Inquest into the death of Edgar Forrester

CITATION: Inquest into the death of Edgar Jungala Forrester

[2021] NTLC 002 TITLE OF COURT: Coroners Court JURISDICTION: Alice Springs FILE NO(s): A0011/2020 DELIVERED ON: 7 January 2021 DELIVERED AT: Alice Springs HEARING DATE(s): 9 December 2020 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Death in custody, natural causes

REPRESENTATION: Counsel Assisting: Kelvin Currie Counsel for family: Daniel Gorry Judgment category classification: A Judgement ID number: [2021] NTLC 002 Number of paragraphs: 30 Number of pages: 8

IN THE CORONERS COURT AT ALICE SPRINGS IN THE NORTHERN TERRITORY OF AUSTRALIA No. A0011/2020 In the matter of an Inquest into the death of

EDGAR JUNGALA FORRESTER ON: 21 MARCH 2020 AT: ALICE SPRINGS HOSPITAL FINDINGS Judge Greg Cavanagh Introduction

1. Mr Forrester’s birth is generally recorded as being on 1 January 1964 (although his daughter thought it was sometime in November). He was born on Coniston Station, Mt Dennison in the Northern Territory. His mother was Peggy Forrester, the last descendant of the Coniston massacre in 1928. His father was Toby Brown. He had five brothers and sisters: Janice Forrester, Glenda Forrester, Dudley Brown, Matthew Brown and Frank Brown. He did not attend school and undertook stock work on the Station from an early age and in later years worked as a bush mechanic.

2. He married Noelene Campbell and they had four children: Shirleen Campbell, Bryce Campbell, Glenda Campbell and Deborah Forrester. He also had another son, Darren Hayes. His wife died and he moved to Alice Springs. While there he entered into a relationship with Marita Bennett.

3. They had an on-again-off-again relationship that was plagued by alcoholism and violence. On 17 August 2013 they had been drinking most of the day. At 4.30pm they got into an argument over jealousy issues. It ended when Mr Forrester stabbed Marita in the chest with a large knife. It penetrated to a

depth of 16.5 centimetres and severed her aorta. She died. At the time of her death her blood alcohol reading was 0.33%. After his arrest he was taken to hospital to allow his withdrawal from alcohol.

4. Mr Forrester was charged with murder. However he pleaded guilty to manslaughter on 9 February 2015 and was sentenced to 7 years imprisonment backdated to his arrest on 17 August 2013. He was given a non-parole period of 4 years and 3 months. At the time of his admission to the prison he was noted to be suffering from ischaemic heart disease and symptoms relating to withdrawal from alcohol.

5. He was released on parole on 17 December 2018. However on the evening of Tuesday, 25 June 2019 he was arrested for driving while intoxicated. He appeared in Court on Wednesday, 26 June 2019. His parole was revoked and he was sentenced to serve the remainder of his sentence (1 year and 8 months being due for release 25 February 2021)). He was returned to prison that same day. He was given a security classification of Low 1. He was 55 years of age.

6. By that stage he had a number of health issues. He suffered significant osteoarthritis and had deformities to the joints of his hands and feet. It resulted in him having difficulty holding crockery and he could not manage cutlery. He had a subarachnoid haemorrhage in 2013 thought to be linked to hypertension. He had myositis thought to be due to a reaction to statin medication first noted in 2014 and stage 2 chronic kidney disease. He had ischemic heart disease and was considered a high cardiovascular risk. He also had type 2 diabetes mellitus.

7. While in prison he had increasing difficulty swallowing medication and then food. On 12 December 2019 he underwent a CT scan that showed a large oesophageal legion in his throat along with metastases. He did not return to the prison thereafter. From 24 December 2019 he was given a series of General Leave Permits from Corrections to undergo treatment (that is, he

was not supervised by any Correctional staff). That also meant that he had the same visiting privileges of any other patient at the hospital. His family were able to provide support and companionship to him each day.

8. His inability to swallow lead to the insertion of a gastrostomy tube directly to his stomach to ensure he was able to receive sufficient nutrition. He received palliative radiotherapy at Royal Adelaide Hospital to treat the lesion and metastases and was palliated on his return to Alice Springs Hospital from 11 February 2020. From late February the advancing lesion in his throat progressively affected his breathing. He died on 21 March 2020 at 9.20am surrounded by his family.

9. The Forensic Pathologist, Dr John Rutherford provided the cause of death as aspiration pneumonitis secondary to airways obstruction from squamous cell carcinoma of the oesophagus (metastasised).

10. Pursuant to section 34 of the Coroners Act, I find as follows: (1) The identity of the deceased was Edgar Jungala Forrester, born on 1 January 1964 at Coniston Station, Mt Dennison in the Northern Territory.

(2) The time of death was 9.20am 21 March 2020. The place of death was the Alice Springs Hospital.

(3) The cause of death was aspiration pneumonitis secondary to airways obstruction from squamous cell carcinoma of the oesophagus (metastasised).

(4) The particulars required to register the death:

1. The deceased was Edgar Jungala Forrester.

2. The deceased was of Aboriginal descent.

3. The deceased was a prisoner.

4. The death was reported to the Coroner by Alice Springs Correctional Centre.

5. Forensic Pathologist, Doctor John Rutherford confirmed the cause of death.

6. The deceased’s mother was Peggy Forrester and his father Toby Brown.

Care, Supervision and Treatment

11. Pursuant to section 26 (1) Coroners Act I must investigate and report on the care, supervision and treatment of a person held in custody immediately before his or her death.

12. He was taken into custody on 25 June 2019 and received into the Alice Springs Correctional Centre on the evening of Wednesday, 26 June 2019.

13. On Saturday 29 June 2019 he said he needed his medication and had not taken any for the last three days. He was provided medication and an appointment made to see the doctor on Monday, 1 July 2019. The doctor updated his medications and referred him for a cardiac stress test.

14. He was unable to complete the stress test because before entering the prison he had been wearing shoes that were too small for his feet and had bruised his toes. He was only able to hobble. He received treatment for his toes and the stress test was rescheduled.

15. On 20 July 2019 he had chest pain. He said he normally got it when he ate bread. He was sent to the hospital. A stress test was performed on 24 July

16. The results were essentially normal. He was provided GTN spray and Ezetimibe. He continued to have the pain but it was eased when he used the spray.

17. On 19 August 2019 the doctor was told by a Correctional Officer that Mr Forrester was showing signs of dementia. The doctor undertook a cognitive assessment on 27 August 2019. There was no signs of cognitive impairment.

18. On 9 September 2019 during the evening medication round Mr Forrester said that he had a sore throat over the last two days. The nurse advised him to submit a medical request form. He did not do so.

19. On the morning medication round on 24 September 2019 after he took his tablets he choked and vomited some of the tablets. He was thought to have a mild cough.

19. He was seen at the Clinic on 29 September 2019 for an annual health check.

He said he was feeling well. He had a lip ulcer that was treated. On 2 October 2019 he attended the Clinic with right lip and gum swelling. He said it had been there for three weeks. It was thought to be a peri-dental abscess. He was booked for dental review the following day and prescribed antibiotics. The following day he had a tooth extracted.

20. On 25 October 2019 a code blue was called due to back pain he was having.

He said he didn’t want to take medication because he found it difficult to swallow. However, he swallowed the medication, was given analgesia and booked to see the doctor on Monday. When he saw the doctor he said he had problems swallowing his tablets and food for a long time. He said it felt like it got stuck in his throat and then he would have to cough it back up. But otherwise he said he was well, he just felt old. He said when he was working he also got chest pain and had to rest. He was referred for an endoscopy and stress test.

21. On 10 November 2019 he complained of severe pain down his left side and difficulty swallowing tablets. He was sent to the hospital where he had a CT scan. He was thought to have an old fractured rib believed to be the source of the pain. The plan was analgesia and to undergo swallowing studies or endoscopy.

22. On 18 November 2019 he was found only medically able to continue working if it consisted of light duties. Two days later he complained of ongoing rib pain and was referred for a bone mineral density test. However shortly thereafter the Final report of the CT scan was received. It did not support a fractured rib and at that time Mr Forrester had no ongoing chest pain. Rather, he said he had diffuse aches. The bone mineral density test was cancelled.

23. On 25 November 2019 he said the pain was in his hands and feet and on 29 November he had acute right ear pain. On 2 December 2019 he refused the analgesia. He said he couldn’t swallow the tablets. The following day he tried while at the clinic and had an extensive bout of coughing. It was noted that he was still awaiting endoscopy. It was decided that thereafter he should attend the clinic for his medications, many were removed and the others changed to liquid form. It was noted he had lost 4 kilograms over the last 6 months. He was referred for a barium swallow on the basis that he would likely be able to be seen sooner than for the endoscopy.

24. On 11 December 2019 he was reviewed once more over his ability to swallow tablets. He said he could only eat little bits of food and put it aside for later. It was noted that he was still awaiting endoscopic review (not anticipated until February). He had a hoarse voice and really struggled to swallow water. He was sent to the Emergency Department at Alice Springs Hospital for inpatient endoscopy and speech therapist review.

25. He was admitted to the hospital on 12 December 2019. He did not return to the prison thereafter. A CT Chest scan showed “a circumferential oesophageal thickening and enlarged lymph nodes and enhancing hepatic nodules concerning for metastatic involvement”. A 20 – 23cm ulcerated lesion was biopsied. The pathology indicated malignancy. He was transferred to the Royal Adelaide Hospital on 24 December 2019 for further investigations and treatment.

26. On 2 January 2020 the South Australian Upper GI Cancer Multidisciplinary Meeting recommended a bronchoscopy and insertion of a tracheal stent, palliative radiotherapy followed by sequential palliative chemotherapy and a referral to palliative care. On that day a Radiologically Inserted Gastrostomy (RIG) was inserted directly into his stomach for feeding. He still ate and drank a little but that was supplemented by feeding and fluids through the RIG. The tracheal stent was unable to be inserted as the site was too high leading to significant risk of perforation.

27. The plan was to commence radiation therapy to the oesophagus and left shoulder on 23 January 2020. Due to Mr Forrester technically being in custody (and therefore not being suitable for local accommodation) he was returned to be cared for at Alice Springs Hospital until that date. He was returned to Alice Springs Hospital on 15 January 2020.

28. On 30 January 2020 he was flown back to the Royal Adelaide Hospital. He received a course of palliative radiotherapy and returned to the Alice Springs Hospital on 11 February 2020. On his return he said he was feeling well. He was referred to the palliative care team and further palliative oncology was planned for 20 February 2020. However, given that his last radiation had only been completed on 6 February 2020 it was believed that it could not commence until early March. It was also believed that chemotherapy was too high risk due to his frailty and futile because of the obstructive nature of the lesion.

29. He was formerly transferred to the palliative care team on 27 February 2020.

From mid-March 2020 Correctional Services and the Hospital were working toward returning Mr Forrester to his country for a visit, however he was not well enough to travel. He experienced progressive airway obstruction and on 20 March 2020 he declined rapidly. He died the following day, 21 March 2020 at 9.20am surrounded by his family.

30. In my view, on all of the evidence, the care, treatment and supervision of the deceased was appropriate.

Dated this 7th day of January 2021.

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GREG CAVANAGH TERRITORY CORONER