Coronial findigns - barry john hockey

OFFICE OF THE STATE CORONER
FINDINGS OF INQUEST

CITATION:
Inquest into the death of
Barry John Hockey

TITLE OF COURT:
Coroners: inquest, death in custody, natural causes; adequacy of medical care Department of Community Safety: Ms Antonietta Kersten Table of Contents

The Coroners Act 2003 provides in s45 that when an inquest is held into a death
in custody, the coroner’s written findings must be given to the family of the person
who died, each of the persons or organisations granted leave to appear at the
inquest and to various officials with responsibility for the justice system. These
are my findings in relation to the death of Barry John Hockey. They will be
distributed in accordance with the requirements of the Act and posted on the web
site of the Office of State Coroner.
Introduction
Mr Hockey was a 58 year old man who died in the Princess Alexandra Hospital
Secure Unit on 29 December 2007. At the time of his death, Mr Hockey was
serving a three-and-a-half year custodial sentence at the Wolston Correctional
Centre (WCC).
On 16 November 2007, Mr Hockey was admitted to the PAH Secure Unit with a
three week history of worsening shortness of breath, a persistent productive
cough, significant weight loss, night sweats and fevers. During this admission, he
was diagnosed with advanced lung cancer with a limited life expectancy. He was
discharged on 27 November 2007, with plans to start palliative chemotherapy the
following week. He was readmitted to hospital twice over the following month to
manage his worsening symptoms. Mr Hockey died in the PAH Secure Unit on 29
December 2007.
Because Mr Hockey’s death was a “death in custody” within the terms of the Act it
was reported to the State Coroner for investigation and inquest.
These findings:
• confirm the identity of the deceased, the time, place, circumstances and • consider whether the actions or inactions of any person contributed to his • consider whether the medical treatment afforded to him while in custody • consider whether any changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice.
The investigation
Detective Senior Constable Pamela Byres, then of the QPS Corrective Services
Investigation Unit (CSIU), conducted the investigation. I note that at the time of
completing this investigation, Detective Senior Constable Byres had attained the
1 s8(3) defines “reportable death” to include deaths in custody and s7(2) requires that such deaths be reported to the state corners or deputy state coroner. S27 requires an inquest be held in relation to all deaths in custody Findings of the inquest into the death of Barry John Hockey rank of Sergeant and is now known by the surname Leech. I will refer to her as Sergeant Leech in these findings. The hospital reported Mr Hockey’s death to the Dutton Park police station after the death was pronounced at 9:50am. Officers from both Dutton Park station and CSIU attended the scene that morning. Mr Hockey’s body had remained in situ in a single occupant room in the PAH Secure Unit. A physical examination of Mr Hockey’s body, performed by the CSIU officers, did not reveal any signs of injury or trauma. A room search revealed nothing suspicious. The room was photographed by a Scenes of Crime Officer during the search. CSIU officers seized Mr Hockey’s clothes and the PAH medical records. Mr George Tully, prison chaplain and Mr Hockey’s principal support person, formally identified the body at the scene shortly after 1:00pm that day. Police then accompanied Mr Hockey’s body to the Queensland Health Forensic and Scientific Services mortuary for autopsy. Dr Nathan Milne, an experienced forensic pathologist, performed an external and full internal autopsy on the morning of 31 December 2007. The autopsy was observed by representatives of CSIU and the QPS Coronial Support Unit. Further inquiries made by CSIU about the circumstances of Mr Hockey’s incarceration, his medical history, recent hospital admissions and the circumstances of his death included obtaining: • Mr Hockey’s criminal history and offender movement history; • Queensland Ambulance Service records; • a detailed statement from the consultant physician responsible for Mr Hockey’s treatment, Dr Geoff Eather, about Mr Hockey’s clinical management from the initial admission on 16 November 2007 to his death; • a statement from a nurse who had cared for Mr Hockey since his readmission on 28 December 2007 and who was with him when he died; and • statements from his principal support person, Mr George Tully, and Mr The investigation was not finalised until nearly two years after Mr Hockey’s death. Given the relatively straightforward circumstances of Mr Hockey’s death, I consider the investigation could have been progressed in a more timely manner. This criticism aside, I consider the scope of the investigation was appropriate. I thank Sergeant Leech for her assistance. The Office of the State Coroner supplemented the findings of Sergeant Leech’s investigation by obtaining the medical records maintained by the WCC medical centre. Associate Professor Bob Hoskins, Director of the Queensland Health Clinical Forensic Medicine Unit, subsequently reviewed this material and the PAH medical records to assess whether Mr Hockey was given appropriate access to, and received adequate medical treatment during his incarceration and in the months prior to his death. Findings of the inquest into the death of Barry John Hockey
The inquest
An inquest was held in Brisbane on 4 March 2010. Ms Kirkegaard was appointed
as counsel to assist me. Leave to appear was granted to the Department of
Community Safety and Queensland Health, Offender Health Services.
All of the statements, photographs and materials gathered during the investigation were tendered. Ms Kirkegaard submitted that the material tendered was such that I would be in a position to make findings without calling any oral evidence. She had discussed this proposed course with Mr Hockey’s next of kin and they had no concerns about the proposal, nor did they wish to have any other issues ventilated at the inquest. There were no submissions from any other parties to the effect that oral evidence should be called. I determined the evidence contained in the exhibits was sufficient to enable me to make the findings required by the Act and that there was no other purpose which would warrant any witnesses being called to give oral evidence.
The evidence
I turn now to the evidence. Rather than summarise all of the information contained
in the exhibits, I consider it appropriate to record in these reasons, the evidence I
believe is necessary to understand the findings I have made.
Personal Background
Mr Hockey was born in Lismore, New South Wales on 27 October 1949. He was
the youngest of seven siblings. Sadly, Mr Hockey spent most of his life in
institutions. He was placed in a church orphanage at six months of age, after his
mother, who suffered from Parkinson’s disease, went into a nursing home. He
remained in the orphanage until he was fifteen years old. He experienced both
physical and sexual abuse during this period of his life. He left high school before
completing Year 10.
After leaving school and the orphanage, Mr Hockey worked a variety of jobs
ending up in catering, until he was 21 years old. From then, he spent most of his
adult life in custody in Victoria, New South Wales and Queensland. His offending
began with mostly fraud and stealing but escalated from the late 1980s with
convictions for a range of serious offences, including deprivation of liberty,
indecent assault, rape and unlawful wounding with intent to do grievous bodily
harm. Alcohol was consistently a significant factor in his offending over the
years.
At the time of his death, Mr Hockey had spent roughly 46 of his 58 years in an
institution (15 in an orphanage and 31 in prison). A psychiatric assessment
contained in his Corrective Services records comments that Mr Hockey had spent
so long in institutions that the general community was a “strange and foreign
world” to him, whereas prison was a “safe, secure, unchallenging haven”. The
Corrective Services records note that Mr Hockey was regularly compliant and
succeeded in holding a range of responsible employment positions during his
many years of incarceration. He was employed as a chef and in a statement
Findings of the inquest into the death of Barry John Hockey taken by the investigating officer from Mr Hockey’s principal support person, he
was described as an exceptional cook.
Mr Hockey was married in 1987. The relationship was short lived, though he and
his wife didn’t ever divorce. He had one child from that relationship. The
statement provided by Mr Hockey’s wife reveals that he maintained sporadic
contact with her over the years but due to his many years in custody, he had no
contact with his daughter after she was about three years of age.
The statement provided by Mr Hockey’s principal support person, Mr George
Tully, indicates that he had known Mr Hockey since late 1990. Mr Hockey spent
much of his leave of absence time with Mr Tully’s family and lived with them from
late1994 to 1997. Mr Hockey would phone Mr Tully every Saturday whenever he
was in custody.
Basis for most recent incarceration
At the time of his death, Mr Hockey was serving a three and a half year custodial
sentence for convictions of attempted kidnapping, unlawful use of a motor
vehicle, break and enter and stealing offences. He was sentenced for these
convictions by the Ipswich District Court on 22 August 2005.
Mr Hockey started serving his sentence on 29 June 2005 as an inmate of the
Arthur Gorrie Correctional Centre. He was transferred to WCC on 9 November
2005. He was transferred in and out of the PAH Secure Unit several times after
this before the final admission on 28 December 2007, during which he died.
Mr Hockey’s medical history
Medical records from both WCC and the PAH show that Mr Hockey had a history
of alcoholism, heavy lifelong smoking, emphysema, gastro-oesophageal reflux
disease (including a perforated duodenal ulcer and vagotomy in 1986) and
anxiety disorder.
In late May 2005, ultrasound examination confirmed an abdominal aortic
aneurism that had been detected by x-rays ordered by Mr Hockey’s general
practitioner, prior to Mr Hockey’s reception at the Arthur Gorrie Correctional
Centre on 9 May 2005.
After being transferred to WCC in early November 2005, Mr Hockey presented to
the WCC medical centre with occasional minor health complaints until May 2007.
Over the following four months, Mr Hockey presented to the WCC medical centre
on three occasions with symptoms suggestive of a recurrent chest infection. He
was referred for chest x-rays and prescribed antibiotics. The WCC medical notes
indicate that his chest complaint initially responded to this course of treatment.
Diagnosis of adenocarcinoma
The WCC medical records show that in late October and early November 2007,
Mr Hockey presented to the WCC medical centre on three occasions with
increasing shortness of breath and a persistent cough that was producing brown
sputum. He was reviewed by a medical officer who ordered a chest x-ray and
prescribed several courses of antibiotics.
Findings of the inquest into the death of Barry John Hockey Mr Hockey was reviewed by a medical officer again on 16 November 2007. His symptoms had not responded to the antibiotics. He had lost almost eight kilograms in weight over the previous two months and had night sweats and fevers. His shortness of breath was such that he could not walk short distances without oxygen. The WWC medical notes indicate a possible diagnosis of bronchopneumonia and the need to exclude lung cancer. He was transferred to the PAH Secure Unit that day for further medical investigation. The PAH medical notes indicate that on admission, Mr Hockey presented with clinical signs consistent with a right sided pleural effusion. This was confirmed by an initial chest x-ray. A pleural tap subsequently drained 1.2L of fluid from his lungs. He was also treated with broad spectrum antibiotics. Lung function testing during this admission confirmed moderately severe chronic obstructive pulmonary disease. Testing of the drained pleural fluid ultimately confirmed the presence of malignant cells, with characteristics consistent with primary lung adenocarcinoma. A subsequent CT chest scan confirmed pulmonary metastatic disease with probable lymphangitis and mediastinal lymphadenopathy. The investigating officer obtained a statement from Dr Geoff Eather, the consultant respiratory and sleep physician, who became responsible for Mr Hockey’s care from 22 November 2007. This statement provided a very detailed and clear summary of the clinical management of Mr Hockey’s condition that has been of great assistance to this inquest. Dr Eather’s statement indicates that Mr Hockey’s case was discussed at the hospital’s lung cancer conference on 22 November 2007. His malignancy was staged as a metastasised adenocarcinoma originating in the lung. The meeting recommended treatment including draining the pleural effusion and pleurodesis should the pleural effusion recur; trialling oral corticosteroid therapy for the lymphangitis; referral for consideration of palliative chemotherapy and referral to the palliative care service. Dr Eather’s statement notes that Mr Hockey responded to pleural drainage and oral corticosteroids, with a significant improvement in his shortness of breath. He was reviewed by a medical oncologist on 27 November 2007, who spoke to him in some detail about the role of palliative chemotherapy. I note that in a letter to the WCC dated 27 November 2007, oncologist indicates that Mr Hockey understood his condition was incurable and that chemotherapy was unlikely to have a significant impact on his life expectancy. Mr Hockey was noted as being keen to proceed and arrangements were made to start chemotherapy on 6 December 2007. He was also reviewed by the palliative care team who prescribed Endone to manage his shortness of breath. In view of his satisfactory response to treatment to this point, Mr Hockey was discharged on 27 November 2007, with plans for outpatient follow up. I note in a letter to the South East Queensland Regional Community Corrections Board dated 23 November 2007, Dr Eather’s RMO advised that the long term prognosis for the majority of patients with this type of disease is poor, with life expectancy usually measuring months, rather than years. Statements from Mr Findings of the inquest into the death of Barry John Hockey Hockey’s wife and his principal support person, Mr George Tully, indicate that Mr Hockey understood that his condition was terminal and that he had only months to live. Mr Tully’s statement suggests that Mr Hockey was prepared to accept this reality. This is supported by notations in the WCC medical records that he talked freely about his diagnosis upon his return from hospital. Readmission to hospital
Mr Hockey was to start palliative chemotherapy as an outpatient on 6 December
2007. However, Dr Eather’s statement and the PAH medical records show that
he was readmitted to the PAH Secure Unit from the medical oncology unit on that
day with recurrent shortness of breath. This was found to be caused by a
worsening right sided pleural effusion.
An intercostal catheter was inserted on 7 December 2007 and immediately
drained one litre of fluid from Mr Hockey’s lungs. He required prolonged
intercostal catheter drainage with suction and ultimately, a talc pleurodesis was
performed on 14 December 2007 to reduce the cavity left by the drained pleural
effusion.
Mr Hockey received his first dose of chemotherapy on 13 December 2007. He
was given Carboplatin and Gemcitabine on this occasion.
Mr Hockey’s condition improved over the following days. He was discharged on
17 November 2007 to be reviewed in a week’s time for chemotherapy and a
repeat chest x-ray.
Mr Hockey was subsequently reviewed by the PAH Medical Oncology Unit on 20
December 2007. He received a further dose of Gemcitabine on this occasion.
He was scheduled to receive his next dose of chemotherapy on 3 January 2008.
Final admission to hospital
The WCC medical notes show that over the following week, Mr Hockey was
coughing up more bloody sputum and experiencing increased breathlessness
and pain, despite receiving palliative doses of Endone to manage these
symptoms. After being reviewed by a nurse at the medical centre in the morning
of 28 December 2007, Mr Hockey was transferred by ambulance to the PAH
Secure Unit for medical review.
Medical examination revealed a recurrence of the right sided pleural effusion. Mr
Hockey was readmitted under the care of Dr Eather. Dr Eather’s statement and
the PAH medical records show that Mr Hockey was treated with supplemental
oxygen, broad spectrum intravenous antibiotics and corticosteroid therapy.
Between 5:00pm and 8:00pm that day, Mr Hockey’s blood pressure fell and his
heart rate rose dramatically. He was also noted to have developed atrial
fibrillation at about this time. His condition deteriorated rapidly over the course of
that evening.
Mr Hockey’s condition continued to deteriorate into the early hours of 29
December 2007. He gradually lost consciousness. He was reviewed by both
medical ward call and the medical registrar during this decline. At about 6:00am,
Dr Eather’s senior registrar, Dr Dan Smith phoned George Tully in his capacity as
Mr Hockey’s principal support person. Mr Tully attended the hospital and
Findings of the inquest into the death of Barry John Hockey following a discussion with Dr Smith, agreed that given Mr Hockey’s advanced lung malignancy and his progressive deterioration, Mr Hockey should be given comfort cares only. Mr Tully’s statement indicates that he stayed with Mr Hockey for about half an hour, during which time Mr Hockey remained unconscious. The nursing notes show that Mr Hockey continued to deteriorate during the morning. A statement obtained from registered nurse Bridgette Mortimer, who was caring for Mr Hockey, reveals that by 9:15am, it was apparent that Mr Hockey was close to death. He was given comfort cares at 9:30am and died in the presence of Nurse Mortimer and another nurse at 9:35am. The resident medical officer, Dr Teng, pronounced Mr Hockey’s death at 9:50am. Adequacy of medical treatment
Dr Bob Hoskins, Director of Queensland Health’s Clinical and Forensic Medicine
Unit (CFMU) was asked to review the WCC and PAH medical records to assess
whether Mr Hockey was given appropriate access to, and received adequate
medical treatment during his incarceration and in the months prior to his death.
Dr Hoskins advised that in his opinion Mr Hockey received appropriate
intervention at each stage of the progression of his irreversible disease.
Autopsy
Dr Nathan Milne, an experienced forensic pathologist, performed an external and
full internal autopsy on the morning of 31 December 2007.
The examination showed no evidence of injury. It confirmed the clinical diagnosis
of adenocarcinoma of the right lung, which Dr Milne considered to be the cause
of Mr Hockey’s death. Histology showed that the tumour had spread extensively
through the lymphatic channels of both lungs and was also identified in lymph
nodes. There were significant secondary changes in the lungs related to the
tumour, including acute bronchopneumonia, which Dr Milne considered would
also have contributed to Mr Hockey’s death.
The examination also revealed other conditions that Dr Milne considered would
have contributed to Mr Hockey’s death, namely emphysema and a degree of
coronary atherosclerosis severe enough to have caused a heart attack or sudden
death at any time.
Toxicological examination of the post mortem blood was consistent with the
palliative administration of morphine and paracetamol to Mr Hockey during the
final hours of his life. Dr Hoskins reviewed this aspect of the autopsy findings. I
note his advice that in the context of painful terminal malignancy, the use of high
dose opiates, including morphine, is appropriate and humane.
Toxicology was also performed on a hospital blood specimen taken from Mr
Hockey at 10:35am on the morning of his final admission. The results were
consistent with medication prescribed to Mr Hockey but showed raised levels of
the antidepressant, paroxetine, and the narcotic analgesic, oxycodone. The
Findings of the inquest into the death of Barry John Hockey concentrations of both these drugs were found to be greater than the usual therapeutic range, but less than a potentially fatal level. Dr Milne considered mixed drug toxicity to have also contributed to Mr Hockey’s death. Dr Milne could not determine why these drug levels were raised. I note Dr Hoskins’ advice that he found nothing in the clinical picture to suggest Mr Hockey was suffering from either opiate or paroxetine toxicity, nor was there anything to suggest that paroxetine, oxycodone or morphine were given at an inappropriate dose or frequency. Dr Hoskins considered that the recorded doses of paroxetine and oxycodone would not be expected to give rise to the blood levels detected by toxicology. Although he could not explain why the levels were elevated, Dr Hoskins considered there was nothing in the clinical picture to suggest that those levels actually caused any adverse effects. Taking Dr Hoskin’s opinion into account, I consider that the autopsy examination and toxicology results are not suggestive of anything suspicious having occurred in respect of Mr Hockey’s death. Investigation findings
Mr Hockey’s body was identified by his principal support person, George Tully, at
the scene. Physical examination of Mr Hockey’s body in situ revealed no signs of
injury or trauma. A search of the hospital cubicle in which he died revealed
nothing suspicious.
Autopsy examination confirmed the clinical diagnosis of adenocarcinoma of the
right lung. Although neither the autopsy nor independent medical review could
explain the elevated levels of oxycodone and paroxetine in the hospital blood
samples taken the day before Mr Hockey died, I accept Dr Hoskins’ opinion that
there was nothing in the clinical picture to suggest that Mr Hockey was given
oxycodone, morphine or paroxetine in inappropriate doses or frequency or that he
was suffering from opiate or paroxetine toxicity.
Independent medical review confirmed that Mr Hockey received appropriate
medical treatment in both WCC and the PAH Secure Unit during his
incarceration.
No evidence suggested anything other than a death by natural causes.
Findings required by s45
I am required to find, as far as is possible, the medical cause of death, who the
deceased person was and when, where and how he came by his death. As a
result of considering all of the material contained in the exhibits, I am able to make
the following findings in relation to the other aspects of the matter.
Identity of the deceased –
The deceased person was Barry John Hockey who was born in Lismore, New South Wales on 27 October 1949. Findings of the inquest into the death of Barry John Hockey How he died –
Mr Hockey died of natural causes while a prisoner at the Wolston Correctional Centre.
Place of death –
He died at the Princess Alexandra Hospital Secure Unit.
Date of death –

Cause of death –
He died from adenocarcinoma of the right lung.
Comments and recommendations
Section 46, insofar as it is relevant to this matter, provides that a coroner may
comment on anything connected with a death that relates to public health or
safety, the administration of justice or ways to prevent deaths from happening in
similar circumstances in the future.
I have found that Mr Hockey died of natural causes and that no other person
contributed in any way to his death. I consider he received an appropriate
standard of medical care in the months and days preceding his death.
In the circumstances, I consider there is no basis on which I could make any
preventative recommendations.
I close the Inquest.
Michael Barnes
State Coroner
Brisbane
05 March 2010
Findings of the inquest into the death of Barry John Hockey

Source: http://www.courts.qld.gov.au/__data/assets/pdf_file/0008/86867/cif-hockey-bj-20100305.pdf