Coroner's Finding: WALSH Patrick Lawrence

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 Patrick Lawrence Walsh.

The said Court finds that Patrick Lawrence Walsh aged 86 years, late of 1 Peter Brown Drive, Northfield, South Australia died at the Royal Adelaide Hospital, Port Road, Adelaide, South Australia on the 15th day of July 2018 as a result of the combined effects of acute myeloid leukaemia, acute renal failure and staphylococcal pneumonia. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Patrick Lawrence Walsh was born on 19 February 1932. He died at the Royal Adelaide Hospital (RAH) on 15 July 2018 aged 86 years. Mr Walsh was a serving prisoner in lawful custody at the time of his death.

1.2. A pathology review based on Mr Walsh’s medical records and casenotes was conducted by Dr Iain McIntyre from Forensic Science South Australia on 18 July 2018.1 Dr McIntyre found that Mr Walsh had died from the combined effects of acute myeloid leukaemia, acute renal failure and staphylococcal pneumonia. I accept his finding and declare it as Mr Walsh’s cause of death.

1.3. Mr Walsh was sentenced to an immediate custodial sentence on 7 April 2016 in relation to sexual offences. At the time of his death Mr Walsh was detained in the custody of 1 Exhibit C2a

the Department for Correctional Services at the RAH and, as such, his death was subject to a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003.

1.4. Mr Walsh was arrested on 3 March 2015 in relation to sexual offences. The matters had been reported to police in February 2014. In December 2015 the charges were resolved by way of guilty pleas. On 7 April 2016 Mr Walsh was sentenced in the District Court of South Australia to imprisonment with a head sentence of 5 years and 11 months and a non-parole period of 4 years.2 The sentence of imprisonment commenced on that day. On 18 September 2017 Mr Walsh’s sentence was reduced on appeal to a head sentence of 3 years and 9 months, with a non-parole period of 2 years imprisonment. The sentence of imprisonment was still being served at the time of Mr Walsh’s death.

2. Background and medical history 2.1. Mr Walsh’s personal history has been provided by one of his daughters.3 Mr Walsh was born in Mount Isa. He attended various schools as a boarder. He married his first wife on 19 February 1953 and they lived in Canberra. Mr Walsh had two daughters with his first wife before the marriage ended in 1956. Mr Walsh married a second time to a woman who already had two daughters. Mr Walsh had a further two children with other partners.

2.2. Mr Walsh worked as a salesman and mortgage broker. He later became a lay preacher.

Through that work he assisted African refugees settle into Australia.

2.3. Mr Walsh had a significant health history.4 The pathology review noted a history of ischaemic heart disease with myocardial infarction in 1992, chronic congestive cardiac failure with ejection fraction 40%, biventricular pacemaker, orthostatic hypotension, myelodysplastic syndrome, gout, osteoarthritis, right hip replacement in 2005, asthma, pneumonia, left pleural effusion and Type 2 diabetes.

3. Mr Walsh’s period in custody 3.1. Following sentencing on 7 April 2016 Mr Walsh was held at the Yatala Labour and Port Augusta Prisons.

3.2. On 28 November 2016 Mr Walsh was seen at the RAH when he had mild anaemia. It was thought Mr Walsh might have myelodysplastic syndrome, a pre-leukemic 2 Exhibit C12 3 Exhibit C4 4 Exhibit C7

condition. It was recommended that Mr Walsh have a bone marrow biopsy. Hospital notes indicated ‘patient prefers not to at this stage and will consider’. Mr Walsh was booked for an appointment two months later but this did not occur. Mr Walsh was incarcerated at the Port Augusta Prison at the time.

3.3. On 31 May 2017 Mr Walsh was again seen by medical staff. His blood count had not had a major deterioration in the previous six months.5 Hospital notes stated ‘refer back if there is worsening cytopenia. Not keen for bone marrow testing.’.

3.4. On 12 June 2018 the Parole Board resolved to release Mr Walsh subject to suitable accommodation being found upon release.6

4. Mr Walsh’s final hospital admission 4.1. On 10 July 2018 Mr Walsh was brought to the RAH from Yatala Labour Prison being lethargic and short of breath. He was having difficulty swallowing, experiencing abdominal pain, and had scrotal and rectal bleeding. Blood analysis suggested acute renal failure and that his myelodysplasia had morphed into acute myeloid leukemia. He had staphylococcal pneumonia. A CT scan of Mr Walsh’s chest revealed bilateral small pleural effusions with compressive atelectasis and consolidation of the lower left lobe and emphysema. He was given antibiotics. His condition was so poor he was given palliative care.

4.2. Dr David Ross saw Mr Walsh on 11 July 2018. He stated Mr Walsh looked like a man who was dying.7 He told Mr Walsh about the poor prognosis. Chemotherapy could not be administered with any impact due to Mr Walsh’s organ failure.

4.3. On 15 July 2018 Mr Walsh continued to deteriorate. He did not eat breakfast nor had he eaten the previous evening. He had three visitors including one of his daughters, however he was asleep and unresponsive during the visits.8 His breathing became laboured and he passed away at approximately 2:30pm. His daughter was with him when he died. Dr Patricia Kazan declared Mr Walsh deceased at 3:05pm.9

5. Coronial investigation 5.1. As Mr Walsh’s death was considered a death in custody, a police investigation was conducted. SAPOL officers attended the RAH at about 4:38pm on 15 July 2018 in 5 Exhibit C6 6 Exhibit C12 7 Exhibit C5 8 Exhibit C3 9 Exhibit C12

relation to the death of Mr Walsh.10 The officers observed the body of Mr Walsh and made other observations in accordance with standard procedure.

5.2. Detective Brevet Sergeant Sherri-Anne Modra investigated the death in custody of Mr Walsh and prepared a comprehensive report for the State Coroner.11 Nothing of concern was noted during the investigation in relation to either Mr Walsh’s care or treatment during his detention.

5.3. Mr Walsh’s daughter noted that her father did not like travelling to hospital from prison due to the lack of toilet stops. She suspected he downplayed his condition due to that concern. She did not know why he did not have treatment for his leukemia.12 She was told by Mr Walsh’s pastor that he did not think Mr Walsh received the best of care.

5.4. Upon review of the evidence at this inquest, it is apparent that Mr Walsh was provided with the best possible care in the circumstances. It is noted that Mr Walsh decided to limit the investigations into his health issues and this is evidenced by him not consenting to a biopsy.

6. Conclusions 6.1. I find that the care and treatment provided to Mr Walsh at the Royal Adelaide Hospital was appropriate. His death was expected due to the multiple serious conditions from which he suffered.

7. Recommendation 7.1. I make no recommendations in relation to the death of Mr Walsh.

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 51/2020 (1313/2018) 10 Exhibits C8, C9 and C10 11 Exhibit C12 12 Supra n4 at paragraph 8