Coroner's Finding: Schuster, Gavin Shawn

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign King at Adelaide in the State of South Australia, on the 6th and 22nd days of December 2023, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Gavin Shawn Schuster.

The said Court finds that Gavin Shawn Schuster aged 45 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at Northfield, South Australia on the 13th day of October 2020 as a result of liver failure due to metastatic hepatocellular carcinoma. The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for Inquest 1.1. Gavin Shawn Schuster was born on 30 September 1975 and died on 13 October 2020 at the age of 45 years in the Yatala Labour Prison1 infirmary.

1.2. His cause of death according to a pathology review conducted by Forensic Science South Australia2 was liver failure due to metastatic hepatocellular carcinoma.3 I accept the opinion of FSSA and make a finding about his cause of death accordingly.

1.3. At the time of his death Mr Schuster was in the custody of the Department for Correctional Services.4 Therefore, this is a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003.

1 YLP 2 FSSA 3 Exhibit C2a

4 DCS

2. Background 2.1. Information about Mr Schuster’s family background has been provided in an affidavit from his sister, Debbie Schuster.5

2.2. Mr Schuster was born at The Queen Elizabeth Hospital6 in Woodville South. His family lived in Snowtown, Peterborough and Whyalla. The family moved to the Elizabeth area when Mr Schuster was around 12 years old.

2.3. When Mr Schuster was aged about 13 years, he and his three siblings were placed into foster care by their mother. Mr Schuster and his siblings resided in various foster homes.

2.4. Sometime after their initial placement into foster care, all four children returned home with their mother. This lasted only a short time however, as Mr Schuster was living at Lochiel Park Boy's Home in Campbelltown when he was approximately 15 years old.

2.5. Mr Schuster attended primary school in Whyalla, and then Terowie from when Mr Schuster was in Year 2. He later attended Elizabeth High School but left at the age of 15 years prior to completing Year 12.

2.6. It is unknown if Mr Schuster undertook any employment at any time in his life.

3. Mr Schuster’s correctional and medical history 3.1. Mr Schuster was first arrested in March 1992 and spent the rest of his life in and out of custody.

3.2. Dr Daniel Pronk, who in 2020 was the Medical Director of the South Australian Prison Health Service,7 has provided an affidavit which provides details of Mr Schuster’s medical history during his time in custody.8

3.3. The main features of Mr Schuster’s health during his first incarceration in September 1994 were a history of asthma and a surgical intervention for undescended testes as a child.

5 Exhibit C12

6 TQEH 7 SAPHS 8 Exhibit C3

3.4. The next medical event of significance was on 25 January 1994 when he alleged that he had walked into a cell door. He received a jaw fracture which required surgical fixation. Later that year, the SAPHS casenotes indicated that he admitted that his jaw injury resulted from an assault.

3.5. In late 1997 he was initiated on medication cyproterone9 with the intent of reducing his libido in the context of his offending. He was released in December 1998, but readmitted on 2 February 1999. On readmission he did not report any new medical complaints and he continued with the cyproterone.

3.6. Between 2000 and 2007 he had regular psychiatric reviews. He also had regular blood tests. The blood tests were to monitor his androgen levels and also his liver function, blood count and kidney function. This was to monitor the effects of the medication in case of unwanted side effects.

3.7. In December 2006 he had an endocrinology review due to his long-term use of cyproterone. At that stage he had a bone density scan which showed thinning of the bones, which may have been a side effect. He was started on a calcium supplement accordingly. He also reported occasional skin rashes which were treated with topical creams.

3.8. Throughout 2007 and 2008 he reported some migraine headaches and was prescribed propranolol. This medication, typically used to lower blood pressure, was being used in this context as a preventative medication to attempt to minimise his migraines. He also reported some periodic neck pain which was treated with anti-inflammatory medications as required.

3.9. On 1 June 2009 Mr Schuster was discharged from prison. On 28 August 2009 he was readmitted. He remained on cyproterone and propranolol.

3.10. An ultrasound performed in November 2015 found a structure in segment 7 of the liver.

A CT of his pelvis showed what was thought to be a small cyst.

3.11. An ultrasound in January 2019 showed he had fatty liver disease and two solid lesions not observed in the previous CT scan. On 21 February 2019 a CT scan of the abdomen 9 Brand name Androcur

and pelvis showed multiple solid lesions with several appearing suspicious for metastasis.

3.12. On 16 May 2019 an MRI of the liver showed multifocal liver lesions which were possibly hepatocellular carcinoma.10 Several other lesions had the appearance of metastatic deposits or multifocal HCC.

3.13. Between July and October 2019 Mr Schuster was admitted to the Royal Adelaide Hospital11 for trans arterial chemoembolisation.12 A CT scan of his abdomen showed multiple regions of suspected residual HCC, and an impression of a mass compressing his right posterior portal vein resulting in obstruction.

3.14. On 21 February 2020 an MRI showed two concerning lesions. He had a further TACE procedure on 30 April 2020 at the RAH.

3.15. A CT scan on 3 June 2020 showed the disease was progressing with enlarged lesions, a new lesion, and increasing thrombus in the portal vein. He was treated with sorafenib13 in July 2020.

4. Mr Schuster’s move to palliative care 4.1. On 3 September 2020 Mr Schuster’s condition was worsening. His chemotherapy drugs were ceased. He was moved to palliative care on 7 September 2020.

4.2. On 25 September 2020 Mr Schuster had a palliative care review in YLP. He stated he would prefer to remain in the Divisions and only go to the Health Centre if absolutely necessary. It was noted at this time he was showing clinical signs of deterioration including jaundice and increasing ascites and leg oedema.

4.3. On 4 October 2020 he was taken to the Emergency Department of The Queen Elizabeth Hospital due to abdominal pain and constipation. He was returned to YLP that same day. On 7 October 2020 he was moved to the Health Centre as he was no longer managing in the Division.

10 HCC 11 RAH 12 TACE 13 Used in the treatment of late stage HCC

4.4. On 9 October 2020 it was noted that he was deteriorating with increased agitation and occasional vomiting. His oral medications were ceased, and he was given subcutaneous medications for agitation and pain, with input from the palliative care team as well as ongoing enemas for constipation to relieve abdominal pain.

4.5. Medical notes from 9 to 13 October 2020 indicate that Mr Schuster was quite settled.

The notes record that he passed away at 12:55pm on 13 October 2020.14

5. Androcur medication 5.1. I make some specific comments about the use of Androcur in relation to Mr Schuster.

Dr Narain Nambiar, psychiatrist, provided an affidavit to the Court.15 He personally prescribed Androcur to Mr Schuster when he treated him between 2006 and 2013, prescribing 150mg in the morning and 200mg at night. Dr Nambiar explained that Androcur is an anti-libidinal medication which is prescribed to suppress testosterone and reduce sex drive and sexual functioning in males, meaning it was an appropriate medication to prescribe to Mr Schuster, a convicted child sex offender who admitted to fantasies about children. Dr Nambiar stated that in order for a prisoner to be prescribed Androcur they must consent to it following explanation of the possible side effects and being advised they would be subjected to ongoing blood tests. Dr Nambiar indicated that blood tests should be taken every three months to check the enzymes in the liver.

Androcur is metabolised by the body in the liver and elevated enzymes could indicate an issue with the liver. If enzymes are elevated, then the patient would be referred to endocrinology at the RAH who may order further tests including a scan of the patient’s liver. The side effects of Androcur may include fatigue, reduced bone density, weight gain, feminisation and thinning of hair. According to Dr Nambiar, the onset of liver cancer is an extremely rare side effect of the medication.

5.2. The SA Police investigating officer expressed in her report that Androcur, like all medications, carried the risk of side effects. This particular medication carried a very low risk of the onset of liver cancer. Mr Schuster was monitored for this via regular blood tests and once an abnormality was detected, it was appropriately managed with scans and specialist appointments. Ultimately, it is not known whether the Androcur caused or contributed to Mr Schuster’s death, but I find that Mr Schuster must have 14 Exhibit C5, Statement of Anthon Njeri, Carer 15 Exhibit C4

consented to the Androcur treatment with full knowledge of the rare possible side effects. He was appropriately monitored for the development of any such side effects, including the extremely rare side effect of liver disease.

6. Conclusions 6.1. I find Mr Schuster was lawfully in custody at the time of his death. His treatment in custody was appropriate.

6.2. 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 22nd day of December, 2023.

Deputy State Coroner Inquest Number 25/2022 (2074/2020)