Coroner's Finding: WRIGHT Martin Norman

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 22nd day of November 2018 and the 12th day of June 2019, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Martin Norman Wright.

The said Court finds that Martin Norman Wright aged 59 years, late of Yatala Labour Prison, Peter Brown Drive, Northfield, South Australia died at Northfield, South Australia on the 26th day of August 2015 as a result of chronic liver disease due to alcoholism and chronic hepatitis C infection with contributing ischaemic heart disease and chronic obstructive pulmonary disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mr Martin Wright who was aged 59 years died on 26 August 2015 at the Yatala Labour Prison (YLP) where he was a prisoner. A pathology review was conducted by Dr Stephen Wills from Forensic Science South Australia1. Dr Will’s report provides the cause of Mr Wright’s death as chronic liver disease due to alcoholism and chronic Hepatitis C infection with contributing Ischaemic Heart Disease and Chronic Obstructive Pulmonary Disease. He stated: ‘As far as I can determine from the information provided, this gentleman's death was not unexpected. There was no indication in the material provided that any other party was involved in his death, and the administration of medication appears to have been controlled by prison nursing staff.

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‘Severe ascites may result in fluid imbalance, possible electrolyte disturbance and potentially respiratory compromise due to restriction of the diaphragm. The deceased’s physiological reserve is also likely to have been significantly compromised by ischaemic heart disease and chronic obstructive pulmonary disease. It appears the combination of his multiple medical problems have resulted in his death at the time.'

1.2. I accept Dr Wills’ report and find that the cause of Mr Wright’s death was chronic liver disease due to alcoholism and chronic Hepatitis C infection with contributing Ischaemic Heart Disease and Chronic Obstructive Pulmonary Disease.

2. Background and reason for inquest 2.1. A statement was tendered to the Court from Mr Wright’s sister, Dianna Jane Bugden2.

In her statement Ms Bugden sets out some of Mr Wright’s personal history. Mr Wright had a number of children from a number of relationships with women.

2.2. It was apparent to Mr Wright's sister that Mr Wright was continually in trouble with the law and had a very serious drinking problem. Mr Wright had a lengthy criminal history dating back to 1971. On 18 August 2011 Mr Wright was sentenced to four years and five months imprisonment for offences of threatening to harm a person, unlawful possession and breaching a bond. The bond which involved two years of supervision was revoked for an offence of producing a controlled substance.

2.3. On 22 January 2015 Mr Wright was released on parole with a number of conditions.

Mr Timothy Buxton, team supervisor at Edwardstown Community Corrections, provided a statement to the Court which sets out Mr Wright's behaviour once released on parole on 22 January 20153.

2.4. Mr Wright breached his parole by failing urine tests, consuming alcohol and for not being of good behaviour. Mr Buxton stated that on 20 March 2015 Mr Wright was arrested for breaching his parole conditions and was returned to custody. He remained in custody from 20 March 2015 until his death on 26 August 2015. The Parole Board had found the breaches of his parole proved on 8 July 2015.

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2.5. Mr Wright's detention and incarceration were lawful. His death was a death in custody.

Therefore, an inquest into the cause and circumstances of his death was mandatory pursuant to the provisions of the Coroners Act 2003.

3. Mr Wright’s medical history 3.1. Due to Mr Wright's extensive criminal history and his numerous comorbidities the Department for Correctional Services had voluminous medical records. He was a previous intravenous drug user, had cirrhosis in the setting of previous alcoholism and chronic hepatitis C infection. Further, he had refractory ascites with multiple hospital presentations for drainage in 2015; hypertension; ischaemic heart disease with two previous myocardial infarctions and stenting in 2010; peripheral vascular disease with femoral angioplasty and stenting in 2005 and 2006; type 2 diabetes; cerebrovascular disease with previous stroke and he was on warfarin.

3.2. Elizabeth Sloggett is employed at SA Prison Health Services as a nurse management facilitator. Ms Sloggett provided a statement in relation to Mr Wright's incarceration4.

Ms Sloggett sets out the history in relation to Mr Wright's care during his remand in custody on 20 March 2015 for breaching parole. Ms Sloggett sets out Mr Wright's several attendances at the Royal Adelaide Hospital (RAH). On 23 August 2015 Mr Wright complained of chest pain and was conveyed to the RAH. He was examined in the Emergency Department. However, tests did not reveal any cardiac episode and so he was returned to prison. This was his last attendance at the RAH.

4. Mr Wright is found deceased 4.1. Rachel Chambers is a registered nurse at YLP. Rosemary Fitzgerald is an enrolled nurse at YLP. Both nurses provided statements which were tendered to the Inquest5.

Both nurses gave an account in relation to finding Mr Wright deceased in the prison infirmary. Mr Wright was found deceased at approximately midnight. No resuscitation was attempted. Nevertheless, ambulance services were called and paramedic Nicholas Kaye declared life extinct6.

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5. Conclusion 5.1. Mr Wright’s death in custody was investigated by Detective Brevet Sergeant Drew Bynoe of SAPOL7. Detective Bynoe found: 'From all evidence gathered in this investigation, Wright’s ultimate death was due to his lifelong acts of self-abuse through alcohol and illicit drugs. This abuse led to chronic and terminal illnesses that were difficult to manage due to his frequency of incarcerations, his lifestyle out of prison and demonstrated behavioural and compliance issues.'

5.2. I accept the conclusions of Detective Brevet Sergeant Bynoe. In my opinion Mr Wright’s care and treatment during his imprisonment was appropriate. He died of natural causes and his death was not unexpected.

5.3. There is no need to make any recommendations in this matter.

Key Words: Death in Custody; Prisoner; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 12th day of June, 2019.

Deputy State Coroner Inquest Number 16/2018 (1518/2015) 7 Exhibit C11