CITATION:	Inquest into the death of John Allan Angeles [2015] NTMC 017

TITLE OF COURT:	Coroners Court

JURISDICTION:	Darwin

FILE NO(s):	D0213/2014

DELIVERED ON:	16 October 2015

DELIVERED AT:	Darwin

HEARING DATE(s):	13 August 2015

FINDING OF:	Mr Greg Cavanagh SM

CATCHWORDS:  	Death in Custody, Terminally ill prisoner	

REPRESENTATION:

Counsel Assisting:     	Kelvin Currie	
Counsel for Family:	Philippa Martin

	

Judgment category classification:	A
Judgement ID number:	[2015] NTMC 017 
Number of paragraphs:	106
Number of pages:	21

IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN 
TERRITORY OF AUSTRALIA

No. D0213/2014
	In the matter of an Inquest into the death of 
	JOHN ALLAN ANGELES
	ON 13 AUGUST 2015
AT DARWIN CORRECTIONAL FACILITY, HOLTZE
	
	FINDINGS

Mr Greg Cavanagh SM:
Introduction
1.	John Angeles (the deceased) was born at the Royal Darwin Hospital on 24 June 1935 to Elna Angeles (nee Erlandson) and Timothy Thomas Angeles. John identified as an Aboriginal and Filipino. He was one of 12 children.
2.	John grew up in Darwin, and apart from five years spent in Brisbane when his family was evacuated during the Second World War, stayed in Darwin most of his life.
3.	Upon finishing school John gained employment at a soft drink factory in the Darwin area. He then worked as a ringer/station hand in Katherine and then as a wharf labourer in Darwin.
4.	On 30 June 1952 John enlisted in the Australian Regular Army and remained in it until 9 February 1954. He then worked for the Department of Health for eleven years before joining the Northern Territory Fire Service. He worked as a fireman for twenty-three years before retiring at the age of 56.
5.	John was a great sportsman in many differing sports and received numerous awards. He represented the Northern Territory at the Australian Basketball Championships in 1954 and 1963.
6.	John married four times throughout his life. His only children were from his first marriage to Joan McGuinness on 23 December 1955. His children were John (Junior) (1956), Geoffrey (1957), Dennis (1958), Colin (1959), Joanne (1960) and Paul (1976).
7.	On 11 June 1998 John married his fourth wife Edna Campo Vergara in the Philippines. They returned to Australia and lived together until they separated at a time a little after August 2001.
8.	On 1 March 2003 at the age of 67 John was arrested for the murder of his estranged wife and her 14 year old daughter.  He plead guilty to the murders and was convicted and sentenced to two life sentences. He was not eligible for parole until 1 March 2028.  Chief Justice Martin in his sentencing remarks accepted that the actions of Mr Angeles were totally out of character and that he was deeply remorseful for his actions.
9.	John died while still in prison on 3 December 2014 at the age of 79 years.
10.	Pursuant to section 34 of the Coroners Act (“the Act”), I am required , if possible, to make the following findings:
		 “(1) A coroner investigating –
(a) a death shall, if possible, find –
(i) the identity of the deceased person;
(ii) the time and place of death;
(iii) the cause of death;
(iv) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act;”
11.	Pursuant to section 15 of the Act where a person dies in custody the Coroner must hold an inquest.
12.	Where there has been a death in custody, pursuant to section 26 (1) and (2)  of the Act a coroner:
“1) 	Must investigate and report on the care, supervision, and  treatment of the person being held in custody; and 
2)	May investigate or report on a matter connected with public health or safety or the administration of justice that is relevant to the death.”
13.	The Correctional Services Act commenced on 9 September 2014. It provides:
82 	Commissioner to arrange health care
(1)	The Commissioner must arrange for the provision of appropriate health care for prisoners.
(2)	The Commissioner must ensure that prisoners are provided with access to health care that is comparable with that available to persons in the general community in the same part of the Territory.
14.	At the time of his death Mr Angeles was held in cell 4 of Sector 6, a low security sector. In the next cell (cell 5) was William (Billy) Maroney. Billy had known the family of Mr Angeles prior to going into prison and had been friends with Mr Angeles for the last eight years while in prison. He had become his self-appointed carer.
15.	Mr Angeles had significant medical issues for some time. His ischemic heart disease and angina were first diagnosed in 1987.
16.	On 16 December 2010 Mr Angeles was taken to hospital suffering significant chest pain. He signed himself out in spite of medical advice to the contrary. The discharge summary in part states:
“Seventy-five year old gentleman presents with troponin positive chest pain. No ECG changes, no CXR changes. Despite my detailed explanation of the diagnosis and risks he is refusing treatment and admission in the hospital. He tells me he feels a lot more comfortable in his cell and that he doesn’t want any treatment. He knows that the heart attack is life threatening and he may die soon without any treatment. He has been diagnosed with triple vessel disease in 2005 when he declined Coronary Artery Bypass Grafting and he stopped his medications in February voluntarily. He tells me he is demoralised but never thought of suiciding. He just doesn’t want any treatment that may prolong his life. He has advance directives to not be resuscitated in case of cardiac arrest. He is capable of making informed decisions and therefor able to self-discharge.”
17.	That was reflected again in the discharge summary of 19 December 2013:
“We discussed at length with John the severity of his current ischaemic heart disease. We recommend that John comes in to hospital for ongoing medical management to attempt to reduce his symptoms. He understands that he is at high risk of dying as a consequence of his coronary artery disease. He adamantly does not want to come into hospital, and he does not want surgical investigation or management. He has signed the form for refusal of medical treatment/advice.”
18.	In October 2014 (that is, approximately 2 months before his death) Coronary Artery Visualisation was performed at the Royal Darwin Hospital. It demonstrated occlusion of all three main coronary arteries of between 70% and 90%.
19.	Mr Angeles experienced angina chest pain up to eight times a day. It occurred on minimal exertion. If he walked short distances he needed to stop and use his angina spray for relief.
20.	He also had Chronic Airways Disease. He was a long term smoker until 1 July 2013 when the prison no-smoking policy prevented him smoking. He had emphysema that lead to shortness of breath. That had worsened leading to his admission to Royal Darwin Hospital on 3 October 2014. He experienced laboured breathing on minimal exertion and would wake up in the night short of breath. He was discharged 10 October 2014.
21.	After his admission to Hospital he had an oxygen cylinder with him at all times. The oxygen was delivered through nasal prongs. When not using the oxygen he was seen to show signs of cyanosis, having blue lips and mouth.
22.	In addition Mr Angeles had Type 2 diabetes, renal impairment and hypercholesterolemia.
23.	In a report of 17 October 2014 Dr Keith Forrest wrote:
“Mr Angeles takes a full range of cardiac medications, diabetes medications and medication for obstructive lung disease. It is perhaps not in the scope of this report to list all of these medications and their doses. However it should be noted that he has reached maximal medical therapy for his ischaemic heart disease. There are no further practical additions to be made to his medication regime that could provide further relief of chest pain.
In summary, Mr Angeles has a most advanced form of coronary artery and chronic lung disease. These, combined with his advanced age render him very frail. He moves slowly, he requires the assistance of a walking frame to get about and requires supplemental oxygen for even minor exertion.
In terms of his prognosis and life expectancy, there is no expectation that his cardiac and respiratory conditions will show any sustained improvement. The inevitable course for this combination of conditions, especially in a person of advanced years is deterioration and death. Mr Angeles is at significant risk of sudden cardiac death, which could occur at any time. While it is not possible to accurately predict his remaining lifespan, I would suggest that this would be measured in months to very short years.”
24.	The report of Dr Forrest was attached to an application to the Commissioner for a leave permit made by the Northern Australian Aboriginal Justice Agency on 17 October 2014 on behalf of Mr Angeles. It was not the first time that representations had been made for release.
25.	That application indicated that Mr Angeles health was such that he might pass away at any time. The application was for release to stay with his sister, Ruth Logan in Stuart Park.
26.	On 3 November 2014 (one month before his death) the Commissioner for Correctional Services denied the request, stating in part:
“I note this is the third occasion, since Mr Angeles pleaded guilty to two counts of murder and was sentenced to life imprisonment with a non-parole period of 25 years on 10 August 2004, consideration for his release has been requested. The first occasion being in November 2005.
In May 2010, I also note that the Solicitor General for the Northern Territory advised the then Attorney-General that Mr Angeles’ health was not an appropriate case for the exercise of the second petition for prerogative mercy and advised the Administrator of the Northern Territory against this course of action.
I have reviewed Mr Angeles file and based on the advice provided by Dr Keith Forrest, there is no doubt that caring for Mr Angeles in the Correctional environment will be challenging. However, Mr Angeles age and medical conditions were taken into consideration by His Honour at the time of sentencing.”
27.	Nevertheless the letter appeared to contemplate a time when the correctional system may not be able to adequately manage the medical condition of Mr Angeles. 
28.	It may have been coincidental but on 3 November 2014, the day that the Commissioner rejected his application, Mr Angeles started refusing his medication.
29.	On 5 November 2014 an assessment was carried out of the residence of his sister, Ruth Logan to determine if it would be adequate to house Mr Angeles. 
30.	On 7 November 2014 Mr Angeles told Dr Forrest that he was upset when his lawyer showed him the report providing such a grim prognosis. But he had come to terms with it and was hopeful of being released on parole soon.
31.	On the morning of 9 November 2014 a nurse tried to compromise with Mr Angeles to get him to take some of his tablets. However he continued to refuse them. He did indicate that he had a couple of episodes of chest pain that morning but the GTN spray had worked.
32.	That evening the pain was coming back and Mr Angeles took his medication.
33.	Later that night at 9.40 pm Mr Angeles called the guard on the intercom and told him he had abdominal pain and requested medication. The guard called the on-call nurse who asked that the guard talk to Mr Angeles on their rounds and get back to her with more information.
34.	However when the guards did their rounds Mr Angeles was sleeping and so they didn’t wake him or call the nurse.
35.	At 1.35 am on 10 November 2014 the guard called the nurse saying that the pain was still there. Given that he had been able to sleep with the pain the nurse asked that he be brought to the clinic in the morning.
36.	Mr Angeles took his medication again that morning. When he was observed by Dr Stevens at 8.10 am 10 November 2014 he still had epigastric pain but was described as “completely in touch mentally. He is clear thinking, rational, articulate”. He was treated and reported that the pain had reduced to 2 out of 10.
37.	At about midday Mr Angeles began to experience considerable pain. He took his GTN spray on six occasions but it made no difference. At 12.58 he called the guards and a code blue was called.
38.	Mr Angeles had pain of 9 out of 10 and it was sought that he be transferred to hospital to manage his analgesia requirements. He said he wouldn’t go to the hospital if he was to be shackled. Corrections agreed to remove the shackles and he went.
39.	After sending him to hospital Dr Stevens wrote “This inmate should have long since been in care and he is probably now properly described as needing palliative care”.
40.	The following day a referral was made to Palliative Care.
41.	He was released from RDH on 11 November 2014. The discharge summary noted:
“After discussion with John, he decided to continue medical treatment for NSTEMI (triple vessel disease), not want to undergo surgery. He would like to go back because of the appointment with the lawyer although he was planned to be observed in hospital for one more day. He did not want anticoagulation Clexane for 5 days in this admission.”
42.	At 3.33 pm that day Dr Forrest discussed pain management for Mr Angeles with the cardiologist. Dr Forrest also discussed the provision of Schedule 8 drugs to Mr Angeles in his cell with Corrections Management. Dispensing S8 drugs to Mr Angeles in his cell was approved by Corrections the same day.
43.	Mr Rawnsley, the lawyer for Mr Angeles, set out a number of concerns in an email to the Commissioner on 14 November 2014. They were:
43.1	That when at night Mr Angeles rang his bell Correctional Services officers made the judgement as to whether or not to call medical;
43.2	Other prisoners were able to access Mr Angeles’ cell some of whom had histories of drug abuse and may take his medication (although it was conceded that hadn’t happened to date);
43.3	Correctional officers were not trained or equipped to support his frailty. The example was given that Mr Angeles was unable to support himself to get water or go to the toilet and that his solicitor was of the understanding that he urinated in his shorts;
43.4	The electricity was unreliable and Mr Angeles was required to manually change his breathing apparatus;
43.5	It was difficult for Mr Angeles to receive visitors. At times he was unable to get to the front visitor area sometimes because he was too unwell;
43.6	Mr Angeles didn’t have his own wheelchair; and
43.7	At night other prisoners made noises making it difficult to sleep and causing stress.
44.	On 17 November 2014 Mr Angeles saw Dr Forrest. The discharge summary states:
“John attended on request as the NFR order needs to be documented on the approved form under the Advanced Personal Planning Act 2014. With Nurse Gazzard attending the consultation as a witness, Mr Angeles confirmed his request to not be resuscitated or given CPR and he requested that box 2 under "Life Support" be ticked. The document was then signed by Mr Angeles and Witnessed by Nurse Gazzard.
Mr Angeles requested to see the Optometrist as his reading glasses supplied recently are not optimum. Recall entered for optometrist.
He also asked whether it was ok with me for him to obtain a second medical opinion from a doctor at his own expense as he believes the Commissioner, in rejecting his request for early release, had not believed the prognosis supplied in my medical report. I advised I have no objection, the matter is up to him. However before going to this trouble and expense recommended he check with his lawyer to see that such an opinion would be likely to make a material difference to the Commissioner’s decision.”
45.	On 18 November 2014 (about 2 weeks before Mr Angeles died) the Commissioner responded to Mr Rawnsley, also by email. He said in part:
“I have had the issues you raised inquired into as I had concern that from your comments that Mr Angeles was not being cared for as I would expect.
I can confirm that it has been reinforced to the correctional staff that when Mr Angeles seeks medical assistance that it is provided and the on-call medical staff are called. I have been assured that the cell in which Mr Angeles stays has running water and it is available to him at all times. I am also advised that the breathing apparatus has a battery back-up system built in and that is a safe-guard during any power failure. Staff advised that from time to time prisoners overload the power circuits but these are restored quickly. I am advised that Mr Angeles has a walking frame in his cell at all times and the wheelchair is provided as and when required, if necessary the wheelchair can be provided and kept in his cell.
I am also advised that Mr Angeles was offered a cell in C block to be closer to the visiting section and the medical clinic, however he requested to remain in L block as he is comfortable there.”
46.	The Commissioner also indicated that he was awaiting an assessment from the Department of Health on Mr Angeles’ longer term care requirements.
47.	Also on 18 November 2014 Mr Angeles was assessed for Palliative Care by Dr Yousuf Zubair, Staff Specialist Palliative Care Medicine at the Royal Darwin Hospital pursuant to the referral made seven days previously. Dr Zubair stated in part:
“I felt John did not have any Acute Specialist Palliative Care needs and have not admitted him to our service for case management. We would be happy to be reinvolved if he deteriorates significantly.”
48.	During that assessment it was noted by Dr Zubair that:
a.	Mr Angeles was of the impression that the referral for the assessment was so he could live out his days in the RDH Hospice;
b.	It was explained to him that only patients in their last days or weeks were accepted at the Hospice but that he may be in the last year of his life;
c.	Mr Angeles stated that his greatest distress was not being able to sleep at night. He was having intrusive thoughts and the prison environment was not peaceful;
d.	He also said the effort of seeing his visitors weekly was too much effort and he had asked his sister to come fortnightly;
e.	The doctor thought he was a little depressed but Mr Angeles said that although at times he wished for it all to end his love for family and the Roman Catholic faith stopped him doing anything;
f.	He had requested the Chaplain weeks ago but hadn’t seen him yet;
g.	His Chest pain was well controlled and he hadn’t needed his GTN spray for 2 weeks (although the medical notes indicate it was only about one week);
h.	He was able to mobilise a few metres without oxygen;
i.	He had longstanding arthritic pain.
49.	Doctor Zubair provided a summary of his recommendations:
a.	Not for case management by Territory Palliative Care at this stage;
b.	Consider ceasing Panadol Osteo 2 Tabs BD and starting Norspan/Buprenorphine patch
c.	Wheelchair with carry hook for Oxygen;
d.	Catholic Chaplain Review
e.	Mirtazepine 30mg Nocte for poor sleep and depressed mood;
f.	If breathlessness worsens PRN Morphine and Alprazolam for comfort;
g.	Re-refer to TPC when patient deteriorates in the future.
50.	The following day Wednesday, 19 November 2014 Mr Angeles was seen at the Clinic by Doctor Stevens. The notes by Registered Nurse Gazzard state:
“Discussion with Dr Stevens, John and myself regarding palliative care appointment yesterday. They have advised some medication changes most significant of which is a Buprenorphine patch for pain relief in regard to his Osteoarthritis. John states he is having no issues with cardiac related pain. He states he receives good pain relief from panadol osteo but is sick of having to take so many tablets. This is his motivation for wanting the patch. John states he doesn’t need the morning panadol osteo so this has been ceased by Dr Stevens.
Review on Friday with Dr Forrest regarding other changes. John is happy with this plan.”
51.	On Friday 21 November 2014 Mr Angeles saw Dr Forrest at the Clinic. The notes state:
“Discussed the recommendations of Pal care consult with Mr Angeles.
Mirtazapine added as per recommendation. Discussed the dual effect of night time sedation and anti-depression.
Also altered metformin presentation as he finds the 1000 mg tabs to be hard to swallow.”
52.	At 9.00 am on 2 December 2014 Mr Angeles was suffering sharp central chest pain. He took three doses of Glyceryl Trinitrate (GTN) but the pain persisted. He called for assistance and a Code-Blue was called.
53.	He was given 2.5 mg of morphine and his pain score was down to 3/10 within a minute. He was given another 2.5 mg at 9.15 am and after five minutes he had no pain. He was advised to stay in bed the rest of the day. Thirty minutes later he was assessed and remained pain free.
54.	Dr Catherine Bruck went to see him in his cell at 4.47 pm that day to ensure that all that could be done for him was being done. She was satisfied that he was having very good care. She wrote:
“He says he is eating and has no complaints.
He appears well looked after. He is clean and his hands were moisturised. The room has a fan and he did not appear in any distress.”
55.	At approximately 5.00 am on Wednesday 3 December 2014, Prisoner Billy Maroney (the carer for Mr Angeles) was making breakfast in Sector 6. Sometime thereafter, he heard the deceased cough a couple of times and went to his cell to check on him. He looked gaunt and drawn.
56.	Mr Angeles said he had a dry throat and Billy got him some water. Mr Angeles said he was feeling nauseous and asked for a container. Billy gave him a blue breakfast bag. He dry retched into the bag.
57.	At little before 7.00 am Billy helped Mr Angeles into a wheelchair and wheeled him to the toilet.
58.	Mr Angeles was still in the toilet at morning muster sometime between 7.10 am and 7.30 am. Prison Officers checked on him there.
59.	A little after 8.00 am Billy heard Mr Angeles call out. He entered Mr Angeles cell and found him clutching at his chest. Mr Angeles said “Get the nurse, I am having a heart attack”. Billy hit the duress alarm/intercom and told the prison officers “Jacko has chest pains”.
60.	A Code-Blue was called at 8.10 am alerting all staff to the medical emergency. At that time Registered Nurse Matthew Maddison was dispensing medication in Sector 6. He arrived at Mr Angeles’ cell less than 30 seconds after the Code-Blue was called. He found him lying on his back on the bed. Mr Angeles said he had self-administered four sprays which the nurse interpreted to mean four oral sprays of GTN.
61.	Shortly thereafter another Registered Nurse, Trina Menera arrived. She had been dispensing medication close by in Sector 7. She located a radial pulse. His respiratory rate was assessed to be 22 but shallow. He was alert but looked tired and pale. 
62.	Mr Angeles agreed to be taken back to the Clinic and was assisted to sit up and then moved to the wheelchair. He was weak but able to partially bear his own weight. He said he didn’t want his oxygen and took his out his nasal prongs.
63.	By that stage Registered Nurse James Gazzard arrived as part of the medical response team and wheeled Mr Angeles to the Medical Clinic. There was some talk of transferring him to a stretcher and taking him in the buggy but it was decided that it would be more efficient to wheel him to the Clinic in the chair.
64.	During the transfer to the Clinic Mr Angeles continued to dry retch into the bag and complained of severe back pain. He arrived at the clinic at about 8.20 am.
65.	Mr Angeles was asked whether he wanted Maxolon for the nausea. He refused.
66.	He was transferred to a bed in the emergency treatment room. He was still conscious and feeling pain, moving around on the bed, unable to get comfortable. He was given 5 millilitres of Morphine at 8.23 am. The nurse said “you’ll be feeling better soon, John”. Mr Angeles just groaned. At that time there was no readable blood pressure and his respiration rate had dropped to about 14.
67.	A short time later he appeared to be unconscious and on examination was not breathing and had no other signs of life.
68.	The Clinic staff aware of his Advance Care Plan, directing that he not be resuscitated, did not attempt resuscitation.
69.	He was declared dead by Dr Bruck at 8.30 am.
70.	When providing a statement to the Coronial Investigators, Dr Bruck noted that when she arrived at the clinic to find Mr Angeles already there with chest pain she started a conversation in relation to longer term options for relief. In explaining that sequence she voiced some concerns and frustrations with the provision of medical care in the secure environment. 
71.	She noted there may be difficulties of getting approval for the use of Fentanyl patches for pain relief. She noted that she was also thinking of giving him more regular subcutaneous morphine. She said “you know that would have been fine”.
72.	However in the event a decision in relation to that was overtaken by the death of Mr Angeles just moments later.
73.	The doctor was then asked if she had anything further she wished to add. She indicated her sadness for the carer of Mr Angeles and hoped that care was being provided to him. She then wondered whether prison was the best place for the deceased. She said:
“It goes to a bigger picture of – which is not my deal, its not my place but you know – ah – was this the best place for him to be? I did actually try to get – you know I try to get these people assessed as to whether this is appropriate but then its – ah – it’s – a gov – it’s a government call actually.
As to whether he has to stay to die in prison or whether he’s allowed out and how does that go and – funnily – well not funnily but you know – ah – maybe he was better cared for and maybe outside, I dunno’ but anyway, he’s at peace so there we are.”
74.	Dr Bruck was asked whether the pain could be managed in the prison. In answering the question she indicated her displeasure at the safety and welfare issues encountered. She said:
“Come look at the welfare issues, come look at the heat stress issues. It is not acceptable that the prisoners are in risk cells that are boiling hot. It is not acceptable that the guards are drenched. It is not acceptable that the nurses are dizzy. This is all bad, this is all – and yes, I’m employed as a General Practitioner here but actually I have a Fellowship in Occupation, Environmental Medicine. People pay me large amounts of money to do this in other contexts.”
75.	She was asked whether any of those issues related to the deceased. She said:
“Yeah, the care – the issues that I have just raised, so it’s actually quite clear in my mind when I went to see him yesterday, was he cool? Was he hydrated, was he in an acceptable environment and yes, he had a fan, he had oxygen, he had fluids, he had a carer, I was absolutely convinced so much so that someone had moisturised his hands, so he was getting exceptionally good care. He was clean, he wasn’t angry, he wasn’t frustrated which he’s been in the past. No he was actually in a very nice environment and I was very calm about that and thought – I was reassured as well”.
76.	The sister of Mr Angeles was of the view that the deceased should have been given leave so as to be cared for by her and die at her house. That was undoubtedly the wish of the deceased also. 
77.	Unfortunately, the lot of a sentenced prisoner is such that they do not have the same freedoms as others. They are not able to enjoy important family celebrations and events such as weddings, funerals, birthdays and the like.
78.	The Commissioner of Correctional Services has the discretion to provide leave to a prisoner. But that is the Commissioner’s discretion. In my view, it is not a matter that the Coroner has jurisdiction to review, in any event, I do not think that the discretion was unreasonably exercised.
79.	Certainly an issue for this Inquest is whether the care, supervision and treatment of the deceased was adequate. The sister of the deceased had a number of concerns.
80.	The first was whether pain relief was adequate. Ms Logan accepted that the pain he experienced when having the heart attack on 3 December 2014 was inevitable and that the actions of the nurses in rushing him to the clinic rather than attempting to relieve the pain could not be criticised.
81.	However she was concerned that perhaps not enough was done for his pain relief and that might well have related to the restraints upon him keeping morphine in his cell.
82.	The evidence is that the deceased had angina for many years in fact some decades. He generally used GTN spray when it occurred. Although he had other ailments the ischaemic heart disease was his main health issue.
83.	Dr Forrest wrote in his report after seeing Mr Angeles on 17 October 2014:
“However it should be noted that he has reached maximal medical therapy for his ischaemic heart disease. There are no further practical additions to be made to his medication regime that could provide further relief of chest pain.”
84.	Certainly as at that date there is no evidence that the pain relief provided was not appropriate.
85.	However Mr Angeles started to refuse medication on 3 November 2014. By the evening of 9 November 2014 the pain was returning.
86.	It was unfortunate that Mr Angeles was not seen and provided with further medication for his pain on that evening after he called the guards. However that was taken up with the Commissioner by Mr Angeles’ lawyer on 14 November 2014 and the Commissioner made a directive such that it would not happen again.
87.	What Mr Angeles said to Dr Zubair on 18 November 2014 suggests that from the time of his return from hospital on 11 November he had no further cardiac pain. Dr Zubair noted:
“John claims his chest pain is well controlled at present and he has not needed any GTN spray for over two weeks.”
88.	Dr Zubair made recommendations for altering medication. Those recommendations were followed. Dr Zubair also recommended, “Consider ceasing Panadol Osteo 2 Tabs BD and starting Norspan/Buprenorphine patch”.
89.	There was some suggestion by the lawyer for Ms Logan that this recommendation was not followed. However, there is clear evidence in the medical notes that consideration was given to making that alteration in discussion with Mr Angeles. 
90.	Mr Angeles saw Dr Stevens on 19 November 2014. The note in the medical records from the registered nurse is as follows:
“Discussion with Dr Stevens, John and myself regarding palliative care appointment yesterday. They have advised some medication changes most significant of which is a Buprenorphine patch for pain relief in regard to his Osteoarthritis. John states he is having no issues with cardiac related pain. He states he receives good pain relief from Panadol osteo but is sick of having to take so many tablets. This is his motivation for wanting the patch. John states he doesn’t need the morning Panadol osteo so this has been ceased by Dr Stevens.”
91.	It is clear that the pain from Osteoarthritis was not an issue at that point. It was the tablet taking that was annoying the deceased. He was part of a discussion where after consideration it was decided not to move to the use of the patch at that time but to reduce his Panadol osteo tablets to one a day.
92.	There was also some suggestion by the lawyer for Ms Logan that perhaps there was a difficulty with the introduction of Fentanyl patches as suggested by Dr Bruck. However the evidence is that Dr Bruck was raising the possibility of the patches on the morning of 3 December 2014, as it turned out, moments before Mr Angeles died. 
93.	There may or may not have been issues with having those patches in the Correctional environment. Dr Bruck thought there may be and was already suggesting the alternative of morphine. She thought morphine might in any event be a better option. But the need did not eventuate.
94.	There is no evidence to suggest that the provision of pain relief was inadequate. Apart from the times Mr Angeles refused his medication he seemed to have the pain well controlled.
95.	Allied to those concerns over pain relief was the suggestion that the recommendations of medical practitioners may not have been followed. However, if the reference is to the patches, as seen above, consideration was given to one (but no recommendation was made) and in relation to the other the issue didn’t arise.
96.	It is not at all clear that any recommendation was ever made in relation to those or any other matters to Corrections by medical practitioners. What is clear is that when an issue did arise and was discussed with Corrections, approval was given the same day. That was as previously noted in relation to dispensing the S8 drugs in Mr Angeles’ cell.
97.	A further concern was the alleged failure to have an identified palliative care plan. However there was the referral to Dr Zubair, the Palliative Care specialist, the deceased being seen by the Palliative Care specialist and the decision being made that he wasn’t to be managed by the palliative care team because it was considered that he was more likely to be in the last year of his life rather than the last days or weeks.
98.	As it turned out he died within weeks. 
99.	There was however a plan as provided in the recommendations of Dr Zubair that when he deteriorated further he was to be referred to the Palliative Care team. He died before that anticipated deterioration.
100.	The evidence is that the medical treatment was of an appropriate standard, that he had a fellow prisoner that undertook to assist him in his daily tasks and that any issues raised were immediately investigated and met by the Commissioner. 
101.	An autopsy was performed by Paull Botterill on 5 December 2013. His report of 10 April 2015 contained his conclusion in these terms:
“This 79 year old male, in a prison care facility, was known to have end stage cardiovascular disease with hypertension, diabetes, and a number of clinical myocardial infarctions.  He required a wheelchair and oxygen supply supplementation.  He described nausea on the morning of 3rd December 2014 and was given pain relief (morphine) later that morning; he had been refusing medical treatment beyond pain relief.  He died between 0825 and 0830 hours that morning.
In plain terms, autopsy findings included severe hardening and narrowing of the arteries of the heart and the rest of the body, honeycomb-like scarring within the lungs, an excess of fluid in the lungs, and some scarring of the kidneys.  No significant injuries or additional unexpected illnesses were identified.  
At the time of autopsy the cause of death was believed to be the consequences of ischaemic heart disease, but the relevant contribution of chronic lung disease and the possibility of concurrent drug toxicity was difficult to completely exclude at that time.  Further investigations were subsequently performed.  Microscopic examination showed heart muscle scarring, lung congestion and scarring, possible lung infarction, patchy inflammation of the thyroid, some liver fatty change and kidney scarring.  Testing for drugs and poisons showed the presence of sublethal levels of painkillers (morphine, paracetamol), fluid excreter (frusemide), antinauseant (metoclopramide), blood pressure lowering agents (irbesartan, bisoprolol), blood thinner (clopidogrel) and an antidepressant (mirtazapine).  No alcohol was detected.
CAUSE OF DEATH
Condition leading directly to death:	1(a) ISCHAEMIC HEART DISEASE

Other significant conditions contributing to death
but not related to the condition causing death:	II    CHRONIC LUNG DISEASE; 
       DIABETES MELLITUS” 	
		
102.	I find that the care, supervision and treatment of the deceased was of an appropriate standard and his medical care was undertaken in accordance with his declared wishes.
103.	It is likely that the disquiet of Ms Logan arises from the fact that she was unable to care for the deceased in the last weeks of his life and was forced to leave that to others in the prison.
104.	That is understandable and it is most unfortunate that she was left wondering whether or not her brother was comfortable in his last days and weeks.
105.	Unfortunate as that may be however it arose because Mr Angeles was a prisoner. As is often the case the anguish arising from his imprisonment was not his alone.
106.	Pursuant to section 34 of the Coroner’s Act, I find as follows: 
(i) 	The identity of the deceased was John Allan Angeles born on 24 June 1935, in Darwin, Northern Territory, Australia. 
(ii) 	The time of death was 8.30am on 3 December 2014. The place of death was the Health Centre, Darwin Correctional Centre, Holtze in the Northern Territory. 
(iii) The cause of death was Ischaemic Heart Disease. 
(iv)  The particulars required to register the death: 
1. 	The deceased was John Allan Angeles.
2. 	The deceased was of Aboriginal descent. 
3. 	The deceased was not employed at the time of his death. 
4. 	The death was reported to the coroner by the Correctional Centre. 
5.	The cause of death was confirmed by post mortem examination carried out by Dr Paull Botterill. 
6. 	The deceased’s mother was Elna Angeles and his father was Timothy Thomas Angeles.

Dated this 16 day of October 2015.
		_________________________
	GREG CAVANAGH
                                                                             TERRITORY CORONER