Coroner's Finding: Wilson, Charles Thomas

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INQUEST INTO THE DEATH OF CHARLES THOMAS WILSON [2026] SACC 10 Inquest Findings of her Honour Deputy State Coroner Roper 23 April 2026

CORONIAL INQUEST Examination of the cause and circumstances of the death of a man who was serving a sentence of imprisonment for serious offences when he developed septic arthritis of the left shoulder. The inquest examined the standard of medical care provided in custody, and the significance of an error in the administration of medication while in custody.

Held:

1. Charles Thomas Wilson, aged 85 years of Northfield, died at the Royal Adelaide Hospital on 10 December 2022 as a result of sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left shoulder on a background of congestive cardiac failure.

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

No recommendations made.

Counsel Assisting: MR D EVANS Hearing Date/s: 10/09/2025 Inquest No: 19/2025 File No/s: 3022/2022

INQUEST INTO THE DEATH OF CHARLES THOMAS WILSON [2026] SACC 10 Introduction and reason for inquest Charles Thomas Wilson was 85 years of age when he died at the Royal Adelaide Hospital on 10 December 2022.

At the time of his death Mr Wilson was in the custody of the Department for Correctional Services, having been convicted of serious criminal offences and sentenced to imprisonment.

As he died in custody, an inquest into the cause and circumstances of his death is mandatory.1 These are the findings of that inquest.

Background Mr Wilson was born on 11 October 1937. During the late 1970s and early 1980s he lived in Renmark with his wife and two children. In about 1998, Mr Wilson separated from his wife and moved to Adelaide. His family remained in Renmark.

On 30 May 2015 Mr Wilson was arrested and charged with historical sexual offences. He was convicted following trial and imprisoned on 1 May 2018. However, he successfully appealed his conviction, and on 13 September 2018 a re-trial was ordered. Mr Wilson was released on bail awaiting his re-trial.

On 17 July 2019, Mr Wilson was again convicted of historical sexual offences following trial. He was taken into custody and initially accommodated at the Yatala Labour Prison.

On 29 August 2019 he was sentenced by the District Court of South Australia to imprisonment for a period of 10 years, 7 months and 18 days. A non-parole period of 8 years, 5 months and 6 days was fixed.

Mr Wilson was transferred to the Mount Gambier Prison on 22 July 2019, where he spent the majority of his incarceration. He was transferred to the Port Augusta Prison on 13 October 2022, where he remained for less than a month due to a hospital admission.

On 18 November 2022 Mr Wilson returned from hospital to the Yatala Labour Prison, where he remained for ten days, until he was transported to the Royal Adelaide Hospital via ambulance. Mr Wilson remained in hospital until his death on 10 December 2022.

What was the cause of Mr Wilson’s death?

Dr Jane Alderman, a medical practitioner experienced in providing opinions as to cause of death, conducted an examination of Mr Wilson’s longitudinal medical history. In consultation with senior specialist forensic pathologist Dr John Gilbert, she formed the view that the cause of Mr Wilson’s death was sepsis due to Staphylococcus aureus 1 Coroners Act 2003, section 21(1)(a)

[2026] SACC 10 Deputy State Coroner Roper bacteraemia due to septic arthritis of left shoulder on a background of congestive heart failure, and I so find.

Was Mr Wilson’s health managed appropriately while he was in custody?

Mr Wilson’s medical history at the time of his first admission to Yatala Labour Prison in May 2018 included osteoarthritis, prostatism, atrial fibrillation, hypertension, valvular heart disease, mild atrial regurgitation and mild mitral regurgitation. He had a documented history of bilateral hearing impairment, for which he utilised hearing aids.

During his time in custody, Mr Wilson attended hospital on several occasions in relation to cardiac issues, ulcers, aching knees and anaemia. He also attended specialist appointments in relation to his hearing, eyesight and heart condition. He was regularly reviewed by Dr Letitia Kavanagh of the Mount Gambier Prison Health Service who managed his day-to-day health.

On 21 December 2021, Mr Wilson had a fall while exercising and sustained fractures to his pelvis. He was transferred via ambulance to the Mount Gamber Hospital, where he was managed conservatively in accordance with the advice of the orthopaedic team.

Following this injury, he began to mobilise with a four-wheeled walker. On 7 January 2022, Mr Wilson was discharged from hospital and transferred to the Yatala Labour Prison medical clinic for rehabilitation. He expressed eagerness to return to the Mount Gambier Prison, where he preferred the company and the environment.

In accordance with his wishes, Mr Wilson was transferred back to the Mount Gambier Prison on 9 February 2022. He continued to experience complications which were attributed to his pelvic fracture, including an ongoing foot drop and swollen legs. These issues appear to have been appropriately managed by Dr Kavanagh, who undertook additional investigations when clinically indicated to exclude serious complications such as deep vein thrombosis, as well as additional imaging to monitor the healing of Mr Wilson’s fracture.

On 19 May 2022 Mr Wilson was assessed by general surgeon Dr McCullough at the request of the Mount Gambier Hospital in relation to his ongoing anaemia. Due to his frailty, he was not considered a suitable candidate for an investigative colonoscopy or endoscopy and, accordingly, a CT scan of his colon with faecal tagging was recommended.

On 8 July 2022 Mr Wilson attended a consultation with Dr Kris Ghosh, a consultant physician and geriatrician at the Mount Gambier Hospital. Dr Ghosh performed an electrocardiogram which indicated atrial flutter with variable AV block with premature ventricular complexes. Accordingly, he prescribed Mr Wilson the medication metoprolol (12.5 mg twice daily) with instructions to titrate up the dose according to Mr Wilson’s response. Dr Ghosh also raised a concern about Mr Wilson’s ongoing prescription for the medication ticagrelor, which did not appear to him to be clinically indicated.

On 20 July 2022 Dr Kavanagh reviewed Mr Wilson and noted that there had been a delay in Mr Wilson commencing metoprolol as it had not been included in his Webster-pak.

However, once Mr Wilson commenced taking metoprolol, he experienced increasing shortness of breath.

[2026] SACC 10 Deputy State Coroner Roper On 21 July 2022 Mr Wilson attended the prison medical clinic complaining that he felt worse after taking metoprolol. The nurse checked his Webster-pak and discovered that the pharmacy had packed it incorrectly, such that he had been receiving metoprolol at a dose of 25 mg instead of 12.5 mg. Mr Wilson, understandably, refused to take metoprolol again until he had seen a doctor.

This occurred on 23 July 2022. Dr Kavanagh reduced Mr Wilson’s metoprolol dose back to the intended 12.5 mg and offered a change to Cardizem 30 mg. She also noted Dr Ghosh’s concerns regarding ticagrelor and replaced this medication with the anticoagulant rivaroxaban pending a cardiology review, for which she completed a referral on 26 July 2022.

The cardiology investigations commenced on 23 August 2022. Mr Wilson was fitted with a Holter monitor to record his heart activity. This demonstrated atrial fibrillation with periods of rapid heart rate. An echocardiogram performed on 31 August 2022 confirmed atrial fibrillation and elevated pulmonary artery pressures. The cardiologist recommended clinical assessment for congestive cardiac failure.

On 20 September 2022, Dr Kavanagh assessed Mr Wilson and noted that he was retaining fluid and that congestive cardiac failure was likely. Blood tests were ordered, and the diuretic medication furosemide was prescribed.

On 27 September 2022, Dr Kavanagh reviewed Mr Wilson again and increased his dosage of furosemide. She observed pitting oedema and noted that if his condition worsened, he may need to attend the Mount Gambier Hospital.

His condition did worsen and, on 1 October 2022, Mr Wilson was transported to the Mount Gambier Hospital Emergency Department. He was diagnosed with, and treated for, non-infective acute exacerbation of chronic congestive heart failure. New medications were prescribed to treat Mr Wilson’s heart failure, including bisoprolol (7.5 mg per day) and digoxin (62.5 mg per day). Bisoprolol is a beta-blocker which reduces heart rate, blood pressure and cardiac contractility. Digoxin is an antiarrhythmic which slows heart rate and reduces atrioventricular nodal conduction. Both medications are indicated in the treatment of atrial fibrillation.

Mr Wilson was discharged from hospital on 9 October 2022 and returned to the Mount Gambier Prison. He was reviewed by a nurse at the prison medical clinic on 10 October 2022, who noted that he had been administered medication as per his hospital medication list. The medication list indicated that Mr Wilson was to take two bisoprolol tablets each morning (one 2.5 mg and one 5 mg), and one digoxin tablet (62.5 mg).

Within the medical records is a photograph of Mr Wilson’s Webster-pak of medications ascribed with the date 10 October 2022. The label of the Webster-pak listed the medications contained therein, which included the newly prescribed bisoprolol and digoxin.

There is a further document within the records dated 10 October 2022, which appears to be a fortnightly record of the administration of medications to Mr Wilson. This document indicates that a Webster-pak had been provided to Mr Wilson twice daily on 10, 11 and 12 October 2022, and once on the morning of 13 October 2022. This document was signed

[2026] SACC 10 Deputy State Coroner Roper by a medical practitioner and pharmacist. The same pharmacist signed the medication list prepared on 10 October 2022. This list included the medications digoxin and bisoprolol.

On 11 October 2022, Mr Wilson was medically reviewed to ensure he was fit for transfer.

It was noted that he was to continue his current medications.

On 12 October 2022, Mr Wilson was transferred to the Adelaide Remand Centre, and then to the Port Augusta Prison, where he arrived on 13 October 2022. Mr Wilson attended the prison medical clinic on several occasions in October, primarily related to wounds on his legs resulting from previous cellulitis, and swallowing difficulties.

Following admission to the Port Augusta Prison on 13 October 2022, no records were made regarding the administration of medication to Mr Wilson until 17 October 2022. It is unknown whether he received medication during this period.

From 17 October 2022 records were made reflecting the administration of medications to Mr Wilson, excluding digoxin and bisoprolol. It appears that Mr Wilson was recommenced on his previous medication regime.

On 2 November 2022, Mr Wilson was reviewed by a medical officer who noted that, due to Mr Wilson’s complex needs, it was not appropriate for him to remain at the Port Augusta Prison. A plan was made to review him in a week and to ‘reconcile meds’.

On 3 November 2022, Mr Wilson was taken to the Port Augusta Hospital due to complaints of chest pain. He was treated for cardiogenic shock and diagnosed with decompensated congestive cardiac failure. A chest x-ray indicated cardiomegaly and a CT scan of his abdomen showed infrarenal dilation of the aorta, a pericardial effusion and bilateral pleural effusions. He was transferred to The Queen Elizabeth Hospital via MedSTAR for admission to the Intensive Care Unit due to rapid atrial fibrillation, acute kidney injury and gastrointestinal bleeding. He was diagnosed with decompensated heart failure.

The Queen Elizabeth Hospital discharge summary authored by Dr Hamish Phillips referred to a medication error as the ‘trigger’ for this presentation, along with possible community-acquired pneumonia. It was noted that, despite changes being made to Mr Wilson’s medication regime following his discharge from the Mount Gambier Hospital in October 2022, specifically to include bisoprolol and digoxin, he had not been receiving these medications in the Port Augusta Prison. The author of the discharge summary from the Port Augusta Hospital wrote that, according to the prison medication chart, Mr Wilson was still receiving his previous medications and that no digoxin or bisoprolol was charted. The discharge summary also recorded the following: The fact that recent medication change was not carried on was revealed after discussing patient with the MedStar consultant Dr Cem Kibar and patient was then prescribed with stat doses 20 mg IV Furosemide and 250 mcg of IV Digoxin.

Mr Wilson remained at The Queen Elizabeth Hospital until 18 November 2022. This admission was complicated by several episodes of gastrointestinal bleeding. Mr Wilson was reviewed by the gastroenterology team on three occasions but was not considered a suitable candidate for invasive investigations due to his frailty.

[2026] SACC 10 Deputy State Coroner Roper Mr Wilson was informed of the risks of remaining on anticoagulation but expressed a strong preference to continue this medication as he was concerned about the possibility of a stroke.

Mr Wilson was discharged to the Yatala Labour Prison on 18 November 2022, where he was noted to be very unsteady on his feet with unclear speech at times. He was reviewed by a doctor in the prison medical clinic on 21 November 2022, who developed a plan to manage his falls risk and requested regular nursing observations and a referral to the palliative care team.

Unfortunately, Mr Wilson had an unwitnessed fall from his bed on 23 November 2022, striking his head. He was taken to the Royal Adelaide Hospital where he underwent a CT scan and x-ray, which revealed no acute pathology. His digoxin level was found to be supratherapeutic in the setting of mild acute kidney injury and was held during his admission. His resuscitation order was amended on 23 November 2022 specifying that he did not wish to receive cardiopulmonary resuscitation or invasive ventilation.

Mr Wilson was discharged to the Yatala Labour Prison on 26 November 2022.

On 28 November 2022, Mr Wilson was returned to the Royal Adelaide Hospital having developed delirium with gradual cognitive decline. A chest x-ray showed stable cardiomegaly and bilateral effusions as well as stable pulmonary oedema. The referring doctor noted that Mr Wilson had deteriorated significantly since discharge, and they could no longer manage him in the prison health care setting.

On 30 November 2022, Mr Wilson became hypotensive and was given intravenous antibiotics. Blood cultures grew Staphylococcus aureus. He developed shoulder pain with a large complex joint effusion identified, which was aspirated. A sample of the fluid aspirated grew Staphylococcus aureus. A transthoracic echocardiogram revealed an area of density on the mitral valve which could not be excluded as representing infective endocarditis, and therefore treatment was commenced as a precautionary measure on the advice of the cardiology team.

On 6 December 2022, Mr Wilson underwent surgery for irrigation of his left shoulder. A chest x-ray the following day showed worsening bilateral effusions and deteriorating pulmonary oedema. On 8 December 2022, Mr Wilson became hypoxic, hypotensive and hypothermic. He was transitioned to comfort care.

At about 10:30 am on 10 December 2022, Mr Wilson was observed to cease breathing.

A doctor declared life extinct at 12:58 pm. He was 85 years old.

What was the impact of the failure to provide Mr Wilson with his prescribed cardiovascular medications at the Port Augusta Prison?

This failure to provide Mr Wilson with his prescribed cardiovascular medications is a matter of concern. Mr Wilson was reliant upon the prison authority to meet his health needs. He had been prescribed medications to manage his congestive cardiac failure, and those medications ought to have been provided to him.

Dr Thomas Turnbull, who at that time was the Medical Director of the South Australia Prison Health Service, provided two affidavits summarising Mr Wilson’s medical treatment in custody. In his first affidavit, Dr Turnbull stated that the South Australia

[2026] SACC 10 Deputy State Coroner Roper Prison Health Service medical record travels with the prisoner regardless of whether they are placed in a private prison, such as Mount Gambier Prison, or a public prison, such as Port Augusta Prison. Accordingly, volume 2 of Mr Wilson’s medical records, in which the abovementioned discharge summaries were located, ought to have been available to staff at the Port Augusta Prison.

In his second affidavit, Dr Turnbull observed that there is no evidence that Mr Wilson’s medication chart was updated by the Mount Gambier Prison staff upon his return on 10 October 2022. The medication chart created on 17 October 2022 by a medical practitioner at the Port Augusta Prison did not reflect the changes made by the Mount Gambier Hospital. Mr Wilson instead received his previously prescribed cardiovascular medications. Dr Turnbull was unable to provide an opinion as to the relative benefits of the two cardiovascular drug regimes, as he considered it beyond his area of expertise.

The Queen Elizabeth Hospital discharge summary indicated that the treating clinicians considered the trigger for Mr Wilson’s decompensated heart failure to be the medication error. There is no evidence to the contrary.

The medication error was identified during a Critical Incident and Adverse Event Team review conducted by the South Australia Prison Health Service, Central Adelaide Local Health Network following the death of Mr Wilson. Notwithstanding identification of the medication issue, the review team, which included Dr Turnbull, found that there were no service or treatment gaps in the care provided to Mr Wilson, and no recommendations were proffered.

The failure to update Mr Wilson’s medication chart by the Mount Gambier Prison does not appear to have been addressed, which is possibly because this prison is a private facility which is not managed by the Department for Correctional Services and, consequently, not serviced by the South Australia Prison Health Service.

The consequences of the medication error were significant for Mr Wilson and the public health system more broadly. Mr Wilson required emergency retrieval by MedSTAR and an intensive care admission that may otherwise not have been necessary at that time.

However, it appears that Mr Wilson’s congestive cardiac failure was able to be stabilised during his hospitalisation, enabling his discharge back into the prison system on 18 November 2022. His next admission on 23 November 2022 was precipitated by a fall.

His final admission, commencing on 28 November 2022, was due to delirium, likely resulting from sepsis. Investigations during that admission indicated that Mr Wilson’s congestive cardiac failure was stable, noting the imaging findings of stable cardiomegaly, stable pulmonary oedema and stable troponin levels.

I am satisfied that the medication error, while unfortunate, did not cause or significantly contribute to the death of Mr Wilson.

Detective Brevet Sergeant Olsen of South Australia Police conducted an investigation into the cause and circumstance of Mr Wilson’s death. In his investigation report he expressed the view that Mr Wilson received community-equivalent medical care whilst incarcerated. With the exception of the medication omission, I concur with his opinion that, generally, Mr Wilson received adequate medical care in custody.

[2026] SACC 10 Deputy State Coroner Roper Conclusions Mr Wilson was sentenced by the District Court to a period of imprisonment in respect of serious offences and was therefore lawfully in custody at the time of his death.

The investigation excluded the involvement of any third party in the death of Mr Wilson.

The cause of Mr Wilson’s death was sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left shoulder on a background of congestive heart failure.

Generally, I find that Mr Wilson received adequate medical care during his incarceration.

I have considered whether a recommendation ought to be made pursuant to s 25(2) of the Coroners Act 2003 in relation to the medication error. I have determined that there is insufficient evidence as to the cause of this error to enable a recommendation to be formulated that may prevent or reduce the likelihood of a recurrence of a similar event.

Accordingly, I have no recommendations to make.

Keywords: Death in Custody; Prison; Natural Causes