CITATION:	Inquest into the death of Kevin John Steel [2016] NTLC 013

TITLE OF COURT:	Coroners Court

JURISDICTION: 	Alice Springs	

FILE NO(s): 	A0045/2015	

DELIVERED ON: 	21 June 2015	

DELIVERED AT: 	Alice Springs	

HEARING DATE(s): 	21 June 2016	

FINDING OF: 	Judge Greg Cavanagh

CATCHWORDS: 	Death in custody, of natural causes while in prison, care and treatment appropriate	

REPRESENTATION:

Counsel Assisting:     	Kelvin Currie	

	

Judgment category classification: 	A
Judgement ID number:	[2016] NTLC 013	 
Number of paragraphs: 	22	
Number of pages: 	5 	

IN THE CORONERS COURT
AT ALICE SPRINGS IN THE NORTHERN 
TERRITORY OF AUSTRALIA

No. A000045/2015
	In the matter of an Inquest into the death of 
	KEVIN JOHN STEEL
	ON 15 AUGUST 2015
AT ALICE SPRINGS HOSPITAL

FINDINGS

Judge Greg Cavanagh 
Introduction
1.	Kevin John Steel (the deceased) was a 65 year old Aboriginal male born 16 January 1950 in Innisfail, Queensland to Coral Steel and Kevin Maroney. His mother was just 17 years of age at the time. He never got to know his father and was raised by his grandmother for the first six year and thereafter his mother and step-father, Finlay Steel. He had six siblings. 
2.	He grew up in Mt Isa, Queensland and went to Barkley Highway School until year six. He left school at 13 years of age and found work on cattle stations and for a time as a miner. He stopped work in 1997 due to a back injury.
3.	It is recounted by one of his sisters that their grandfather molested him has a child. He alleged that he was raped by a cousin when he was eight years of age and sexually abused by his extended family.
4.	The deceased married Dianne in 1972 and together they had three children. However in 1990 the deceased was sentenced to six years imprisonment for child related sexual offences. His wife separated and divorced him.
5.	In 2010 he was sentenced to three years six months imprisonment, again for child related sexual offending in Queensland and upon his release on 9 May 2014 he was extradited to the Northern Territory in relation to allegations of sexual assault on children dating from 2002. 
6.	On 24 April 2015 he was sentenced to imprisonment for fourteen years with a non-parole period of 10 years, his earliest date of release was 9 May 2024.
7.	Shortly after his incarceration in Alice Springs Correctional Centre he was suspected of having lung cancer. He was referred to the Oncology service at Alice Springs Hospital on 25 May 2014. In June he was transferred to the Royal Darwin Hospital where he underwent a Computed Tomography (CT) guided biopsy procedure. That confirmed that he was suffering from Non-small Cell Lung Cancer.
8.	That was not the only medical condition from which he suffered. He also suffered from ischaemic heart disease, atrial fibrillation, obesity, obstructive sleep apnoea, bronchiectasis, chronic obstructive pulmonary disease, prostate cancer and lumbar osteoarthritis.
9.	He was sent to the Royal Adelaide Hospital where between 25 August 2014 and 8 September 2014 he underwent a course of radiotherapy. The treatment complicated the functioning of his lungs and it was determined that he would not be suitable for any further similar treatment.
10.	He returned to the Alice Springs Correctional Centre but had frequent admissions to Alice Springs Hospital for increasing shortness of breath, pleural effusion, worsening heart failure and recurrent chest infections. Examination in January 2015 confirmed that the lung cancer was progressing.
11.	On 3 April 2015 his prognosis was poor and he was expected to live for only “short months”. Discussions were had with the deceased and it was determined that there was no justification for further investigation and treatment and at the deceased’s request the management plan was that he be provided with palliative care only on any further admissions. He was provided with oxygen on a full time basis.
12.	On 8 May 2015 and 7 June 2015 he was transferred to the Hospital suffering from shortness of breath. On 19 June 2015 he was transferred to the Hospital suffering chest pains and then on 20 July 2015 and 31 July 2015 due to shortness of breath.
13.	On 9 August 2015 he was transferred to the Hospital. He was feeling generally unwell. He was diagnosed with heart and respiratory failure. He was admitted to Medical West Palliative Care. He remained there until 2.32 am on Saturday 15 August 2015 when he was observed to have stopped breathing. 
14.	Doctor Fariba Nadimi Specialist in Palliative Medicine provided the cause of death as Congestive Cardiac Failure secondary to Ischaemic Heart Disease on a background of Non-Small Cell Lung Cancer with disseminated metastatic pleural disease and malignant pleural effusion.
15.	Other conditions contributing to, but not directly causing the death, were stated to be atrial fibrillation, obstructive sleep apnoea, chronic obstructive pulmonary disease and obesity.
16.	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;”
17.	Pursuant to section 15 of the Act where a person dies in custody the Coroner must hold an inquest.
18.	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.”
19.	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.

20.	The investigation has disclosed that the care, supervision and treatment of the deceased was of an appropriate standard.
21.	The Commissioner of Correctional Services did arrange for the provision of appropriate health care for the deceased.
22.	Pursuant to section 34 of the Coroner’s Act, I find as follows: 
(i) 	The identity of the deceased was Kevin John Steel born on 16 January 1950, in Innisfail, Queensland, Australia. 
(ii) 	The time of death was 2.32am on 15 August 2015. The place of death was Alice Springs Hospital, Alice Springs in the Northern Territory. 
(iii) 	The cause of death was Congestive Cardiac Failure secondary to Ischaemic Heart Disease due to Non-Small Cell Lung Cancer with disseminated metastatic pleural disease and malignant pleural effusion. 
(iv)  The particulars required to register the death are: 
1. 	The deceased was Kevin John Steel.
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 Alice Springs Hospital. 
5.	The cause of death was confirmed by Doctor Fariba Nadimi Specialist in Palliative Medicine. 
6. 	The deceased’s mother was Coral Steel and his father was Kevin Maroney.

Dated this 21 day of June 2016.
		_________________________
	JUDGE GREG CAVANAGH
                                                                             TERRITORY CORONER