Inquest into the death of Ronnie Nelson

CITATION: Inquest into the death of Ronnie Pangata Nelson

[2018] NTLC 004 TITLE OF COURT: Coroners Court JURISDICTION: Alice Springs FILE NO(s): A0003/2017 DELIVERED ON: 19 January 2018 DELIVERED AT: Alice Springs HEARING DATE(s): 1 December 2017 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Death in custody, natural causes, released on bail for payback

REPRESENTATION: Counsel Assisting: Kelvin Currie Judgment category classification: A Judgement ID number: [2018] NTLC 004 Number of paragraphs: 41 Number of pages: 8

IN THE CORONERS COURT AT ALICE SPRINGS IN THE NORTHERN TERRITORY OF AUSTRALIA No. A0003/2017 In the matter of an Inquest into the death of

RONNIE PANGATA NELSON ON 14 JANUARY 2017 AT ALICE SPRINGS HOSPITAL FINDINGS Judge Greg Cavanagh Introduction

1. Ronnie Pangata Nelson (the deceased) was born 1 July 1954 in Ti Tree in the Northern Territory. He was 62 years of age at the date of his death.

2. Mr Nelson had two children, Aaron (1983) and Joseph (1999).

3. In the year 2000 he entered into a relationship with Lisa Haines. On 12 January 2002 he was living with Lisa at his residence in the Old Homestead at Utopia. He was drinking wine with a number of other persons.

4. He began to argue with another male about him making advances toward Lisa. He then went with Lisa into the house. He punched her and she ran. He fell over and lost sight of her.

5. After she returned she sat on the floor and he sat on the bed and he started to accuse her of having an affair. He became angry and took a nulla nulla out from under the bed and beat her with it until it broke. He then retrieved a 20 centimetre axe from under the bed and struck her to the head cutting her scalp and skull. She tried to run to the door and he struck her to the knee with the axe cutting her leg to the bone. She fell and he struck her head numerous times with the axe. He also stabbed her in the pubic area, the back and the buttocks with the broken nulla nulla.

6. He then put some sheets under her head and asked someone to call the Health Clinic. When the nurses arrived Lisa was dead and Mr Nelson was shortly after arrested. He confessed to murder.

Payback

7. On 19 February 2002 he was given court bail by Magistrate Ward for a period of six days to travel to Ti Tree Community to undergo payback. The circumstances of what then occurred were recounted by Justice Mildren during the course of Mr Nelson’s trial: “Subsequent to his arrest, the accused was released on bail. Whilst on bail on Saturday, 23 February 2002, the accused underwent payback whilst at Ti Tree at a place referred to, locally, as the Creek Camp. The pay-back took place in the presence of a registered nurse and mid-wife, Ms Gayle Blennerhassett, as well as a police officer, Constable Leith Phillips, who were requested to attend by the elders.

The pay-back took the form of the accused being hit with nulla nullas by various members of both his own family and the family of the deceased. Quite a number of blows were delivered to the accused's body, particularly on the arms and legs. There were no blows administered above the shoulders. The accused, who also gave evidence on the voir dire, said that he was also hit by a boomerang on his back. The blows were delivered over a period of between 15 to 20 minutes; people in groups of three or four came forward, hit the accused a few times, then retreated and, after some discussion, others would come and repeat the punishment. On two occasions, the accused had to be assisted to his feet after he had fallen down as a result of the blows.

When the punishment was completed, he was assisted onto a stretcher, placed in an ambulance and driven back to the Ti Tree clinic for full assessment. When the ambulance arrived at the clinic, the accused was able to walk from the ambulance into the examination room, where he was sat down on a chair and Nurse Blennerhassett did a full medical assessment. On clinical examination, she was unable to find any evidence of fractures. The accused had some soft tissue injuries to the left hand, left arm and left leg. Some swelling was noted. There was a full range of movement with discomfort in the arm and the leg. The left elbow was

also swollen and there was swelling to both lower legs, as well as the left hand.”1 Incarceration

8. In May 2003 he was found guilty of murder by a jury. He was sentenced to life imprisonment on 4 June 2003 with a non-parole period of 20 years. He appealed his conviction and sentence. However on 10 September 2004 withdrew that appeal by filing a Notice of Discontinuance.

9. In late 2005 Mr Nelson was sent to Royal Adelaide Hospital to have coronary artery bypass surgery. He had the surgery on 1 December 2005.

10. From the beginning of 2016 he began to decline due to liver disease and on 25 May 2016 he was noted to be suffering confusion. He was referred for a dementia review. He also had ongoing issues with perirectal bleeding and on 28 August 2016 was put on the waiting list for surgery.

11. On 2 November 2016 he was transferred back to Alice Springs Correctional Centre at his request. There he was able to be with his son who was also in prison at that time. On 5 November 2016 his son advised medical staff that Mr Nelson was suffering from increased confusion and had been shaking all night.

12. He was admitted to the Alice Springs Hospital. He was treated and his medications altered and he returned to prison on 21 November 2016.

However he continued to decline due to his chronic liver disease. That was mainly seen in his continuing confusion, weakness and headaches.

13. On 13 December 2016 the doctor at the prison, Doctor Honeymoon, communicated to the Alice Springs Hospital that Mr Nelson’s liver failure could no longer be adequately treated in the prison. He was transported to Hospital by Ambulance that same day. His ammonia levels were noted to be 98.

1 R v Nelson [2003] NTSC 64

14. He was treated in the Medical Ward East for hepatic encephalopathy and cirrhosis. He was often noted to be alert and oriented. He appeared to be improving. He was mobilising independently and tolerating his medications.

15. On 6 January 2017 at 10.00am he had a flexible sigmoidoscopy procedure for perirectal bleeding. The following day at 1.44pm his blood pressure dropped. He was thought to be dehydrated and he improved with fluids.

16. Thereafter to become more alert and oriented. However, at 5.50pm he said he was feeling “crook” and went to the bathroom. He fell and hit his elbow.

He was assessed and his elbow x-rayed. There was no break observed.

17. It was noted that his kidneys continued to functionally decline. The reasons for that were not clear and on 11 January 2017 the prison and his family were notified of his continued deterioration.

18. It was considered that given his deterioration over the last 6 months and “precipitously” over the last 3 days that an ICU admission was not appropriate and that Mr Nelson would not benefit from being intubated and ventilated. A Do Not Resuscitate form was completed.

19. By 7.00pm that evening (11 January 2017), his Glasgow Coma Score (GCS) had dropped. At 2.30am the next morning (12 January 2017), a meeting was held by the Hospital with family.

20. With family present Mr Nelson was much more alert (GCS 12). It was explained to the family that he had chronic single organ failure (liver) and renal dysfunction that was worsening despite treatment. It was explained that he may die in the very near future. The family agreed that renal replacement therapy and resuscitation were not appropriate.

21. By 10.00am there were 8 members of the family present. Mr Nelson was drowsy but could recognise family. At 1.00pm on 13 January 2017 he was formerly placed under the palliative care team.

22. At 4.05am on 14 January 2017 the prison guard noticed that Mr Nelson had stopped snoring. He alerted the nurse and the doctor was called. The doctor confirmed that Mr Nelson had died at 4.35am.

23. The Coroners Act at section 26(1)(a) requires that where a person dies in custody the Coroner: “(a) must investigate and report on the care, supervision and treatment of the person while being held in custody.”

24. At the inquest there was significant dissatisfaction by one of the deceased’s sons because, he said, his father had died as a result of the payback.

25. In statements provided, both sons had indicated that their father had suffered significantly due to that payback. His son, Joseph stated: “About long time ago my father started getting sick from payback.

People have been hitting him for payback whilst in gaol … people were hurting him. I don’t know who. This was long time ago when I was just a little boy. I think that’s why he got sick.”

26. His son Aaron stated: “That’s before jail, from there they have hit him up, hit him real hard, put him in hospital, he had a lot of injury, broken bones and from there he been get better, not really better - just a little bit better then lock him up …that’s why he had a lot of injury, and he had a lot of broken bones and that’s what they’re all on about you know … and from there they sent him for 25 years …they should have lowered it down …cause it payback they should have lowered it down. He was really sick in hospital, with a lot of broken bones, it was really hard.”

27. He went on to say that was the first time his father had been really sick in hospital.

28. However that story, although consistent with much of the secondary material contained in the brief of evidence, differed to the circumstances recounted by Justice Mildren (at paragraph 7 above).

29. The original medical records support the version recounted by Justice Mildren. They indicate that on Sunday, 24 February 2002, Mr Nelson was taken to Alice Springs Hospital Emergency Department by Police (having taken him back into custody).

30. The history recorded in the medical notes was that he had been hit by a person with a nulla nulla at about 2.00pm the day before. He had a very swollen and painful back of the left hand over the metacarpals, a swollen and painful left wrist and pain over the left lower leg.

31. Mr Nelson said that he was not hit over the chest or head. He said he got hit on the abdomen once but that it was not painful. He said he had suffered no loss of consciousness.

32. An x-ray showed an undisplaced fracture of the third midshaft metacarpal, a chipped lateral condyle left humerus with an overlying wound. There were no leg fractures.

33. He was referred to the orthopaedic clinic for review. There is no record of him being admitted to hospital. On 28 February 2002 an orthopaedic surgeon, Dr Dayananda, placed a plaster back slab on his left hand and told him it was to remain in place for four weeks. The doctor also indicated that the elbow needed to be mobilised as much as he was able and to have regular dressings over the wound.

Pre-existing health

34. The Hospital records show that before the payback Mr Nelson had a significant number of conditions. Those included:

• Perianal haematoma

• Deafness

• Recurring urinary tract infections and urethral strictures

• Type II diabetes

• High blood pressure

• Fatty liver

• Hepatitis B and C

• Kidneys under investigation

35. There is also an entry that on 20 August 2001 at Utopia, his right eye was injured when he was kicked on the nose and punched below the right eye.

Mr Nelson thought he may have pre-existing visual impairment.

36. The prison files do not record any significant injuries being occasioned to Mr Nelson while in prison. There was an incident on 26 February 2016, when he was assaulted by another inmate but he suffered no significant injuries and was cleared by the medical clinic.

37. I am satisfied that the care, supervision and treatment of Mr Nelson was appropriate.

38. Mr Nelson died due to his longstanding chronic diseases.

Mandatory Sentence

39. On sentencing, Mr Nelson having been convicted of murder was subject to the mandatory sentence of life imprisonment with a minimum period to be served of 20 years. It was not within the power of the Judge to reduce that minimum period.

40. As noted above, Arron, one of Mr Nelson’s sons was unhappy that despite offering himself for payback, Mr Nelson did not receive any allowance when sentenced. During the inquest I indicated that the lack of discretion by Judges in sentencing persons such as the deceased was concerning.

Formal Findings

41. Pursuant to section 34 of the Coroner’s Act, I find as follows:

(i) The identity of the deceased was Ronnie Pangata Nelson born 1 January 1954 at Ti Tree in the Northern Territory.

(ii) The time of death was between 4.05am on 14 January 2017. The place of death was Alice Springs Hospital in the Northern Territory.

(iii) The cause of death was hepatic encephalopathy due to acute renal failure.

(iv) The particulars required to register the death:

1. The deceased was Ronnie Pangata Nelson.

2. The deceased was of Aboriginal descent.

3. The deceased was in prison and not employed at the time of his death.

4. The death was reported to the Coroner by Police.

5. The cause of death was confirmed by Dr Rachel Yuen.

6. The medical records record the deceased’s mother as Alice and his father as Big Tommy. His birth was not registered.

Dated this 19th day of January 2018.

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GREG CAVANAGH TERRITORY CORONER