Coroner's Finding: Foster, Stephen John

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INQUEST INTO THE DEATH OF STEPHEN JOHN FOSTER [2025] SACC 10 Inquest Findings of her Honour Coroner Giles 20 May 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of Stephen John Foster who died whilst in lawful custody at the age of 74 years after a brief period of illness relating to liver failure.

Held:

1. Stephen John Foster, aged 74 years of Yatala Labour Prison, died at The Queen Elizabeth Hospital on 1 July 2022 as a result of acute on chronic liver failure complicating common bile duct cholangiocarcinoma (operated).

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MR M KIRBY Hearing Date/s: 01/04/2025 Inquest No: 10/2025 File No/s: 1566/2022

INQUEST INTO THE DEATH OF STEPHEN JOHN FOSTER [2025] SACC 10 Introduction and cause of death Mr Stephen John Foster was born on 21 May 1948 and died on 1 July 2022 at The Queen Elizabeth Hospital (TQEH). He was 74 years old.

A pathology review informed by Mr Foster’s medical records was conducted by Dr Jane Alderman and discussed with forensic pathologist, Dr John Gilbert, of Forensic Science South Australia.1 The cause of death provided was ‘acute on chronic liver failure complicating common bile duct cholangiocarcinoma (operated)’.2 I so find.

No concerns were raised in the review and an autopsy was not recommended.

Reason for inquest At the time of his death, Mr Foster was receiving treatment at TQEH while serving a sentence of imprisonment.

In October 2019 Mr Foster was sentenced for offending that he pleaded guilty to. This offending breached a bond that had been granted for prior criminal offending the year before. He was sentenced to a cumulative term of imprisonment of three years, 11 months and 11 days, which commenced on 15 February 2019. A non-parole period was fixed at two years and one week.3 As he was lawfully in the custody of the Department for Correctional Services at the time of his death, an inquest into his death is mandatory pursuant to section 21(1)(a) of the Coroners Act 2003.

Background and medical history Mr Foster was born in London, England. At age 11 he emigrated to Adelaide, South Australia with his family.

He returned to England for a period of time and married his wife Marie at the age of 26, before returning to Adelaide with her.4 Together they had three daughters.

The family lived in Rostrevor until Mr Foster and his wife separated in about 1996 or

1997. Following their separation, Mr Foster remained in the family home for another two years before moving in with his parents to care for them.5 Mr Foster maintained an amicable relationship with his ex-wife and daughters and remained involved throughout their childhoods.

1 Exhibit C5a 2 Bile duct cancer 3 Exhibit C7a 4 Exhibit C7, page 8 5 Exhibit C2 at [4]

[2025] SACC 10 Coroner Giles Mr Foster was placed into the care of the South Australian Prison Health Service (SAPHS) upon being remanded into custody. There was no relevant medical history noted at this time.

Events leading to death Dr Tom Turnbull was the Medical Director of SAPHS at the time of Mr Foster’s incarceration. Dr Turnbull provided an affidavit summarising the issues leading up to Mr Foster’s death.

When he was initially incarcerated in 2019 Mr Foster was admitted to Yatala Labor Prison, before being transferred to Mount Gambier Prison on 20 February 2019.

Between 2019 and 2021, Mr Foster experienced various health issues, including nausea, bursitis of the hip and vitamin B12 deficiency for which he received medical treatment.6 On 28 April 2022 Mr Foster was sent to the nurse with signs of jaundiced skin and eye sclera. He complained of a dry, non-productive cough for the previous three months, and that his urine was orange and his bowel functions chalky and loose for the previous six weeks. He also complained of a reduced appetite over the last two weeks. The following day he was examined by Dr Kavanagh, a medical officer employed by SAPHS, who noted Mr Foster’s liver was not enlarged and his abdomen was not tender. A referral was made for a CT scan of his abdomen and pelvis, as well as a referral to the Mount Gambier Hospital.

The CT results were discussed with Mr Foster on 3 May 2022. They revealed signs of suspected bile duct cancer. A magnetic resonance cholangiopancreatography (MRCP) was recommended and Mr Foster was advised he would need surgery. Mr Foster agreed to the surgery.

On 11 May 2022 Mr Foster reported experiencing issues with his bowels. He was given medication by the nurse.

On 18 May 2022 Mr Foster was feeling dizzy and losing balance. His bowels were still problematic for him.

On 21 May 2022 Mr Foster was admitted to the Mount Gambier Hospital where the MRCP was performed. It showed a mass lesion at the confluence of the hepatic ducts of the porta hepatis, which supported the diagnosis of bile duct cancer.

On 21 May 2022 Mr Foster was transferred to TQEH.

On 23 May 2022 he had a percutaneous transhepatic cholangiography insertion. This procedure involved transhepatic insertion of a needle into a bile duct, followed by injection of contrast material to opacify the bile ducts. The procedure was technically difficult and complicated by hypotension, and Mr Foster had to remain in the Intensive 6 Exhibit C4, pages 3-5

[2025] SACC 10 Coroner Giles Care Unit for some time before he was discharged to the ward on 24 May 2022. His liver function gradually improved, and he was considered a suitable candidate for surgery.7 On 25 May 2022 a multidisciplinary team (MDT) meeting was held where doctors planned a right hemi-hepatectomy8 and hepaticojejunostomy9 which was conducted on 16 June 2022.10 Mr Foster’s bilirubin levels were monitored in the leadup to the surgery, and he was noted to be clinically well. The surgery was completed without complications.

Despite the surgery proceeding without complications, Mr Foster’s condition subsequently deteriorated with worsening decompensated liver failure and fluctuating confusion attributed to hepatic encephalopathy.11 His case was reviewed at an MDT meeting on 22 June 2022. The consensus opinion was that once Mr Foster had recovered from surgery, he should be referred to medical oncology and consideration be given to adjuvant treatment.

However, on 26 June 2022, Mr Foster developed disseminated intravascular coagulation, which is a rare but serious condition causing abnormal blood clotting. Despite intervention, Mr Foster developed fulminant acute liver failure and failed to show any meaningful clinical improvement.

A family meeting was held on 27 June 2022 and a decision was made for Mr Foster to be referred to the palliative care team.

Mr Foster remained under palliative care until he died in the early morning of 1 July 2022.12 Conclusion and recommendations I agree with the conclusion reached by the SAPOL investigating officer in this matter, Detective Brevet Sergeant Daniel Rolevink, that Mr Foster’s custody at his time of death was lawful.

Mr Foster’s death was the result of a medical condition which was unable to be corrected despite appropriate medical and surgical measures taken by medical staff both in custody and in hospital. I have no concerns regarding the care and treatment Mr Foster was afforded in custody or in hospital.

I do not make any recommendations in this matter.

Keywords: Death in Custody; Prisoner; Natural Causes 7 Exhibit C5a 8 Removal of the right half of the liver 9 A surgical process to bypass a blockage in the bile duct 10 Exhibit C3, pages 4-5 11 A brain disorder caused by liver dysfunction 12 Exhibit C3, pages 6-7