Inquest into the death of Frank Valentine

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Frank Valentine Hearing dates: 22 August 2025, NSW Coroners Court Lidcombe Date of findings: 22 August 2025 Place of findings: NSW Coroners Court - Lidcombe Findings of: Magistrate Stuart Devine, Deputy State Coroner Catchwords: CORONIAL LAW – Mandatory inquest pursuant to s 23 (1)(d)(ii) of the Coroners Act 2009 (NSW) – natural causes – no care or treatment concerns.

File number: 2024/292825 Representation: Advocate Assisting the Inquest: Sgt Amanda Chytra Commissioner of Corrective Services NSW (CSNSW): Ms Gage Justice Health and Forensic Mental Health Network (JHNSW): Ms Amal Findings: Identity The person who has died is Frank Valentine Place of death Westmead Hospital Westmead NSW 2145 Date of death

8 August 2024 Cause of death 1(a) Congestive cardiac failure 1(b) Ischaemic and valvular heart disease 2 hereditary haemorrhagic telangiectasia and anaemia Manner of death Natural causes while in the custody of Corrective Services New South Wales (CSNSW).

Recommendations: Nil Non-publication Orders: Protected Information Orders apply to the evidence in this inquest. A copy of the orders made by Deputy State Coroner Devine can be obtained from the Court Registry.

FINDINGS Introduction 1 These are the findings of an inquest into the circumstances of the death of Frank Valentine on 8 August 2024, then aged 83.

2 This inquest is held pursuant to the jurisdiction conveyed by ss 23 (1)(d)(ii) and 27 of the Coroners Act 2009 (NSW) (the Act) in circumstances where at the time of his death, Mr Valentine was an inmate in a correctional centre within the meaning of the Crimes (Administration of Sentences) Act 1999 (NSW).

3 An inquest in these circumstances is mandatory and must be heard by a senior coroner.

4 Section 81(1) of the Act requires that when an inquest is held, the coroner must record in writing their findings as to whether the person has died and if so, the date and place of the person’s death, and the cause and manner of their death.

5 In addition, the coroner may make recommendations in relation to matters which have the capacity to improve public health and safety in the future, arising out of the death in question, pursuant to s82 of the Act.

The issues examined at the inquest 6 An inquest into the circumstances of Mr Valentine’s death was held on 22 August 2025 in Lidcombe, NSW.

7 The issues identified in the coronial investigation to be explored in the inquest were limited to: (1) Findings as required by s 81(1) of the Act.

(2) Whether any recommendations are considered necessary or desirable in relation to any matter connected with Mr Valentine’s death.

The evidence 8 Tendered to the court was a 1 volume brief of evidence compiled by the Officer in Charge of the coronial investigation, Senior Constable Nadia Restuccia.

9 Evidence in the form of witness statements, a CSNSW Serious Incident Report, photographic evidence and a post-mortem report is contained in the brief.

There is also a very large number of medical and Justice Health records provided in electronic format.

10 At the inquest, the court received oral evidence from Senior Constable Restuccia to the following effect: (1) No suspicious circumstances were identified in the course of her investigation; and (2) No care or treatment issues were identified in the course of her investigation.

11 At the inquest, the Court also received 2 further exhibits concerning Custodial Operations Policy and Procedure 13.9 and the video recording of an inmate’s death.

12 Although I will touch on aspects of this evidence that I consider important, and not make mention of other aspects, I have had the opportunity to consider the entirety of this material during the coronial process.

13 It is important to stress at the outset that the length of this inquest and the number of witnesses called is in no way a reflection of the importance this court places on Mr. Valentine’s life. That is more accurately reflected in the preparation and investigations undertaken by police and other responsible parties.

14 Additionally, when a person is detained in custody the State is responsible for his or her safety and medical treatment. Given that inmates are not free to seek out and obtain the medical treatment of their choice or have their families directly assist them in this task, it is especially important that the care they are offered is of an appropriate standard and is culturally appropriate.

Findings 15 The facts of this matter not being in dispute, I am enormously grateful for the observations and submissions made by the NSW Police Force Advocate assisting me. I have drawn extensively (and directly) from her assistance in relation to non-contentious issues.

16 As will be seen, I have concluded that: (1) Mr Valentine died on 8 August 2024 at Westmead Hospital directly from congestive cardiac failure, due to ischaemic and valvular heart disease, with hereditary haemorrhagic telangiectasia and anaemia contributory conditions.

(2) In the absence of any criticism of Corrective Services NSW or Justice Health, no recommendations are required.

Background 17 Mr. Mr Valentine was born on 10 September 1940 in the United Kingdom.

Around the age of 21 or 22 he emigrated to Australia where he met and married his wife, Maris, in the late 1960s. Mr and Mrs Valentine had five children together and were married until Mr Valentine’s death. Mr Valentine undertook an apprenticeship as a telephone technician before attending university and graduating with a Bachelor of Arts.

18 Mr Valentine was employed by the New South Wales Department of Child Welfare and Social Welfare, initially as a field district officer. Between January 1971 and July 1973, he was the Deputy Superintendent of a child welfare institution run by the NSW Government. In July 1973 he was transferred to a training school and acted as the Relieving Deputy Superintendent until February 1975. Following this, Mr Valentine performed various roles within the department until he retired.

Mr Valetine’s Custodial History 19 In 2013 the Royal Commission into Institutional Responses to Child Sexual Abuse was established to inquire into, and report on, institutional responses to allegations and incidents of child sexual abuse and related matters. In 2014, the NSW Police Force established Strike Force Bilvo to investigate numerous complaints of historical sexual assault and referrals from the Royal Commission.

20 In 2016 and 2017 Mr Valentine was charged with a total of thirty-nine offences relating to his time as Deputy Superintendent and Superintendent of two staterun child welfare institutions between 1971 and 1974. Prior to this, Mr Valentine had no criminal history.

21 A judge alone trial was held at the Sydney District Court and on 9 April 2019, Mr Valentine was found guilty of 21 of the offences. On 24 May 2019, Mr Valentine was sentenced to an aggregate sentence of 22 years imprisonment with a non-parole period of 13 years. On appeal, one sequence was quashed which resulted in the sentence being reduced by two years. His earliest release

date was 23 May 2031. In reducing Mr Valentine’s sentence, consideration was given to the arduous conditions he faced in custody during the Covid-19 pandemic.

22 Whilst in custody, Mr Valentine was a Special Management Area Placement (SMAP) inmate due to the nature of his convictions, his age and frailty. His most recent placement before his death was at the Metropolitan Remand and Reception Centre (MRRC) at Silverwater.

Mr Valentine’s Medical History 23 Mr Valentine was 78 years old when he entered custody and had a lengthy and complex medical history. After his conviction, Mr Valentine remained on bail until his sentence to allow for the preparation of extensive medical reports to accompany him when he went into custody. On sentence, it was noted that Mr Valentine’s treating cardiologist had estimated his life expectancy to be between 1 and 3 years due to the nature of his medical conditions.

24 The most significant of Mr Valentine’s medical conditions included hereditary haemorrhagic telangiectasia (HHT) complicated by iron deficiency anaemia and exacerbated by concurrent anticoagulation for valvular heart disease. HHT is a rare genetic disorder causing abnormal vessel connections which can leave to telangiectasias (dilated blood vessels on the skin mucous membranes) and bleeding in the nose, lungs, brain and liver. Mr Valentine reported that he had experienced severe nose bleeds in the past requiring hospitalisation.

25 Mr Valentine was diagnosed with a complete Atrioventricular Block which resulted in the implantation of a DDDR pacemaker in 1997, an upgrade to a CRT pacemaker in 2002, a further upgrade to a CRT defibrillator in 2013 and an ICD pocket effusion in 2014. He was also diagnosed with dilated cardiomyopathy with left ventricular dysfunction and underwent a mitral and tricuspid valve annuloplasty in 2014. He underwent mitral and aortic valve replacements in 2019. Mr Valentine also suffered from hypertension, hyperlipidaemia, paroxysmal and permanent atrial fibrillation, sleep apnoea, single vessel coronary artery disease with a bare metal stent inserted in 2013

and a patent coronary stent inserted in 2014 as well as chronic kidney disease.

Progressive deterioration of Mr Valentine’s symptoms had been observed prior to him entering into custody.

Medical Care in Custody 26 Mr Valentine’s medical conditions were managed by the Justice Health and Forensic Mental Health Network (JHFMHN) whilst he was in custody.

Throughout his time in custody, Mr Valentine had numerous hospital admissions and attendances related to his medical conditions. And in the months prior to his death, his condition declined further.

27 On 31 January 2024, Mr Valentine was admitted to the Prince of Wales Hospital under the gastroenterology team. It was believed that he had chronic gastrointestinal bleeding secondary to his HHT and exacerbated by his anticoagulation medications. He was given an iron infusion as he was anaemic with a haemoglobin level of 59. It was recommended that Mr Valentine recommence Warfarin with Clexane bridging until his INR levels returned to therapeutic levels. Mr Valentine decided to discharge himself from hospital against medical advice on 3 February 2024 and he was returned to the Kevin Waller aged care ward at Long Bay Hospital.

28 On 6 February 2024, Mr Valentine was returned to the Prince of Wales Emergency Department for hypotension and dizziness. He was reviewed by the cardiology team and discharged on 7 February with a plan to commence frusemide, outpatient renal function monitoring and outpatient cardiac clinic follow up.

29 On 19 February Mr Valentine was taken to an appointment with a Respiratory medicine specialist at the Prince of Wales Hospital. On 21 March he attended the outpatient cardiac clinic at Prince of Wales Hospital.

30 On 31 May 2024, Mr Valentine was taken to Auburn Hospital via ambulance with worsening peripheral oedema over the previous week. The medical team at the hospital were of the view that there was an exacerbation of his heart failure with fluid overload, and he was admitted under the Cardiology team.

31 On 6 June 2024 an urgent transfer was arranged to Westmead Hospital for Mr Valentine to undergo an endoscopy due to ongoing gastrointestinal bleeding.

X-rays during his admission at Westmead showed his cardiac size was enlarged with plum venous congestion, left atrial dilation, right lower lobe collapse and consolidation, linear collapse at the left lung base and right basal pleural fluid. An endoscopy didn’t find any obvious source of the bleeding but did show multiple angioectasias throughout the stomach and small bowel, being dilated blood cells that can lead to bleeding. Warfarin was reintroduced due to Mr Valentine’s predisposition to gastrointestinal bleeding. He was transferred back to Auburn Hospital where he remained until 14 June when he was well enough to be discharged back to Silverwater MRRC.

32 On 15 June 2024 when Mr Valentine attended the Hamden Primary Care Clinic at the MRRC for his medication, the nursing staff noticed that he had bruising on the left side of his face under his eye and chin. Mr Valentine said that he had fallen from the bed the previous night and he had been dizzy but he was feeling alright and didn’t have a headache. A GP review was booked, and Mr Valentine was put on daily medical observation.

33 On 19 June 2024, Mr Valentine was seen by a Cardiac Care Nurse at the Hamden Clinic in MRRC for a planned review. Then on 21 June 2024, Mr Valentine was reviewed by a general practitioner in relation to his fall and most recent hospital admission. As a result, his furosemide was reduced to 40mg daily, a blood test was ordered and a further GP review recommended if the light headedness and hypotension continued.

34 Around 2.20pm on 24 June 2024, Mr Valentine attended the Hamden Clinic for the blood test ordered after his GP review. At about 7.50pm the same day, the Nurse Unit Manager attended Mr Valentine’s cell after Westmead Pathology called to report that the blood test results showed that his haemoglobin was 51 which was a critical level. Mr Valentine said that he was not surprised, and he had been advised he would probably need another blood transfusion. The Nurse Unit Manager observed that Mr Valentine was alert and oriented and was in good spirits. Given the pathology results and Mr Valentine’s comorbidities, the decision was made to transfer him to Westmead Hospital.

35 Mr Valentine was admitted to Westmead Hospital on 24 June 2024 and underwent numerous investigative procedures. On 28 June 2024, an endoscopy was performed which identified active bleeding in his stomach which was treated with argon plasma coagulation (APC). A gastroscopy on 11 July showed active bleeding at the site of previous clips. The bleeding was persistent and was treated with snare tip soft coagulation and then the whole area had to be clipped.

36 Mr Valentine’s overall diagnosis was upper gastrointestinal bleeding secondary to multiple bleeding telangiectasias on the background of hereditary haemorrhagic telangiectasia, worsening renal function, progressive heart failure with reduced ejection fraction, cardiomyopathy and cardiorenal symptoms. There was significant contribution from both the cardiology team and the gastrointestinal team in Mr Valentine’s care. His history of atrial fibrillation meant that anticoagulation was recommended, but his HHT meant that there was simultaneously a high risk of bleeding.

37 Medical staff tried to balance Mr Valentine’s multisystem issues. The bleeds in his small bowel were difficult to reach and a further endoscopy was classified as high risk due to his heart failure. Mr Valentine’s congestive heart failure was difficult to treat because of fluid overload, but diuretics couldn’t be increased because of his acute kidney issues. Blood thinners were ceased because of the ongoing gastrointestinal bleeding, but Mr Valentine was still at risk of blood clots because of his heart issues.

38 Mr Valentine’s condition continued to deteriorate over the course of his admission. By the 6 August 2024, his prognosis was guarded, and clinicians were considering whether the goal of his care should be comfort. Discussions were held with Mr Valentine and his family about his ongoing multiple organ failure and recurring gastrointestinal bleeding and the possibility of palliative care.

39 On 7 August 2024, a resuscitation plan and advanced care plan was completed for Mr Valentine confirming that in the event of cardiopulmonary arrest, he did not wish for CPR to be performed. Mr Valentine was transferred to palliative

care after multiple conversations between the cardiology and gastroenterology teams and consultation with Mr Valentine. Mr Valentine told a Palliative Care consultant that he did not want his time prolonged and that he was happy with the decision he had made.

Circumstances of Mr Valentine’s Death 40 On 8 August, Mr Valentine was noted to have rapidly deteriorated which was in keeping with expected organ failure and a Catholic Priest was requested to attend the ward at the request of his family.

41 As Mr Valentine was still in custody whilst admitted to Westmead Hospital, he was escorted by CSNSW Correctional Officers throughout his admission.

Around 3.41pm on 8 August 2024, Correctional Officers from the Medical Escort Unit (MRRC) were present with Mr Valentine when they noticed that he had stopped breathing. They pushed the nursing assistance buzzer and alerted nursing staff. Dr Kayla Ramires attended and confirmed that Mr Valentine had died. Dr Ramires confirmed the time of death as 3.48pm. Mr Valentine’s wife, son, and daughter were present at the time of death.

CSNSW and NSW Police Response 37 A crime scene was established by Correctional Officers and notifications were made in accordance with procedures following a death in custody. Parramatta Police Area Command were notified, and Constables Murray and Mujica from Parramatta Police Area Command attended Westmead Hospital taking over the crime scene at 8.22pm. At about 8.50pm, Detective Senior Constable Nadia Restuccia and Senior Constable Fergusson from Parramatta Detectives office attended Bed 3 ward K12A. At 11.40pm Mr Valentine’s body was transported to the Forensic Medicine and Coroners Court Complex (FMCCC) at Lidcombe.

Post-Mortem 42 Dr Elsie Helena Burger, Forensic Pathologist, performed an external postmortem examination on Mr Valentine on 15 August 2024 and her report was finalised on 31 October 2024.

43 A post-mortem computed tomography (CT) scan showed that Mr Valentine’s heart was enlarged and there was three-vessel calcification of coronary arteries. The aortic valve was also calcified, and a cardia device was visualised. There appeared to be evidence of terminal aspiration of gastric contents. Abnormal fluid was noted in the pleural cavities, and oedema of the body wall was seen radiologically.

44 On external examination, extreme swelling of the body was noted, together with features of hospitalisation.

45 Dr Burger explained that hereditary haemorrhagic telangiectasia is a condition that involves abnormal blood vessels. In Mr Valentine’s case, the abnormal blood vessels were pronounced in the upper Gastrointestinal tract, where they were prone to bleeding that was difficult to control. Underlying cardiac issues such as ischaemic heart disease or valvular disease can cause congestive cardiac failure, but HHT can also contribute to cardiac failure by causing abnormal blood vessel connection in organs. The anaemia that resulted from significant blood loss would exacerbate the symptoms of congestive cardiac failure.

46 The conclusion stated by Dr Burger as to Mr Valentine’s cause of death, based on the reported circumstances and the findings at autopsy, was that he died from congestive cardiac failure due to ischaemic and valvular heart disease, with hereditary haemorrhagic telangiectasia and anaemia as contributory conditions.

Coronial Issues 47 There is no controversy surrounding Mr Valentine’s identity, where or when he died, nor the manner or cause of his death. The circumstances of Mr Valentine’s death were carefully examined. Mr Valentine entered custody with serious preexisting medical conditions with a limited life expectancy. There is no evidence to suggest that the care provided by Corrective Services NSW and Justice Health staff contributed in any way to his death. There is also no evidence that

the care provided to Mr Valentine at Westmead Hospital where he spent the final weeks of his life was anything other than adequate and appropriate.

48 The CSNSW Serious Incident Report on Mr Valentine’s death identified 3 Custodial Operations Policies and Procedures (COPP) as being relevant. It determined that those policies were appropriate and complied with but for the requirement of Correctional Officers to video record the death in custody of an inmate. The evidence received at inquest (Exhibits 2 and 3) makes clear that policy required the Correctional Officers not to video record the death of an inmate and thus there was not a breach of any policy in the circumstances of Mr Valentine’s death.

49 It follows that there are no issues or recommendations that arise for consideration.

Concluding remarks 50 I will close by conveying to Mr Valentine’s family my sympathy for their loss.

51 I thank Sgt Chytra again for her support in the conduct of this inquest and the Officer in Charge, SC Restuccia, for her work in conducting the investigation and compiling the brief of evidence.

Statutory findings required by s 81(1) 52 As a result of considering all the documentary and the oral evidence heard at the inquest, I make the following findings: Identity The person who has died is Frank Valentine Place of death Westmead Hospital Westmead NSW 2145 Date of death 8 August 2024 Cause of death

1(a) Congestive cardiac failure 1(b) Ischaemic and valvular heart disease 2 Hereditary haemorrhagic telangiectasia and anaemia Manner of death Natural causes while in the custody of Corrective Services New South Wales (CSNSW).

I close this inquest.

Magistrate S Devine Deputy State Coroner Lidcombe **********