Adams, Adrian John

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Adrian John Adams TITLE OF COURT: Coroners Court

JURISDICTION: BRISBANE FILE NO(s): 2021/968 DELIVERED ON: 23 September 2022

DELIVERED AT: BRISBANE HEARING DATE: 23 September 2022 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, death in custody, natural causes, palliative care, exceptional circumstances parole.

REPRESENTATION: Counsel Assisting: Ms Katie Ward Queensland Corrective Services: Ms Vanessa Price

Contents

Introduction

1. Mr Adrian Adams was aged 76 years and serving an eight-year head sentence for sexual offences at Wolston Correction Centre (‘Wolston CC’) at the time of his death.

2. Mr Adams was sentenced on 6 September 2019 in the Brisbane District Court for three counts of indecent treatment, and three counts of rape. He had no prior criminal history. The offending behaviour occurred when he was aged between 64 and 66 years.1

3. After periods of remand at Arthur Gorrie Correctional Centre (‘Arthur Gorrie CC’) and Brisbane Correctional Centre, Mr Adams was transferred to Wolston CC on 11 October 2019, where he remained until his death at the Princess Alexandra Hospital (‘PAH’) on 27 February 2021.2 His parole eligibility date was 10 May 2023 and full-time discharge date 9 May 2027.

The Investigation

4. The Corrective Services Investigation Unit within the Queensland Police Service was advised of the death and attended the scene at 12:15pm on 27 February

5. A targeted coronial investigation was ordered in lieu of a full covering report. The investigation included statements from primary medical and nursing staff at Wolston CC and PAH, medical and QCS records, and a statement from a family member about Mr Adams’ treatment while in custody. Detective Sergeant Bates from the CSIU provided a brief coronial report in July 2021.

6. A review of Mr Adams’ health care in custody by the Clinical Forensic Medicine Unit was not considered necessary in the circumstances, as he was known to have terminal cancer when he was sentenced in 2019, with a poor prognosis and life expectancy of only six to twelve months.3

7. Inspector David Lewis from the Operational Inspection and Major Incident Review Group within Queensland Corrective Services also completed a desktop review of Mr Adams’ death. Inspector Lewis concluded that all QCS directions, guidelines, policies, and procedures were complied with. There were no additional issues or concerns identified.4

8. I am satisfied that the investigation was sufficient in the circumstances of an apparent natural causes death, and that all relevant material was accessed.

The Inquest

8. When he died, Mr Adams was a prisoner in custody, as defined in Schedule 4 of the Corrective Services Act 2003. Although his death was from natural causes, pursuant to section 27(1)(a)(i) of the Coroners Act 2003 an inquest was required as it was a death in custody.

1 Ex B6, 6 September 2019 2 Ex C3, pg. 5 3 Ex B6 4 Ex C3, pg. 6 Findings of the inquest into the death of Adrian John Adams Page 3 of 10

9. The inquest was held in Brisbane on 23 September 2022. All statements, records of interview, medical records, photographs and materials gathered during the investigation were tendered at the inquest. No oral evidence was heard. Helpful submissions were received from Counsel Assisting.

10. I am satisfied that all the material necessary to make the requisite findings was placed before me at the inquest.

The evidence Personal circumstances and correctional history

11. Mr Adams had been married for over 45 years. He and his wife had three children, together with grandchildren and great-grandchildren. He had been a foster carer and worked as a jeweller for 50 years before retiring.5

12. Mr Adams’ widow provided a statement on 6 February 2022 outlining his personal, medical, and remand history to the best of her knowledge.6

13. Mrs Adams reported that Mr Adams was highly appreciative of the care provided by his assigned prison carer, however there had been several instances of incorrect or missing medication. Mrs Adams stated that this was eventually corrected when his chart was reviewed by a doctor.7

14. Although not directly related to Mr Adams’ death or treatment in custody, Mrs Adams expressed disappointment that she was not informed about his declining health until 26 February 2021. She reported that this reduced the time that she and two of their children could spend with him to say their farewells. A third child did not have time to travel from interstate.8

15. In 2018, Mr Adams was diagnosed with stage III midgut colorectal cancer, and he underwent an open right hemicolectomy in August 2018. In September 2019, a lymph node biopsy showed metastatic spread. Mr Adams subsequently advised that he did not wish to receive chemotherapy.9 An Advanced Health Directive was completed in May 2020 reflecting these wishes, including a request that he receive supportive cares for pain management only, even if it were to accelerate his passing.10

16. Mr Adams’ complex medical history included: 11

• Metastatic colorectal cancer, diagnosed in 2018;

• Renal Cell Carcinoma managed with a radical nephrectomy in 2017;

• Type 2 Diabetes Mellitus;

• Hypertension;

• Hypercholesterolaemia;

• Depression;

• Fibromyalgia; 5 Ex B6 6 Ex B5 7 Ex B5 [6] 8 Ex B5 [9] 9 Ex B3 [11] 10 Ex D1, PHS Vol 1 IM pg. 2-24 11 Ex B3 [12] Findings of the inquest into the death of Adrian John Adams Page 4 of 10

• Benign Prostate Hypertrophy; and

• Chronic venous ulcer right medial ankle.

17. He was prescribed and taking a range of medications, including:12

• Dutasteride (Urinary treatment);

• Coloxyl with Senna (Constipation);

• Paracetamol (Pain management);

• Ramipril (Blood pressure);

• Oxycontin (Pain management);

• Metformin (Diabetes);

• Aspirin (Blood clots);

• Duloxetine (Mood and chronic nerve pain);

• Pregabalin (Chronic nerve pain);

• Oxycodone (Pain management);

• Metoclopramide (Nausea); and

• Movicol sachets (Constipation).

18. While incarcerated at Wolston CC, Mr Adams experienced six medical emergencies.13 He experienced one additional medical emergency earlier while remanded at Arthur Gorrie CC, prior to being transferred to Wolston CC. Each of these incidents related to Mr Adam’s declining health due to his terminal cancer.

On each occasion he was transported to hospital for treatment and later discharged back to the correctional centre.

19. On 3 December 2020, Mr Adams underwent a CT scan of his chest, abdomen, and pelvis at PAH. This scan confirmed an increase in size of all previously known metastatic cancer deposits, and identified that Mr Adams was at a high risk of developing a fatal bowl obstruction.14 A further CT scan was performed on 22 January 2021, which identified an incomplete small bowel obstruction. He was subsequently discharged from PAH on 26 January 2021.15 Records suggest that Mr Adams’ abdominal pain worsened throughout February 2021, resulting in several code blues being called.16

20. The events of 26 February 2021 – 27 February 2021 are summarised as follows:17 26 February 2021

• 8:00am – Mr Adams was reported as being in poor health following a routine welfare check at Wolston CC. Medical staff attended and he was moved to the Health Centre;

• 8:34am – QAS were called, however the assigned vehicle was diverted to a higher priority job;

• 11:15am – QAS priority increased, and paramedics attended the Health Centre;

• 12:15pm – Mr Adams arrived at PAH Emergency Department via QAS; 12 Ex B3 [13] 13 Ex C3 pg. 5 14 Ex B3 [47] 15 Ex B3 [51] 16 Ex B3 [52] – [53] 17 Ex A4 Findings of the inquest into the death of Adrian John Adams Page 5 of 10

• 2:26pm – Medical staff advised corrective services officers that Mr Adams’ family should be contacted;

• 3:25pm – Palliative care team reviewed Mr Adams and the decision was made to commence comfort cares in accordance with his Advanced Health Directive;

• 4:02pm – Mr Adams was reviewed by Dr Mathew. It was recorded that Mr Adams had generalised abdominal distension and absent bowel sounds, suspicious for a bowel obstruction. He was in a confused state with myoclonic jerks. Investigations were undertaken, including blood tests and X-rays which identified Mr Adams to have severe hyperkalaemia, severe Renal impairment, white cell count 33.7, and dilated bowel loops;

• 6:05pm – Mr Adams’ wife and two of his children arrived and were given access to him. Mr Adams had phone contact with his third child who lived interstate.

27 February 2021

• 8:15am – Mr Adams was reviewed by Dr Lockett. Treatment consisted of symptomatic management as recommended by the palliative care team;

• 11:30am – Nursing staff called Dr Lockett to attend and verify the passing of Mr Adams;

• 11:34am – Mr Adams was confirmed deceased by Dr Lockett.

AUTOPSY

21. On 2 March 2021, an external autopsy examination was conducted by Senior Staff Specialist Forensic Pathologist, Dr Rohan Samarasinghe.18 Toxicology samples were taken and stored without testing.19 Post-mortem CT scans showed evidence of metastatic colorectal carcinoma with right mesenteric mass, evidence of right hemicolectomy and multiple further small omental and peritoneal metastases.20

22. Dr Samarasinghe concluded that death was due to the combined effects of small bowel obstruction and acute renal failure, secondary to metastatic colorectal carcinoma. Mr Adams’ other comorbidities were also considered to be significant contributing factors in death, including hypertension, left bundle branch block, type 2 diabetes mellitus and hypercholesterolaemia.21

OTHER CONCERNS

23. In October 2020, Mr Adams began the process of applying for Exceptional Circumstances Parole in relation to his terminal diagnosis, to be released from custody prior to his parole eligibility date of 10 May 2023.22 This was eventually granted by the Parole Board on 23 December 2020.23 Mr Adams had been identified as an inmate who was vulnerable to COVID-19.

18 Ex A3 19 Ex A3 pg. 4 20 Ex A3 21 Ex A3 pg. 8 22 Ex B1 [15] 23 Ex B1 [17] Findings of the inquest into the death of Adrian John Adams Page 6 of 10

24. Following the Parole Board’s approval, medical and nursing staff from Wolston CC made multiple attempts to secure discharge accommodation in a nursing home capable of caring for Mr Adams.24

25. RN Manuel went to considerable effort to conduct enquiries with seven different providers including St Vincent’s Care Services, TriCare, St Johns Aged Care, and Wesley Mission Queensland.25

26. The difficulties faced by RN Manuel included facility capacity issues, lengthy timeframes, information sharing in relation to offender history, and financial issues (Centrelink were not willing to confirm that Mr Adams’ pension would be recommenced without a discharge date, however a discharge date would not be provided until a nursing home placement was secured).26 RN Manuel expressed sadness that Mr Adams died in custody despite his efforts.27 I commend him for his efforts over the two months leading up to Mr Adams’ death.

27. Dr Pidgeon reiterated RN Manuel’s concerns and identified several further challenges in relation to caring for Mr Adams in prison, including the inability to manage his breakthrough pain after hours, as there is no funding to provide 24hour nursing care at Wolston CC.28

28. Dr Pidgeon advised that she is currently involved in a project aiming to improve the process of discharging palliative care inmates into nursing homes, which is occurring in consultation with Queensland Corrective Services, Parole Board Queensland, and the Office of Prisoner Health and Wellbeing.29 Conclusions

29. Based on the material gathered in the coronial investigation, it appears that Mr Adams received regular and appropriate medical care during his incarceration, including consistent clinical engagement with the Senior Medical Officer, Dr Pidgeon, an allocated prisoner carer, and nursing/diversional therapy support.30 The focus of Mr Adams’ care, in accordance with his Advanced Health Directive, was comfort and pain management as his terminal cancer progressed.

30. The circumstances of Mr Adams’ death were not unexpected. His cancer was terminal, and he had a poor prognosis with a life expectancy of six to twelve months even before he was sentenced and imprisoned.

31. The primary issue for consideration in this inquest, apart from the findings required by s 45 of the Coroners Act 2003, was whether Mr Adams had access to, and received, appropriate medical treatment while in custody. Despite the minor issue raised by Mrs Adams about several instances of missed or incorrect medication, this was corrected. It appears that Mr Adams’ medical care was otherwise comprehensive, noting Dr Pidgeon’s concerns about the challenges in managing breakthrough pain after hours.

24 Ex B1 [19] – [67] 25 Ex B1 [61] 26 Ex B1 [61] – [64] 27 Ex B1 [66] 28 Ex B3 [62] 29 Ex B3 [63] 30 Ex B3; Ex B1 Findings of the inquest into the death of Adrian John Adams Page 7 of 10

Findings required by s. 45

32. I am required to find, as far as is possible, the medical cause of death, who the deceased person was and when, where and how he came by his death. After considering all of the evidence and the material contained in the exhibits, I make the following findings: Identity of the deceased – Adrian John Adams How he died – In 2019, Mr Adams was sentenced to eight years in custody for sexual offending. In August 2018 he had been diagnosed with, and underwent surgery for, midgut colorectal cancer. He died in custody after a lengthy history of serious illness, including metastatic colorectal carcinoma. Mr Adams elected not to have his cancer treated. Mr Adams had an application for exceptional circumstances parole approved in 2020 but a suitable community placement could not be found for him before his death.

Place of death – Princess Alexandra Hospital, Woolloongabba in the State of Queensland.

Date of death– 27 February 2021 Cause of death – Small bowel obstruction and acute renal failure, due to or as a consequence of metastatic colorectal carcinoma. Other significant contributing factors were hypertension, left bundle branch block, type 2 diabetes mellitus and hypercholesterolaemia.

Comments and recommendations

33. The evidence of Dr Pidgeon and RN Manuel highlighted the challenges associated with managing palliative care patients in custody and sourcing discharge accommodation for persons on parole. However, it was not asserted that the outcome for Mr Adams would have been different had he been released into discharge accommodation sooner.

34. The topic of exceptional circumstances parole and the discharge of palliative care inmates into suitable accommodation has been considered in several previous inquests. The Inquests into the deaths of Jay Maree Harmer31 and Barry Haynes32 dealt with similar factual circumstances and considered the issue of palliative care in the correctional setting.

31 https://www.courts.qld.gov.au/__data/assets/pdf_file/0009/578916/cif-harmer-jm-20180810.pdf 32 https://www.courts.qld.gov.au/__data/assets/pdf_file/0006/659607/cif-haynes-b-20201116.pdf Findings of the inquest into the death of Adrian John Adams Page 8 of 10

35. In the August 2018 findings of the Inquest into the death of Jay Harmer, I noted that one of the major barriers to the granting of exceptional circumstances parole is suitable supported accommodation for prisoners requiring palliative and other care, as well as access to comprehensive and timely information in support of such applications.33 I made four recommendations, including:34

• That the Queensland Government comprehensively review the current model for the provision of palliative care to prisoners with a view to improving how and where palliative care is delivered, including the provision of a range of post-release supported accommodation options for infirm prisoners eligible for parole, including exceptional circumstances parole.

36. The Queensland Government response to this recommendation was last updated on 8 July 2021.35 The response indicated that all proposed actions in response to the recommendation have been implemented. In responding to this recommendation Queensland Health has:

• “established an Office for Prisoner Health and Wellbeing to provide statewide leadership regarding the health and wellbeing of prisoners with the support of Queensland Corrective Services

• established a clinical network to improve the delivery of health services for people in prison

• reinforced the Queensland Health End of Life Care Strategy 2015 and its application to all people in Queensland, including people in prison

• established a memorandum of understanding with Queensland Corrective Services to clarify each agency’s roles and responsibilities regarding the provision of health care for prisoners

• established a memorandum of understanding with the Parole Board Queensland to support the sharing of confidential information to assist the Parole Board Queensland to make parole decisions including those that are approaching the end of life

• worked in partnership with Queensland Corrective Services to develop the Reducing barriers to health and wellbeing: The Queensland Prisoner Health and Wellbeing Strategy 2020-2025, released in September 2020.

This strategy commits Queensland Health and Queensland Corrective Services to work in partnership to provide timely resolution to complex cross agency issues, such as personal care for prisoners with high care needs.

Queensland Corrective Services continues to work with Queensland Health to deliver health services to prisoners with high care needs, including prisoners requiring palliative care.” 33 Inquest into the death of Jay Harmer [106] 34 Inquest into the death of Jay Harmer [109] 35 https://www.courts.qld.gov.au/courts/coroners-court/findings Findings of the inquest into the death of Adrian John Adams Page 9 of 10

37. West Moreton Health has advised that while there have been some delays associated with the COVID-19 pandemic, work is ongoing in relation to processes for discharging palliative care inmates to nursing homes after they have been granted exceptional circumstances parole.

38. An Aged and Infirm Working Group was established in 2021 to examine the process with members from Prison Health (WMH), QCS, and the Office of Prisoner Health and Wellbeing. The Ipswich Hospice has been identified as a potential location for palliative end of life patients. The PHS is in the process of developing a pathway to give effect to the revised process.

39. In circumstances where recommendations have already been made for the Queensland Government to comprehensively review this issue, and where there is ongoing work on this issue including consultation with medical staff from WMH, it was not necessary to further consider this issue in relation to Mr Adams’ death.

40. However, I accept that at the time of Mr Adams’ death the process to facilitate the discharge of palliative care inmates to nursing homes or similar facilities remained complex and involving multiple stakeholders. The lack of a clear pathway contributed to delays in his release to parole.

41. I close the inquest and extend my condolences to Mr Adams’ family.

Terry Ryan State Coroner

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