Coroner's Finding: SCHACHE Leon John

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 18th day of December 2020, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Leon John Schache.

The said Court finds that Leon John Schache aged 47 years, late of 7 Luxmore Street, Port Vincent, South Australia died at the Adelaide Remand Centre, 208 Currie Street, Adelaide, South Australia on the 7th day of November 2017 as a result of acute subarachnoid haemorrhage with contributing ruptured saccular aneurysm of the basilar artery. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Leon John Schache was born on 20 December 1969. He died at the Adelaide Remand Centre1 on 7 November 2017 aged 47 years. Mr Schache was a remand prisoner in lawful custody at the time of his death.

1.2. An autopsy was conducted by Dr Stephen Wills, a Forensic Pathologist from Forensic Science South Australia, on 8 November 2017. A report was furnished to the State Coroner on 15 August 2018.2 Dr Wills determined that Mr Schache died due to a ruptured saccular aneurysm of the basilar artery causing an acute subarachnoid haemorrhage with intraventricular extension. This was confirmed by neuropathologist, Professor Peter Blumbergs.3 There was no indication of blunt force injury. I find the cause of Mr Schache’s death to have been acute subarachnoid haemorrhage with contributing ruptured saccular aneurysm of the basilar artery.

1 ARC 2 Exhibit 2a 3 Exhibit 3a

2. Reason for inquest 2.1. Mr Schache had been arrested on 1 November 2017 for breaching an Intervention Order. At the time of his death Mr Schache was in the custody of the Department for Correctional Services at the ARC. Therefore, his was a death in custody requiring a mandatory inquest pursuant to Section 21(1)(a) of the Coroners Act 2003.

3. Background and medical history 3.1. Mr Schache’s personal background has been described by his brother Bruce Schache in an affidavit received at this inquest.4 Mr Schache was the youngest of four children of the late Victor Schache and his wife Brigetta. He attended school until about Year 11 when he left to commence work. In his mid-twenties Mr Schache met and married his wife Peta. Together they had three sons, Darren, Brett and Sean.

3.2. Over the 20 years prior to his death Mr Schache was rarely out of employment. He worked in the mining industry, gas industry, concreting and, in the last few years, as a truck driver.

3.3. In about 2007 Mr Schache’s marriage began to break down. At the time he was working away in the mines on alternate fortnights. It was during this time that Mr Schache commenced using methamphetamine.

3.4. Mr Schache initially used methamphetamine on a social basis. However his usage increased and in early 2016 Mr Schache moved out of the family home at Stansbury to an address in Port Vincent where he lived alone. Mr Schache became addicted to methamphetamine, using it on a daily basis. The methamphetamine caused fluctuations in Mr Schache’s mood and he struggled with depression.

3.5. His former wife had an Intervention Order put in place on 1 March 2017. The Order meant Mr Schache could not approach within 100 metres of her. This Order was allegedly breached on a few occasions and Mr Schache was arrested. After the last alleged occasion Mr Schache handed himself in to police. His bail was revoked and he was incarcerated at the ARC.

3.6. Mr Schache did not have a significant health history. There was no family history of aneurysm or other significant health issues.5 4 Exhibit C1a 5 Ibid, at page 5

4. Mr Schache is placed in custody 4.1. As previously indicated, Mr Schache presented himself at the Wakefield Street Police Station on 1 November 2017. He was placed under arrest by Constable Ante Gracin in relation to a breach of the Intervention Order. Mr Schache was transported to the City Watch House where he was placed in a holding cell. He was charged with a breach of the Intervention Order and two breaches of bail.6 Mr Schache did not apply for bail and remained in custody. He appeared in good health. Mr Schache told police he did not take drugs.7

4.2. Mr Schache was transferred to the ARC on 2 November 2017. It was the first time he had been placed in gaol. At about 7pm Mr Schache underwent the standard health admission procedure with a registered nurse. No significant health issues were noted.8 Mr Schache’s only pain issue noted was lower back pain. He denied any drug issues.9

4.3. Mr Schache met Jesse Borman when admitted and they were placed in a cell together in the induction wing. Mr Schache told Mr Borman that his head was spinning due to the remand process and that he could not understand why he had not been bailed.

Mr Schache was concerned his family did not know where he was.10

4.4. Further screening was undertaken by general practitioner, Dr Lien Sea Tee at 2:10pm on 3 November 2017. Mr Schache admitted to being an ice user on a social basis. He did not raise any concerns other than being worried about his mother.11

4.5. Medical progress notes indicated that on 4 November 2017 Mr Schache raised that he was having difficulty sleeping at night as his normal pattern, being a truck driver, was to sleep during the day and work at night.12

4.6. On 6 November 2017 Mr Schache’s phone account was activated and he could speak to his sons. He was happy about that.13 At 9:27am he rang one of his sons. In that call, he complained ‘it’s doing my fucking head in…Everything’s just echoing, and I can’t 6 Exhibit C14 7 Exhibit C15 8 Exhibit C9 9 Exhibit C9a 10 Exhibit C5 11 Exhibit C10 12 Exhibit C10a 13 Exhibit C5

hear fucking jack shit and it’s not from the fucking shit mate…I’m not fucking sleeping’.14 In a further call at 2:43pm to the same son, Mr Schache repeated ‘I’m having a fucking hard time fucking sleeping’. His son then told Mr Schache to tell ‘them’ he was struggling.

4.7. On the evening of 6 November 2017, according to Mr Borman, Mr Schache told ARC staff he had a headache and his head was spinning.15 The induction unit was locked down at its normal time of 4:30pm that day. At about 7pm Mr Schache was given 1gm of paracetamol and 400mg of Brufen by Registered Nurse Jenny Phan. Nurse Phan cannot recall the reason for which this medication was requested.16

4.8. On 4, 5 and 6 November 2017 Mr Schache did not raise any other physical or mental issues with Corrections staff.17 However, it appears that on 6 November 2017 Mr Schache completed a ‘Prisoner Request Form’ in which he sought to see a doctor in relation to sleeping and health issues and ‘tinniea’ (sic).18 It is unclear whether the form had been handed to Prison Health or Corrections staff at the time of Mr Schache’s death although CCTV seems to suggest Mr Schache gave a form to Nurse Phan on the night of his death.19 At some point after 9:30pm on 6 November 2017 Mr Schache’s cellmate noticed him change the television channel, but nothing was said.

5. The events surrounding Mr Schache’s death 5.1. At about 8:15am on 7 November 2017 Mr Schache did not rise when prison staff knocked on his cell. His cellmate noticed he was unresponsive and called for help.

Prison and SAAS staff attempted resuscitation but were unsuccessful.20 A defibrillator was used.21 The first device was flat so a second device was sought causing a delay of approximately one minute.22 14 Exhibit C19a 15 Supra n10, at paragraph 10 16 Exhibit C11 17 Exhibit C6 18 Exhibit C13a 19 Final Report of Detective Brevet Sergeant Britta Rivett 22 May 2018 at page 14 20 Supra n18 at page 5 21 Exhibit C8 22 Exhibit C7

6. Coronial investigation 6.1. As Mr Schache’s death was a death in custody, a SAPOL investigation was conducted on behalf of the State Coroner. SAPOL officers attended the ARC at about 10:05am on 7 November 2017 in relation to the death of Mr Schache. Officers observed the body of Mr Schache and made other observations in accordance with standard death in custody procedures.23

6.2. Detective Brevet Sergeant Britta Rivett investigated the death in custody of Mr Schache and prepared a comprehensive report for the Court.24 Detective Rivett found no issues of concern during the investigation into his death.

7. Conclusions 7.1. I find that Mr Schache’s care and treatment at the ARC was appropriate. His death was unfortunate and unexpected. It was the result of an aneurysm. I further find that Mr Schache was in lawful custody as the time of his death.

8. Recommendations 8.1. I make no recommendations as to the death of Mr Schache.

Key Words: Death in Custody; Natural Causes; Prison In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 18th day of December, 2020.

Deputy State Coroner Inquest Number 41/2020 (2278/2017) 23 Exhibit C16 24 Exhibit C19