Inquest into the death of Matthew Smith

CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Matthew Geoffrey Smith Hearing dates: 8 March 2023 Date of findings: 15 March 2023 Place of findings: Coroner’s Court of New South Wales Findings of: Magistrate David O’Neil, Deputy State Coroner Catchwords: CORONIAL LAW – death in custody – natural causes File number: 2022/131088 Representation: Advocate Assisting Senior Constable Kai Jiang Ms Skye McKinnon DCJ Legal for the NSW Commissioner of Corrective Services Ms Katharine Guilford for Justice Health & Forensic Mental Health Network

Findings: I make the following findings in relation to the death of Mr Smith, pursuant to s81 of the Coroners Act 2009 NSW: Identity: Matthew Geoffrey Smith Date: 5 May 2022 Place: Prince of Wales Hospital, Intensive Care Unit, NSW Cause: Follicular lymphoma with transformation to acute lymphoblastic leukemia and the complications thereof Manner: Natural causes Recommendations Nil Non-publication orders: A Non-publication order was made pursuant to section 74(1)(b) of the Coroners Act 2009 (NSW) on application by the commissioner of Corrective Services NSW. A copy of this order can be requested from the Coroners Court registry if required.

JUDGMENT Introduction 1 An inquest was held into the death of Mr Matthew Geoffrey Smith on 8 March 2023.

2 Mr Smith died in custody at the intensive care unit, Prince of Wales Hospital, on 5 May 2022.

3 Because Mr Smith died while in custody, an inquest is required by the Coroners Act 2009 NSW (the Act).

4 When someone is in lawful custody they are deprived of their liberty, and the State assumes responsibility for the care and treatment of that person. In such cases the community has an expectation that the death will be properly and independently investigated.

The Coroner’s role 5 An inquest is a public examination of the circumstances of death. It provides an opportunity to closely consider what led to the death. It is not the purpose of an inquest to blame or punish anyone for the death. The process of holding an inquest does not imply that anyone is guilty of wrongdoing.

6 The primary function of an inquest is to identify the circumstances in which the death occurred, and to make the formal findings required under s 81 of the Act; namely

• the person's identity;

• the date and place of the person's death; and

• the manner and cause of death.

7 Another purpose of an inquest is to consider whether it is necessary or desirable to make recommendations in relation to any matter connected with the death. This involves identifying any lessons that can be learned from the death, and whether anything should or could be done differently in the future, to prevent a death in similar circumstances.

BACKGROUND 8 Mr Smith was born in Caringbah, New South Wales, on 27 December 1974.

He was 47 years of age at the time of his death.

9 Before entering custody, Mr Smith was employed full time as a nursing assistant at an aged care facility in Dungog, NSW. At that time, he was residing with his fiancée and her three teenaged daughters.

10 Mr Smith has one child with his ex-partner.

11 On 31 January 2014 Mr Smith was arrested and charged with a number of offences of a sexual nature. He was convicted of these offences on 13

February 2015 and was sentenced at the Newcastle District Court to a term of imprisonment of 16 years with a non-parole period of 12 years. His earliest release date was to be 30 January 2026.

12 Mr Smith had not been in custody before.

13 From November 2021 he was held at Long Bay Correctional Centre to facilitate specialist oncology treatment at the Prince of Wales Hospital for follicular lymphoma.

14 Whilst in custody Mr Smith had been compliant, with no breaches of discipline or offences recorded.

15 As is the usual course, there was a thorough police investigation into the circumstances of Mr Smith’s death.

16 There are no suspicious circumstances attached to Mr Smith’s death and it is clear he died as a result of natural causes.

Medical treatment 17 On 30 April 2021 Mr Smith was admitted to the Calvary Mater Newcastle Hospital for investigation and management of a low-grade follicular lymphoma which had been diagnosed in 2020. He received six cycles of immunochemotherapy. At the completion of the therapy a further large cell lymphoma developed in his abdomen.

18 On 16 November 2021 he was transferred to the Long Bay Hospital at the Long Bay Correctional Centre for further treatment and easier access to oncology at Prince of Wales Hospital.

19 On 27 April 2022 Mr Smith was admitted into the Corrective’s annex, Prince of Wales Hospital for medical treatment for his cancer as the required treatment was not available in the Long Bay Hospital. After assessment Mr Smith’s lymphoma was assessed to be acute lymphoblastic leukemia which was

complicated by tumour lysis syndrome, neutropenic sepsis and worsening kidney injury.

20 On 4 May 2022 a decision was made for him to be transferred into the intensive care unit for end-of-life care due to deterioration of his condition.

21 Around 10:00am on 5 May 2022 Mr Smith was taken to the intensive care unit.

22 At 6:43pm on 5 May 2022 Mr Smith was found to have passed away.

23 In addition to the police investigation, a Corrective Services serious incident investigation found no issues with the response to Mr Smith’s death by Corrective Services officers and no issues in relation to his management in custody, which was compliant with all relevant policies and procedures.

Findings 24 Upon review of all the evidence there were no coronial issues identified. No concerns were voiced by Mr Smith’s family. Mr Smith had little contact with his family in the latter years of his life.

25 In the circumstances there is no need for any recommendations to be made.

26 I make the following findings in relation to Mr Smith’s death: Identity: Matthew Geoffrey Smith Date: 5 May 2022 Place: Intensive Care Unit of the Prince of Wales Hospital, NSW Cause: Follicular lymphoma with transformation to acute lymphoblastic leukaemia and the complications thereof Manner: Natural causes

Closing 27 I acknowledge and express my gratitude to the Coronial Advocate assisting the Coroner, Mr Kai Jiang, for his assistance both before and during the inquest. I also thank Detective Senior Constable Middleton, for his investigation and evidence.

28 On behalf of the Coroners Court of New South Wales, I offer my condolences to the family of Mr Smith.

29 I close this inquest.

David O’Neil Deputy State Coroner Coroners Court of New South Wales 15 March 2023