Coroner's Finding: KEIRL Dennis Frank

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 25th day of June and the 12th day of October 2020, by the Coroner’s Court of the said State, constituted of Simon James Smart, Deputy State Coroner, into the death of Dennis Frank Keirl.

The said Court finds that Dennis Frank Keirl aged 63 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at Northfield, South Australia on the 14th day of January 2019 as a result of metastatic carcinoma of the lung.

The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Dennis Frank Keirl was born on 16 February 1955 and died on 14 January 2019 at the Yatala Labour Prison in Northfield. He was 63 years old.

1.2. A post mortem examination of Mr Keirl’s remains was undertaken by Dr Stephen Wills, forensic pathologist, at Forensic Science South Australia. In his report of that examination Dr Wills provided the cause of death as metastatic carcinoma of the lung, and I so find1.

1.3. Dr Wills noted a tumour present at the pulmonary hilum, maximal upon the left, with further tumour deposits present within the right interlobar fissure and within the left lower lobe. There was possible sub pleural lymphatic involvement by tumour.

Metastatic tumour was seen in the left lobe of the liver and the left adrenal gland. There was a focus of necrosis within the right renal medulla2 of uncertain origin.

1 Exhibit C2a 2 Part of the brain stem

1.4. Histological examination performed by Dr Sophia Otto, consultant anatomical pathologist, identified a high-grade carcinoma of the lung with features of small cell neuroendocrine carcinoma and elements consistent with poorly differentiated adenocarcinoma. The lungs showed background emphysema, possible interstitial lung disease and focal diffuse alveolar damage.

2. Reason for inquest 2.1. Mr Keirl’s death was the subject of a mandatory inquest pursuant to Section 21(1)(a) of the Coroners Act 2003 as Mr Keirl was serving a prison sentence at the time of his death.

2.2. There are no concerns in relation to the lawfulness of that custody.

3. Background 3.1. Dennis Keirl had two brothers, Jeffrey and Stephen Keirl, and a sister, Susan Smith.

Dennis Keirl was the second youngest of the siblings. Mr Keirl was born in Adelaide and grew up in the suburb of Hillcrest.

3.2. Jeffrey Keirl3, the youngest sibling, states that Dennis, Stephen and their father were all truck drivers. At one point, they were all driving for the business that is now known as Ready Mix. Jeffrey Keirl states that after his brother’s second divorce in 1997 he became a hermit and he did not see him again for a long time. He left the family home in Oakden and put a caravan on his work site. He lived there for the following ten years. It is understood he worked almost every day, including weekends, and spent his private time smoking and drinking port.

4. Medical history 4.1. In 1997 Dennis Keirl developed severe dermatitis which was thought to have been caused by his exposure to chemicals. This skin condition impacted his ability to work.

He was laid off in 2010 at the age of 55 years and moved in with Jeffrey Keirl where he remained for four years. He then moved into a Housing Trust unit in Elizabeth Downs.

3 Exhibit C3

4.2. In 2011 Mr Keirl was treated for anaemia. In 2014 he was admitted to the Lyell McEwin Hospital after a fall. A CT scan revealed some brain volume loss that was suspected to be related to chronic alcoholism. Mr Keirl suffered thromboembolic disease with a deep vein thrombosis and a pulmonary embolism in 2015.

4.3. Mr Keirl had a history of ataxia4, chronic obstructive pulmonary disorder (COPD), alcohol abuse and he was a smoker. Hospital notes from an admission at the Royal Adelaide Hospital on 31 October 2018 note that he was an ex-smoker who had smoked 25 to 30 cigarettes per day for many years.

5. Mr Keirl’s incarceration and the involvement of SAPHS 5.1. Mr Keirl was imprisoned at the age of 63 years. His Honour Judge Soulio had received advice from Mr Keirl’s general practitioner that at the time of sentence Mr Keirl required ongoing warfarin following a stroke, that he suffered from COPD, hypertension and high cholesterol. Hospital records confirmed a diagnoses of severe dermatitis and severe macrocytic anaemia due to alcohol abuse. After Mr Keirl’s fall in 2014 it was suggested that he was suffering from ongoing alcohol-related brain damage.

5.2. Dr Pronk is the Medical Director for the South Australian Prisoner Health Service (SAPHS). He stated that Mr Keirl was admitted to the Adelaide Remand Centre on 3 September 2018 and underwent a nursing assessment. It was noted that Mr Keirl had a previous diagnosis of pulmonary embolism and that he was prescribed warfarin for anticoagulation, simvastatin to manage cholesterol and Olmesartan for blood pressure.

Mr Keirl was also using Spiriva and Ventolin for his COPD.

5.3. Dr Pronk also stated that a medical consent was signed by Mr Keirl and SAPHS were able to obtain a medical history from Mr Keirl’s general practitioner. This confirmed the COPD and a history of pneumonia, confirmed his medications, his history of cigarette use and anaemia.

5.4. Throughout his imprisonment Mr Keirl received medical assistance including blood testing to monitor his warfarin dose. Mr Keirl’s brother raised a concern within his 4 A degenerative disease that causes impaired balance

affidavit in relation to whether his brother was receiving appropriate care whilst in prison; including appropriate medication.

5.5. With respect to his concerns about appropriate medication, I note that SAPHS were provided with a letter from Mr Keirl’s general practitioner. The same medical history was raised at the nursing assessment on admission. I also note that SAPHS had access to Mr Keirl’s relevant medical notes and discharge summaries from his previous hospital admissions. There is no evidence to suggest that SAPHS were not aware of Mr Keirl’s medical conditions and provided the appropriate treatment.

5.6. There was a further matter raised by Mr Keirl’s brother in that he queried whether Mr Keirl should have been ‘spared a prison sentence to serve his sentence at home’.

This concern is not a coronial issue, but was a matter for the sentencing judge and the appeal process.

6. The events and clinical circumstances leading to Mr Keirl’s death 6.1. On 19 September 2018 Mr Keirl was transferred to the Mount Gambier Prison. On 5 October 2018 Mr Keirl reported significant swelling in his left leg after a bus trip from Adelaide. He was sent to Mount Gambier Hospital for an ultrasound with a suspected blood clot. A large deep vein thrombosis (DVT) was located in the lower left leg. Mr Keirl underwent a chest CT scan on 8 October 2018 that revealed irregularities in the chest suggestive of lung cancer with potential metastatic disease throughout the chest and right lung. There was no knowledge of this cancer prior to Mr Keirl’s imprisonment and it was only noted as a result of the scan following the

DVT.

6.2. Due to the potential of lung cancer Mr Keirl was transferred to the Royal Adelaide Hospital where he spent approximately one month. A biopsy of a lung lesion confirmed the diagnosis of small cell lung cancer. Palliative chemotherapy was commenced.

Mr Keirl was discharged to the Yatala Labour Prison Health Centre on 6 November

2018. His anticoagulant was changed because of the DVT whilst on warfarin and further chemotherapy was planned.

6.3. On 10 November 2018 Mr Keirl had a fever but declined hospital transfer and medical treatment. The fever later resolved itself. Dr Pronk stated that Mr Keirl was reviewed

multiple times a day by nursing staff and was seen at least weekly by the medical officer.

6.4. On 24 November 2018 Mr Keirl was transferred to the Royal Adelaide Hospital due to low oxygen levels, on 14 December 2018 for palliative chemotherapy, and on 31 December 2018 due to his haemoglobin levels. On 4 January 2019 Mr Keirl attended an oncology follow-up and his blood was monitored. Mr Keirl’s condition progressively deteriorated.

6.5. Associate Nursing Unit Manager, Barbara Doyle5, was the last person to see Mr Keirl alive at about 5am on 14 January 2019 when she conducted a check on him. He looked to be asleep with laboured breath and wearing a nasal cannula. Ms Doyle stated that she was concerned for his welfare as he had been very unwell for some time.

6.6. Ms Doyle conducted another check at about 5:40am. The nasal cannula was lying on the ground and she could not see his chest rising or falling. The door was opened and Mr Keirl was declared life extinct at 5:50am.

7. Conclusion 7.1. Consistent with the conclusions of the SAPOL investigating officer, Detective Brevet Sergeant James Clegg6, Mr Keirl was in lawful custody at the time of his death. I find that Mr Keirl was receiving appropriate medical treatment during his period of custody.

7.2. I have no recommendations to make in this matter.

Key Words: Death in Custody; Prison; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 12th day of October, 2020.

Deputy State Coroner Inquest Number 67/2020 (0102/2019) 5 Exhibit C1a 6 Exhibit C8