Coroner's Finding: KEIPERT Mathew James

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 18th day of June and the 16th day of July 2020, by the Coroner’s Court of the said State, constituted of Paul Marvin Foley, Deputy State Coroner, into the death of Mathew James Keipert.

The said Court finds that Mathew James Keipert aged 44 years, late of 2/21 Bells Road, Glengowrie, South Australia died at Glengowrie, South Australia on the 21st day of November 2018 as a result of ischaemic heart disease due to coronary atherosclerosis. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Mathew James Keipert was born on 16 November 1974 and died on or about 21 November 2018 at his unit at 2/21 Bells Road, Glengowrie. He was 44 years old.

1.2. A post mortem examination was performed by Dr John Gilbert of Forensic Science South Australia on 26 November 20181. In his report Dr Gilbert provided the cause of Mr Keipert’s death as ischaemic heart disease due to coronary atherosclerosis, and I so find.

1.3. Findings at autopsy included pulmonary oedema and congestion, mild left ventricular dilatation of the heart with patchy myocardial pallor, moderate to focally severe coronary artery atherosclerosis and severe steatosis of the liver. The histology of the lungs indicated a smoking habit.

1 Exhibit C2a

1.4. No alcohol was detected in the post mortem blood. Therapeutic levels of buprenorphine and its metabolite, norbuprenorphine, as well as naloxone and pregabalin were detected.

2. Reason for inquest 2.1. Mr Keipert’s death was the subject of a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003 as Mr Keipert had been in custody on home detention bail at the time of his death. There are no concerns in relation to the lawfulness of custody.

3. Background 3.1. Mr Keipert was the son of Terry and Charmaine Keipert and he had an older sister, Natasha Keipert. According to Charmaine Keipert her son had a normal childhood, however he was introduced to smoking marijuana by his uncles whilst in primary school. At about this time Mr Keipert attempted suicide by hanging. He was found by his sister who took him down and he suffered no significant injuries as a result.2

3.2. Mr Keipert’s home detention bail enquiry report states that he reported having a history of several suicide attempts whilst in custody ten years ago at the Adelaide Remand Centre and Yatala Labour Prison. The report refers to a cut wrist, an attempt to hang himself and an attempt to cut his own throat. There is no recent history of attempts at self-harm or suicide and nothing to suggest that his death was the result of suicide.

3.3. Mr Keipert was in and out of prison for much of his life. His parents were supportive of him, assisting with taking Mr Keipert to appointments and on outings. Despite Mr Keipert’s criminal behaviour they kept a good relationship. Charmaine Keipert states that her son was not a big drinker but used drugs including heroin, speed and ‘everything he could find’. She states that he ‘used prescription drugs a lot’.

3.4. Mr Keipert was released from Mount Gambier Prison on 18 June 2018 on bail with home detention and electronic monitoring. He was originally released to live with his parents, however the bail agreement was amended on 23 August 2018 so that he could live in his own unit at Glengowrie3. At the time of his death Mr Keipert was subject to an 18 month good behaviour bond for serious criminal trespass offences committed in July 2016.

2 Exhibit C7 3 Exhibit C11c

3.5. On 5 April 2018 Mr Keipert was arrested for interfering with a motor vehicle in Glenelg, theft and possession of a taser. Bail was refused. Between 6 and 9 April 2018 Mr Keipert was remanded at the Adelaide Remand Centre before being transferred to Yatala Labour Prison. On 11 April 2018 he was transferred to Mount Gambier Prison prior to his release on home detention on 18 June 2018.

4. Medical history 4.1. Mr Keipert’s medical history included stress, hypertension, asthma, neuropathic back pain, substance abuse, hepatitis C and smoking. His Noarlunga Hospital notes state he reported smoking about 40 cigarettes per day for the past 30 years. Dr Vu believes that Mr Keipert quit smoking in 2017, however Mr Keipert did not report that he quit when referring to his cigarette use on his admission to Noarlunga Hospital on 29 November 2017.

4.2. Mr Keipert was taken to Mount Gambier Hospital on 15 August 2009 after collapsing with a queried seizure whilst an inmate at Mount Gambier Prison.4 He was noted as falling and hitting his head and that it was the second time in one month. Mr Keipert was discharged for ongoing treatment by the prison general practitioner, Dr Kavanagh.

A CT scan and blood tests were recommended, however Dr Kavanagh noted that Mr Keipert was not taking his medications and was not keen for further investigation as he would be released in four weeks. He told the doctor that he would follow-up out of prison if he had further attacks. I note that Mr Keipert underwent an exercise stress test on 4 August 2009 with inconclusive results as the test was stopped due to shortness of breath and the effort was recorded as submaximal.

4.3. In May 2016 Mr Keipert was referred by a general practitioner, Dr Chuong Vu, for a CT scan after suffering a seizure5. He comments that no cause was identified but that it might have been from possible drug or alcohol toxicity or drug withdrawal.

4.4. Dr Vu states that Mr Keipert had been on the Suboxone program for a time due to a history of heroin abuse. On 21 June 2018 he told Dr Vu that he had taken himself off the program when he went to prison in 2017. It is however clear from the toxicology analysis and hospital notes that Mr Keipert had recommenced the program. Noarlunga Hospital notes include an outpatient visit on 2 October 2018 in which it is noted that 4 Mount Gambier Hospital notes 15/8/09; Prison Health Services notes 19/8/09 5 Exhibit C5

Mr Keipert recently recommenced a DASSA Suboxone program for opioid dependence. This is consistent with notes on the DASSA case file that indicate that Mr Keipert re-commenced Suboxone treatment after self-referring to DASSA following his release on home detention. He received Suboxone throughout August and September with the final dose on 16 November 2018. Mr Keipert was receiving Hepatitis C treatment under Dr Vu’s guidance.

4.5. On 27 August 2018 Mr Keipert attended Flinders Medical Centre with regards to leg swelling.6 He was referred to the Outpatient Clinic at Noarlunga Hospital (MACS)7 on 29 August 2018 for further investigation. He described having intermittent bilateral lower limb pain over the last year and a half and felt the pain was worse since he started experiencing swelling on about 27 August 2018. He complained of becoming short of breath on physical exertion over the last four to five years. Mr Keipert was prescribed Furosemide but then self-ceased the medication after two weeks once his oedema went down. Mr Keipert had a chest X-ray and abdominal ultrasound on 30 August 2018 which showed nothing abnormal.

4.6. Dr Vu’s final consultation with Mr Keipert was on 21 September 2018. Dr Vu states that due to a computer virus he no longer has access to his patient notes, but according to his handwritten notes Mr Keipert attended the Noarlunga Hospital in relation to the swelling and was waiting on test results. This is consistent with the hospital notes.

4.7. On 25 September 2018 Mr Keipert attended Flinders Medical Centre for an echocardiogram that showed nothing of significance. However it was noted that he did not attend an ultrasound on his legs or follow-up blood tests that had been requested by SA Health.

4.8. Mr Keipert attended Noarlunga Hospital on 2 October 2018 for a follow-up on test results. He was reviewed by Dr Hofmann, consultant physician, who noted the acute episode of bilateral lower limb oedema had resolved, but was from an unknown cause.

No further investigation was required at this stage.

4.9. On 11 October 2018 Mr Keipert attended Marion Domain Medical Centre and saw Dr John Cruickshank reporting poor sleep and low mood. A Mental Health Care Plan 6 Exhibit C6 7 Medical Ambulatory Care Service

was created and the notes state that there was a ‘long chat re strategies and role of meds’, and ‘declines antidepressants’.

4.10. I note that this is inconsistent with Dr Vu’s statement. Dr Vu states that Mr Keipert told him he had been diagnosed with anxiety and depression and Dr Vu agreed with the diagnosis. He states that Mr Keipert seemed stable and saw him every three to four weeks for counselling. Dr Vu states that he prescribed Serepax, 30mg twice a day and that Mr Keipert ‘had been taking that for about twelve months or so and was doing well’.

4.11. On 8 November 2018 Mr Keipert attended the general practitioner for ‘neuropathic back pain’ for which he was prescribed Lyrica.

5. The circumstances of Mr Keipert’s death 5.1. Mr Keipert was located by his father, Terry Keipert, at about 4:20pm on 22 November 2018 after he received a telephone call from the Department for Correctional Services advising that his son had missed a court appearance. Terry Keipert attended Mr Keipert’s house at Glengowrie and found him lying on the lounge room floor with his upper body on top of the lounge. He described him as being ‘slumped over the couch in a kneeling position’.8

5.2. Mr Scott Jones and Mr Ryan Kermode, Intensive Compliance Officers with the Department for Correctional Services, were present at Mr Keipert’s house when he was located. They arrived at 4:17pm to perform a check on welfare, however the house was locked and they could not gain access.

5.3. Mr Keipert’s life was certified extinct at 4.35pm on 22 November 2018.

6. Conclusions 6.1. Detective Brevet Sergeant Belinda Laird from the Southern District Volume Crime Team of SAPOL investigated Mr Keipert’s death in custody. Detective Laird’s report of that investigation was tendered to the Court9. Detective Laird determined that the circumstances surrounding Mr Keipert’s death were not suspicious and did not indicate 8 Exhibit C1a 9 Exhibit C11

the involvement of a third party. It was also deemed that Mr Keipert was in lawful detention at the time of his death.

6.2. I agree with the conclusions of the investigating officer and have no recommendations to make in this matter.

Key Words: Death in Custody; Natural Causes; Home Detention In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 16th day of July, 2020.

Deputy State Coroner Inquest Number 73/2020 (2276/2018)