notification was a part of the nt coroner’s act for many years yet these professionals somehow ‘forgot’ that fact. this move to have inmates die outside of the purview of the relevant custodial services is not new as every state and territory penal institution has tried it on. all thankfully to no avail to my knowledge. i believe that the bacterium problem was not properly recognised and at the very least nt health should have at least done tests of the nt gaols. moreso when one considers the chronic ill health of the inmates to which they have a sworn duty of care.

kylie hampton has informed me that the justice for peter clarke account was closed in january having raised $3 500 and a heartfelt thank you by the family and isja to all who donated to the call for justice.

taking into consideration the moral conservatism of coroner’s everywhere, with two exceptional exceptions, we done as well as we could. it is now up to the nt government to release the required dollars to provide the x-ray machines for their gaols. and for commissioner ken middlebrook and his gaol governors to push them for it.

fkj

ray jackson
president
indigenous social justice association

2013 Laureate
Prix de l’Homme de Francais
(French Human Rights Medal 2013)

isja01
(m) 0450 651 063
(p) 02 9318 0947

1303/200 pitt street waterloo 2017

www.isja.org.au

we live and work on the stolen lands of the gadigal people.

sovereignty treaty social justice

ray jackson
president
indigenous social justice association

isja01
(m) 0450 651 063
(p) 02 9318 0947
address 1303/200 pitt street waterloo 2017

www.isja.org.au

we live and work on the stolen lands of the gadigal people.

sovereignty treaty social justice

A00312012 Clarke2.pdf

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