Record of Investigation Into Death (With Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Simon Cooper, Coroner, having investigated a death of Dennis Robert Carr

WITH AN INQUEST HELD AT Launceston Coroners Court in Tasmania on 14 January 2015


Dennis Robert Carr died on 4 June 2014 in the Royal Hobart Hospital. At the time of Mr Carr's death he was serving a sentence of 23 years imprisonment for murder. Section 24(1)(b) of the Coroners Act 1995 (the 'Act') requires a coroner who has jurisdiction to investigate a death to hold an inquest into such a death occurring when the deceased was "immediately before death a person held… in custody".

Formal Findings:

In every case the subject of a coronial investigation s28 of the Act requires a coroner to make, if possible, various findings. In that regard the evidence at the inquest satisfied me that:

(a) The identity of the deceased is Dennis Robert Carr;

(b) Mr Carr died in the circumstances described in this finding;

(c) Mr Carr died of natural causes namely, hepato-renal syndrome due to multifactoral advanced cirrhosis;

(d) Mr Carr died on 4 June 2014 at Royal Hobart Hospital;

(e) Mr Carr was born in Hobart on 24 September 1963 and was aged 50 years at the time of his death; he was married and serving a sentence of imprisonment at the date of his death; and

(f) No other person contributed to Mr Carr's death.

In making the finding that I have with respect to the cause of Mr Carr's death, I expressly accept the opinion of Dr Donald Ritchey, Forensic Pathologist.

Background and Circumstances of Death:

Dennis Robert Carr was born in Hobart on 24 September 1963. He had a lengthy and extensive history of prior convictions dating back to as early as 1976. He was sentenced to, and served, numerous periods of imprisonment for a variety of crimes and offences including dishonesty matters, drug offences, driving offences, violence (and in particular family violence).

Mr Carr had a long-standing addiction to illicit drugs. In addition he had a lengthy and extensive history of alcohol abuse.

On 20 December 2010 he was sentenced for the murder on 2 September 2009 of Robert Porter at Ravenswood in Tasmania. Crawford CJ sentenced Mr Carr to 23 years imprisonment with a non-parole period of 14 years. As such at the time of his death he was serving that sentence.

Mr Carr had been infected with Hepatitis C approximately 30 years ago. Medical material tendered at inquest makes it clear that he had developed cirrhosis of the liver some years ago as a result of alcohol abuse and that his health generally had been in a significant decline since 2011.

Whilst serving his sentence of imprisonment at the Rison Prison complex he was constantly subject to, and in receipt of, treatment. A review of that treatment makes it quite clear that it was entirely appropriate. Attempts were made to determine whether Mr Carr was suitable for liver transplant or any new drug regime. No treatment was identified as being suitable for Mr Carr.

In the six months prior to his death Mr Carr suffered several infections of the liver. He was admitted on a number of occasions to the Royal Hobart Hospital. Those admissions were in my view appropriate; the treatment that he received at the Royal Hobart Hospital was also entirely appropriate.

During this time Risdon Prison medical staff, in consultation with Mr Carr, created a palliative care planned to be initiated as and when it was required. Again I am satisfied that this approach was entirely appropriate.

On 26 May 2014 Mr Carr was admitted for the final time to the Royal Hobart Hospital suffering from advanced liver disease. He was non-responsive to treatment and developed a hepato-renal syndrome. Accordingly the palliative care plan previously developed in consultation with Mr Carr was initiated. He was treated with sedatives and morphine for pain relief.

At 8.05am on 4 June 2014 in the presence of prison staff Mr Carr died.

His death was reported as required to the coroner's office and thereafter investigated. That investigation did not reveal any suspicious circumstances.

Mr Carr's body was subject of an autopsy carried out by Dr Ritchey. Dr Ritchey expressed the opinion, which opinion I accept, that the cause of Mr Carr's death was a hepato-renal syndrome, multifactorial advanced cirrhosis as well as other issues including as asplenia and obesity with chronic opioid dependence.

Report on Care and Mr Carr Whilst in Custody

Section 28(5) of the Act is in the following terms:

"(5) If a coroner holds an inquest into the death of a person who died whilst that person was a person held in custody or a person held in care or whilst that person was escaping or attempting to escape from prison, a secure mental health unit, a detention centre or police custody, the coroner must report on the care, supervision or treatment of that person while that person was a person held in custody or a person held in care."

It should be clear from the foregoing that I am affirmatively satisfied on the basis of the evidence at the inquest that the care and supervision of Mr Carr was of an entirely acceptable standard and in no way caused or contributed to death.

Comments and Recommendations:

The circumstances of Mr Carr's death are not such as to require me to make any comments or recommendations pursuant to section 28 of the Coroners Act 1995.

I wish to convey my sincere condolences to Mr Carr's family. 

Dated: 23 January 2015 at Hobart in the State of Tasmania. 


Simon Cooper