Inquest into the death of Kamalavati Sundar

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Kamalavati Sundar TITLE OF COURT: Coroners Court

JURISDICTION: BRISBANE FILE NO(s): 2023/5127 DELIVERED ON: 23 October 2025

DELIVERED AT: BRISBANE HEARING DATE(s): 23 October 2025 FINDINGS OF: T Ryan, State Coroner CATCHWORDS: Coroners: inquest, natural causes, death in custody.

REPRESENTATION: Counsel Assisting: Ms K Dodds Queensland Corrective Ms E Limerick Services

Contents

Introduction

1. Kamalavati Sundar (“Kamalavati”) was 86 years of age when she passed away in palliative care at the Townsville University Hospital (TUH) in the early hours of 30 October 2023. Kamalavati had been transported from the Townsville Women’s Correctional Centre (TWCC) to the TUH on 12 June 2023.

2. Kamalavati was serving a term of life imprisonment for murder. Kamalavati died of natural causes as a result of metastatic ovarian cancer. Kamalavati’s conditions of dementia, bronchoalveolar carcinoma, ischaemic heart disease, hypertension, and dyslipidaemia were also considered to have contributed to her death.

Coronial jurisdiction

3. At the time of her passing, Kamalavati was a prisoner in custody as defined in Schedule 4 of the Corrective Services Act 2006 (Qld). Kamalavati’s passing is a reportable death under section 8(3)(g) of the Coroners Act 2003 (Qld) (the Act) as it is a ‘death in custody’.

4. In cases such as this, an inquest is mandatory pursuant to s27(1)(a)(i) of the Act. An inquest is intended to provide the public and, most importantly, the family of the deceased, with transparency regarding the circumstances of the death, and to answer any questions which may have been raised following the death.

5. The role of the coroner is to independently investigate reportable deaths to establish, if possible, the identity of the deceased, the medical cause of death, and the circumstances surrounding the death – how the person died. Those circumstances are limited to events which are sufficiently connected to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

The investigation

6. The investigation into Kamalavati’s passing was led by Detective Senior Constable Sym Khaile of the Queensland Police Service Corrective Services Investigation Unit (CSIU).

7. On 27 September 2023, the CSIU were provided advice about Ms Kamalavati’s declining health. On 13 October 2023, investigators from the CSIU were contacted by Detective Senior Sergeant Graham Greentree, the Northern Coronial Coordinator, and advised that Kamalavati was likely to pass away in the very near future. The health status of Kamalavati was then monitored by the CSIU from this date.

8. After being notified of the passing on 30 October 2023, Constable Ben Matthews from the Stuart Police Station attended the Palliative Care Centre.

9. Constable Matthews met Custodial Correctional Officers (CCO) Tayla Jenkins and Patrick Turner who had guarding Kamalavati at the time of her passing.

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10. Police observed Kamalavati laying on the bed, with a hospital sheet covering up to her waist. No injuries or marks inconsistent with medical treatment were identified. Kamalavati was then conveyed to the Townsville University Hospital Mortuary.

11. On 31 October 2023, I made a direction for a targeted police investigation to occur. A Coronial Investigation Report was prepared and provided to the Coroners Court in August 2024.

12. Detective Senior Constable Khaile conducted a thorough investigation in response to the targeted direction. Detective Senior Constable Khaile concluded that there were no suspicious circumstances surrounding Kamalavati’s passing, and she was provided with appropriate care and treatment while incarcerated.

The inquest

13. The inquest was held at Brisbane on 23 October 2025. All statements, medical records, photographs and materials gathered during the investigation were admitted into evidence. No witnesses were called to give oral evidence.

Counsel Assisting proceeded to submissions on the investigation material in lieu of any oral evidence.

14. The issues considered at the inquest were the issues required by section 45(2) of the Act, and whether Kamalavati had access to, and received appropriate medical care, while she was in custody.

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

The evidence Social and Medical History

16. Kamalavati was born on 1 August 1937 in Fiji.

17. She first married at the age of 17 to an older man who had five children of his own between the ages of six months and 12 years. Kamalavati then gave birth to three children and had a total of eight children in her care.

18. In 1997, Kamalavati migrated to Australia and subsequently married again in around 2002 or 2003.

19. On 19 December 2005, Kamalavati attended the Logan Police Station and declared that she had killed her husband. She was arrested and remanded in custody.

20. On 4 December 2008, after a trial by jury, Kamalavati was convicted and sentenced to life imprisonment. A period of sixty-seven days of pre-sentence custody was declared.

21. While in custody, Kamalavati was a model employee, regularly attending work in the tailor shop and/or linen service. She also participated in education classes and enjoyed cooking meals in her unit.

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22. Over time, Kamalavati’s work commitments were appropriately adjusted to reflect her functional decline and increasing health needs. Carers were also appointed to assist Kamalavati in completing daily tasks and living routines (while at work and within her accommodation unit). She was also the subject of a medical intensive management plan.

23. In late 2022, Kamalavati was issued a wheelie walker to help with her mobility.

24. As Kamalavati’s ability to understand the English language was limited, a Hindi interpreter was appointed for key discussions during her imprisonment.

25. On 3 May 2023, an earlier guardianship order made by the Queensland Civil and Administrative Tribunal was amended to appoint Kamalavati’s granddaughter, and next of kin, Ms Vandana Singh Prasad, as Kamalavati’s guardian for the following matters:

(a) Accommodation

(b) Health care

(c) Legal matters not relating to Kamalavati Sundar’s financial or property matters.

26. Ms Prasad shared a close relationship with Kamalavati. She was in regular contact with her grandmother via telephone, video chats during the COVID19 pandemic, and in-person. Kamalavati also received visits from her daughters, Sulochana Singh and Prabha Kumar. I extend my condolences to Kamalavati’s family and friends.

27. Ms Prasad provided a family statement to the inquest in which she shared the following about her grandmother: For majority of her life, she was known as Kamla Wati.

She was a mother to 8 children, a grandmother to 25 children and a great grandmother to over 41 children, and she was also a great great grandmother.

She was known for her family and friends. Always serving, doing for others and taking care of others.

She was not just a mother and caretaker. She was an extremely skilled tailor, an ethical farmer, an honest businesswoman and a lady of kindness and community spirit.

She was always lending a helping hand, using her many skills where she could, sharing her knowledge and spreading love to all.

To her dying day, she was a woman of high integrity and she was a law abiding citizen. While it is important to know why she was in Queensland Corrective Services, it is also equally important to remember that when she realised the gravity of her actions, she went to the police station herself, truthfully recalled the events and surrendered herself.

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It makes me proud to share that although she went through many traumas, she never let that break her. With her unshakeable resilience, she looked forward to another day with appreciation and gratefulness. She was humble, she was intelligent and she always had a willingness learn. In her 70s she was excited to learn how to read and write, a skill she did not have the opportunity to learn when she was younger.

In her family's view, she was a remarkable woman. She touched many people with her humour, kindness and zest for life. It was a pleasure to have her in our lives and it is a pleasure to now have her in our memories.

28. Kamalavati’s family received regular updates regarding her condition and general wellbeing.

29. No concerns have been raised by Kamalavati‘s family in relation to her treatment by staff from Queensland Corrective Services (QCS) or medical personnel.

30. Kamalavati had a significant medical history including hypertension, non-insulin dependent diabetes mellitus, hypercholesterolaemia, ischaemic heart disease, mild renal impairment, multi-nodular thyroid goitre, glaucoma in the right eye (requiring operative management in 2012), osteoarthritis (both hips), moderate to severe Alzheimer’s dementia (diagnosed in 2020), and incurable bronchoalveolar lung cancer (suggestive of slow-growing adenocarcinoma).

Care in custody

31. In April 2023, Kamalavati was formally diagnosed with metastatic ovarian cancer following presentation to the TUH with acute abdominal pain. A CT abdomen scan was conducted which showed a cystic ovarian neoplasm (cancer) with metastases throughout the omentum (fatty tissue within the abdomen) and ascites (free fluid within the abdomen).

32. Kamalavati was admitted under the gynaecology team for further investigation.

During this admission, an ascitic aspirate (drainage of the abdominal fluid) was obtained which diagnosed a high-grade serous carcinoma. I was informed that this diagnosis carries a very poor prognosis.1 At this time, Kamalavati was also suffering from increasing confusion due to her progressive dementia.

33. Consequently, Ms Prasad and the TUH’s gynaecology team discussed potential healthcare interventions including palliative chemotherapy as Kamalavati’s primary treatment. It was agreed that palliative chemotherapy would not be in her best interests, having regard to her inability to understand the treatment, retain the reason for the treatment, and the risk of the development of side effects from the chemotherapy. Kamalavati was subsequently discharged from the gynaecology team back to the TWCC on 5 May 2023 with a referral for palliative care and treatment goals defined to focus on symptomatic management only.

34. Upon her return to custody, Kamalavati had three inmate carers appointed, and her General Practitioner (GP), Dr Glenda McDonald, continued to liaise with the Palliative Care Outreach Nurse and Ms Prasad.

1 Exhibit F1: Forensic Physician Statement, dated 10 June 2025.

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35. Kamalavati was reviewed daily by nursing staff within the facility, and her GP liaised with her carers weekly. Her GP also consulted directly with Kamalavati as required. During this period, Kamalavati experienced increasing pain relief requirements which were appropriately managed with heightened prescription of opioid analgesia by her GP.

36. From mid-April 2023, Kamalavati was the subject of four medical emergency incidents at the TWCC.

37. At about 11:09am on 21 April 2023, Kamalavati’s carer used the intercom system to report that Kamalavati was not feeling well. Kamalavati was escorted to the medical unit and at 1:00pm, she was transported to the TUH for further assessment. Kamalavati remained at the TUH until 29 April 2023.

38. Shortly after 8:00am on 30 April 2023, residential staff entered Kamalavati’s unit to check on her as she was still in bed. Kamalavati reported soreness in her abdominal area. At about 8:40am, registered nurses from the TWCC attended and assessed Kamalavati. She was placed in a wheelchair and taken to the medical clinic to await the arrival of Queensland Ambulance Service (QAS). At 9:48am, QAS officers attended and transported Kamalavati to the TUH. She was admitted at the TUH until 5 May 2023.

39. At about 9:40pm on 10 June 2023, Kamalavati suffered an unwitnessed fall in the bathroom of her unit at the TWCC.

She had used a wheelchair to mobilise to the toilet without notifying her assigned carers (despite her carers sleeping by her bedside to assist with mobility where required). On attempting to transfer from the wheelchair to the toilet, Kamalavati had a fall.

Correctional staff responded to the incident and upon arrival, found Kamalavati sitting on the bathroom floor and observed a large lump on her head. There was no indication that this matter was the result of a criminal act by another person.

Kamalavati reported pain to her right shoulder, elbow, and body.

Preliminary first aid was applied and the attendance of QAS officers was requested. Staff from QCS also reported that Kamalavati had suffered a recent decline in her behaviour with notable increased confusion and agitation.

At 10:15pm, Kamalavati was transported by ambulance to the TUH for further medical assessment. She was reviewed in the emergency department where she was found to have swelling to the back of her head. A CT head scan was conducted which showed no acute intracranial pathology. Kamalavati was subsequently discharged and returned to the TWCC at about 6:35am on 11 June 2023.

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4. At about 12:42pm on 12 June 2023, the TWCC received email correspondence that a bed had become available for Kamalavati at the Palliative Care Centre within the TUH. It was requested that Kamalavati be transported there as her care needs exceeded the capacity the TWCC was able to provide, particularly with respect to pain management. At about 2:26pm, Kamalavati was transported by ambulance to the centre.

Kamalavati’s family was notified.

Kamalavati was admitted under the palliative care team who commenced regular strong opioid pain relief. A repeat CT abdomen was completed on 14 June 2023 which showed stable disease, relatively unchanged from the scan in April 2023.

Palliative Care Admission: June 2023 – October 2023

37. During her admission to the Palliative Care Centre, Kamalavati became increasingly confused and agitated. On 23 June 2023, a delirium screen, including urine microscopy, bloods, and a chest x-ray were completed which revealed no infective source. Kamalavati was commenced on a low dose antipsychotic (Quetiapine) at night.

38. Following this, Kamalavati had a slow deterioration suffering constipation and developing a wheeze; both of which were treated symptomatically.

39. On 4 August 2023, Kamalavati became febrile and acutely confused again and a urine microscopy at this stage showed a possible urinary tract infection (UTI).2 A course of oral antibiotics (trimethoprim) was administered to which Kamalavati clinically responded.

40. On 20 September 2023, Kamalavati developed a small furuncle (boil) on her left ear which was treated with a short course of antibiotics.

41. On 26 September 2023, Kamalavati developed increasing abdominal pain and was diagnosed clinically with bowel obstruction with an abdominal x-ray demonstrating a distended small bowel loop in the mid-section of her abdomen.

She was treated conservatively with the commencement of syringe drivers containing palliative medications including opioid analgesia (methadone and oxycodone) and an anti-sickness medication (cyclizine).

42. Kamalavati then experienced a steady clinical decline requiring increasing palliative medications to control her pain and agitation. From approximately two weeks prior to her passing, Kamalavati was no longer able to leave her bed.

From 24 October 2023, Kamalavati was no longer able to consume any sustenance and was ‘nil by mouth’.

43. Between 7:00pm on 29 October 2023 and 7:00am 30 October 2023, CCO Jenkins and CCO Turner were rostered to guard Kamalavati at the Palliative Care Centre. CCO Jenkins maintained a running log of all events for the evening including the administration of Kamalavati’s medications.

2 The sample was contaminated with epithelial (skin) cells which made interpretation difficult.

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44. At 1:13am 30 October 2023, Kamalavati was observed to have ceased breathing. CCO Jenkins also noticed a mucus-like fluid coming from Kamalavati’s mouth. The CCO activated the room’s emergency button, and nurses Whittingham and Bell-Shepherd promptly entered. At 1:14am, Kamalavati re-commenced breathing, albeit sporadically. At around 1:17am, one of the attendant nurses was cleaning around Kamalavati’s mouth and reported that Kamalavati had ceased breathing again. It was further noted that Kamalavati’s pulse was very weak (at 1:19am). At 1:22am, Kamalavati ceased breathing altogether.

45. At 1:37am, 30 October 2023, Doctor Isobel Brereton arrived to assess Kamalavati and certified that she had passed at 1:45am.

46. At the time of her death, Kamalavati had an active Acute Resuscitation Plan which specified that upon acute deterioration and/or the occurrence of a critical event, only comfort cares were to be administered.

Exceptional Circumstances Parole

47. On 10 February 2020, Kamalavati was reviewed by the Respiratory and Sleep Unit within the Townsville Hospital and Health Service in relation to her multifocal lung opacities, which were suspected to be bronchoalveolar carcinoma. Kamalavati was informed, with the aid of an interpreter, that any medical management would be palliative as no curative options were available.

This opinion reflected earlier advice received by Kamalavati in 2017 regarding the growth.

48. At the appointment in 2020, Kamalavati communicated that, “…she did not wish for any treatment or procedures as she does not have any symptoms now”, that she was quite happy to have an expectant approach, and that she did not want any interventions that may worsen her quality of life and/or potentially cause her side effects.

49. Following this review, consideration was given by QCS as to whether Kamalavati could apply for an exceptional circumstances parole order on the basis that her health condition would require substantial ongoing care.

However, it was noted that Kamalavati may be deported were she to be granted parole.

50. On 8 February 2023, Ms Prasad was provided with information about the process for applying for an exceptional circumstances parole order on behalf of Kamalavati.

51. There are no records to indicate that any application for exceptional circumstances parole was ever made.

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Forensic Medicine Queensland advice

52. In April 2025, I sought advice from Forensic Medicine Queensland (FMQ) as to the appropriateness of Kamalavati’s health care and medical management in custody. On 10 June 2025, Dr Armitage of FMQ provided the following advice: Ms. Sundar had a life-limiting diagnosis of high-grade serous cancer (HGSC) which was ovarian in origin and had already metastasised at the time of diagnosis. HGCS is one of the most aggressive forms of ovarian cancer and is often diagnosed at an advanced stage following metastasis due to the cancer’s rapid progression.3 Following diagnosis, Ms. Sundar’s management options were limited to palliative interventions only. While palliative chemotherapy can sometimes prolong life, side effects are commonly anticipated. Due to Ms. Sundar’s advanced dementia, management discussions were conducted between the treating gynaecology team and her tribunal appointed EPOA. The risks and benefit of palliative chemotherapy were considered and the decision was appropriately made to limit treatment to symptom control only.

Dr McDonald and TWCC have provided thorough and compassionate care with regular medical reviews and the allocation of personal carers. From the medical notes provided, Ms. Sundar received comprehensive and holistic care throughout her incarceration.4

53. I accept the advice of Dr Armitage.

Autopsy results

54. On 31 October 2023, Dr Rebecca Williams conducted an autopsy consisting of an external examination of the body, and a review of the medical records.

Samples of blood and urine were also collected for toxicological analysis.

55. Dr Williams concluded that the cause of death was (1) metastatic ovarian cancer with (2) dementia, bronchoalveolar carcinoma, ischaemic heart disease, hypertension, and dyslipidaemia listed as other significant conditions.5

56. The results of the toxicological analysis were consistent with Kamalavati’s medical history and administered medications.

3 Biology Insights (29 April 2025): “High-Grade Serous Carcinoma Life Expectancy and Prognosis” – Pathology and Diseases. Accessed via: https://biologyinsights.com/high-grade-serous-carcinoma-lifeexpectancy-and-prognosis/.

4 Exhibit F1: Forensic Physician Statement, dated 10 June 2025.

5 Exhibit A3: Form 30A Coronial certificate, dated 31 October 2023.

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Conclusions

57. I am satisfied that Kamalavati died from natural causes. I find that none of the inmates, correctional or health care staff at the TUH or the TWCC caused or contributed to her death. There were no suspicious circumstances.

58. It is an accepted principle that the health care provided to prisoners should not be of a lesser standard than that provided to other members of the community.

The evidence tendered at the inquest established the adequacy of the health care provided to Kamalavati when measured against this benchmark.

Findings required by s. 45

59. I am required to find, as far as possible, the medical cause of death, who the deceased person was and when, where and how she came to her death. After considering all of the evidence, including the material contained in the exhibits, I am able to make the following findings: Identity of the deceased – Kamalavati Sundar How she died – Ms Sundar commenced a term of life imprisonment in December 2008. In April 2023, she was diagnosed with metastatic ovarian cancer.

Following this diagnosis, Ms Sundar’s management options were limited to palliative interventions only. A decision was subsequently made, in consultation with Ms Sundar’s next of kin, and legal guardian, for Ms Sundar to receive symptomatic management at the Townsville University Hospital.

Due to her failing health, Ms Sundar was transferred to the hospital’s Palliative Care Centre on 12 June 2023. Following this admission, Ms Sundar’s health deteriorated further and she passed away in palliative care. Ms Sundar died of natural causes.

Place of death – Townsville University Hospital.

Date of death – 30 October 2023 Cause of death – (1) Metastatic ovarian cancer Other significant conditions (2) Dementia, bronchoalveolar carcinoma, ischaemic heart disease, hypertension, and dyslipidaemia.

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Comments and recommendations

60. Section 46 of the Act enables a coroner to comment on anything connected with a death that relates to public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in the future.

61. In the circumstances, I accept that there are no comments or recommendations to be made that would assist in preventing similar deaths in the future, or that otherwise relate to public health or safety or the administration of justice.

62. I close the inquest.

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