Record of Investigation into Death (Without Public Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Rod Chandler Coroner, have investigated the death of

Zane David Webb

Findings, Recommendations and Comments of Coroner Rod Chandler following an inquest held in Hobart on 30 March and 15 November 2012.

Introduction:

1. Zane David Webb (“Mr Webb”) was born in Hobart on 14 May 1982 and was aged 28 years.  He was the son of David and Trudy Webb of Glenorchy.  He was employed as a labourer by the Hobart City Council.
2. On 25 May 2010 Mr Webb was found guilty by a jury on a charge of assault.  He was remanded in custody.
3. On 28 May 2010 Mr Justice Blow of the Supreme Court of Tasmania sentenced Mr Webb to fourteen months imprisonment for the assault.  He was conveyed to Her Majesty’s Prison at Risdon (‘the prison’) to serve his sentence.  He was assigned to the prison’s Gordon A unit which is a medium security division and was housed in Cell 3.
4. Dr Christopher Wake is the Clinical Director of the Tasmanian Prison Services Correctional Primary Health Services.  Dr Wake’s responsibilities include the medical care of all inmates at the prison.

The Death:

Shortly after 7.00 am on Wednesday 30 June 2010 a morning muster was carried out for the inmates of Gordon A Unit.  Mr Webb was not present.  Correctional officer Andrew Smith, along with two other correctional officers attended Mr Webb’s cell.  They gained access using a master key.  Mr Webb was found lying face down on his bed.  He did not respond when touched.  A ‘code blue’ was called and nursing staff promptly attended.  Mr Webb’s body was cold to touch and was stiff.  A heart beat could not be detected.  It was evident that he was deceased.

Post Mortem Examination:

A post-mortem examination was carried out by Forensic Pathologist, Dr Donald Ritchey.  In his report Dr Ritchey makes these comments:

“The autopsy revealed a well developed, well nourished adult Caucasian man with copious pulmonary oedema in the lungs, airways and emanating from the mouth.  In addition, there were peri-mortem lacerated contusions of the sides of the tongue that were the apparent source of bleeding from the mouth.
There were no suspicious or defence/restraint-type injuries of the fingers, hands, wrists, forearms, upper arms or neck.  There were no petechial haemorrhages of the eyes.  An in situ layered dissection of the neck revealed no trauma of the neck organs.
A review of the medical records from the Glenorchy Medical Centre and RHH confirm a previous evaluation for a generalised seizure disorder and plans for evaluation for a possible sleep-related breathing disorder.
These findings are interpreted by me to suggest that Mr WEBB has suffered a seizure as evidenced by the injuries to his tongue and copious pulmonary oedema.
Sudden unexpected death in epilepsy (SUDEP) is defined as the sudden unexpected non- traumatic, non-drowning death of an individual with epilepsy,  witnessed or unwitnessed, in which post-mortem examination does not reveal an anatomical or toxicological cause for the death. ”

Toxicological testing indicated the presence of a sub-therapeutic level of paracetamol recorded at “less than 1.0mg/L.”  No other drugs were detected.
In Dr Ritchey’s opinion the cause of Mr Webb’s death was sudden unexpected death in epilepsy. 

Circumstances Surrounding the Death:

Mr Webb was employed in the prison’s laundry.  He worked on the morning of Tuesday 29 June.  He had lunch with his fellow prisoners ending at about 12.45 pm.  He was then due to resume work but did not do so telling a correctional officer that he had a headache.  Mr Webb spent that afternoon either in or around his cell.  He was seen to clean out his cell which was his weekly practice.  He had a coffee at the common table and chatted with Leonard Hillier, a fellow inmate.  He made no complaints about his health.  He had his evening meal and was later observed socialising and playing cards in the common area.  His cell door was open and at about 10:00 pm he was seen lying on his bed watching TV.  Jonathon Meddich occupied the cell alongside Mr Webb’s.  He observed Mr Webb go to the toilet that evening sometime between 10:30 and 11:00 pm.  He was then seen to return to his cell.  This appears to have been the last observation made of Mr Webb whilst he was alive.

The following morning, Mr Webb did not attend for a shower.  His cell door was seen to be closed.  Sometime before 7.00 am Mr Meddich knocked on his door but did not get a response.  It was after this that the muster was called and Mr Webb’s absence was noted by the correctional officers. 

Mr Webb’s cell door was fitted with a standard mortice lock.  He was provided with a key for this lock.  The door could be locked from the inside using a latch.  This could be over-ridden externally, either by use of Mr Webb’s key or by a master key.  Correctional Officer Joseph Shorrock was one of the staff members who entered Mr Webb’s cell when he was found deceased.  It was his evidence that the door to Mr Webb’s cell had been locked from the inside.  This is consistent with Correctional Officer’s Smith’s evidence that he had to use a master key to gain access to Mr Webb’s cell.  Correctional Officer Shorrock further said that he was “99.9% sure that (Mr Webb’s) key was in his room and attached to his lanyard.” 

The foregoing evidence leads me to the view that it is likely that Mr Webb, when he retired after using the toilet in the late evening of 29 June, locked his door from the inside and that it remained locked until the correctional officers attended the following morning.  It follows that it is highly unlikely, in my opinion, that any person   accessed Mr Webb’s cell at any time that night. 

Mr Webb’s cell, along with all others in Gordon A, was equipped with an intercom.  Records show that the intercom system was checked on 28 June and on 1 July 2010 and no faults were found.  There is not any evidence of Mr Webb using or attempting to use his intercom at any time during the night of 29 June. 



Mr Webb's Medical History:

Mr Webb had been a long term patient of the Glenorchy Medical Centre.  His usual general practitioner was Dr Ian Beltz although it seems that he last saw Mr Webb on 23 April 2006.  The material presented at inquest indicates the following relevant medical history:

• In April 2001 Mr Webb was referred to the Royal Hobart Hospital (‘the Royal’) for further investigation after suffering a probable seizure.  A CT scan and an EEG carried out at this time were both reported as normal. 
• On 3 December 2003 Mr Webb attended the Glenorchy Medical Centre after a ‘fit.’  He was referred to Mr R Nightingale for specialist review.  It is not known whether he attended Mr Nightingale.
• On 1 April 2006 Mr Webb presented at the Royal with a left shoulder dislocation“from rolling over in bed.”  This presentation was on a background of multiple previous dislocations.
• In late 2006 Mr Webb had left shoulder stabilisation surgery.  It was reported at this time;“He has been thoroughly investigated for epilepsy as a cause for these nocturnal dislocations and this has been ruled out.”
• On 23 June 2009 attended at the Glenorchy Medical Centre.  He was seen by Dr Keith Miller who obtained this history; “…Mr Webb presented having had an event that he called a ‘seizure’ the night before.  Also that this was associated with him dislocating his right shoulder, something that had been happening about once a month.  He also mentioned that he bit the inside of the tongue and that he passed urine without control.  He described having had 4-5 similar episodes over the previous 5 years, though passing urine had not occurred before……..these episodes only occurred at night….he had been investigated with an EEG and CT of the brain in the past and these were apparently normal, and also that no restriction to his driving had been put in  place.”  It was also noted that Mr Webb was a snorer and Dr Miller considered the possibility that he may have had episodes of apnoea.  He therefore referred Mr Webb to the Royal’s Respiratory Clinic for investigation of possible sleep apnoea.  He also sent a second referral to the Royal for an orthopaedic assessment of his on-going shoulder problem.  Of the possibility of epilepsy Dr Miller has commented; “As epilepsy appeared to have been excluded it seemed unlikely to me that these represented true epileptiform seizures.  It seemed more likely that some other episode had occurred at night…….given that these (‘seizures’) were rare events occurring over a long period of time that had been investigated in the past, they appeared to be less sinister.” 
• In July 2009 Dr Miller was advised by the Royal that the referral of Mr Webb to the Respiratory Clinic should be re-directed to Dr Hugh Mestitz.  It is not known whether this occurred and if so whether Mr Webb saw Dr Mestitz.
• On 28 July 2009 Mr Webb did attend the Royal’s Orthopaedic Clinic.  He was advised to arrange further x-rays of his shoulder before a decision was made on further surgery. 

Mr Webb's Medical Treatment/Management Whilst in Custody:

In the morning of 26 May 2010 Registered Nurse David Noble carried out a Tier 1 Assessment of Mr Webb’s physical and mental health at the Hobart Reception Prison.  Mr Noble did not have access to Mr Webb’s medical records at this time.  During the assessment he ascertained that Mr Webb had suffered from a shoulder injury for which he had surgery in 2007.  He also indicated that he had previously been investigated for epilepsy but this had “been ruled out” and that it was suspected that he may have been suffering from sleep apnoea.  However, Mr Webb said that he was not using a C-Pap machine for this condition.  Mr Webb further indicated that he suffered from heartburn/ulcer.  Overall it was Mr Noble’s view that Mr Webb “presented as being fit and healthy.”  In accord with routine practice applicable to new inmates Mr Webb was then triaged as a category 2 patient meaning that he should attend Dr Wake for a medical examination within 48 hours. 

Later on 26 May Mr Webb was transferred to the prison.  There he was seen in the Medical Centre by Registered Nurse Matthew Chick for a routine ‘meet and greet.’  Mr Chick had access to Mr Webb’s Tier 1 assessment and Mr Webb confirmed it to be accurate.  In Mr Chick’s view Mr Webb “appeared relaxed and expressed no concerns about being in prison.” 

Dr Wake first examined Mr Webb on 1 June 2010.  He recorded that Mr Webb outlined to him a history of heavy alcohol use but denied other drug use.  He noted a possible history of sleep apnoea which required further investigation.  Mr Webb described reflux oesophagitis for which he took Omeprazole 20mg daily.  Mr Webb further reported that he had had micro-surgery to his left shoulder in 2007 and that he continued with a recurrent dislocating left shoulder joint.  He indicated no history of mental illness or self-harm.  He gave no history of cardiac or other vascular disease.  His full blood screening was normal.  Apart from being over- weight Dr Wake considered Mr Webb’s health to be “essentially normal to examination.” 

An appointment was made for Dr Wake to carry out a routine review of Mr Webb on 29 June.  The purpose of that appointment was to review how Mr Webb was settling into prison life, to discuss the results of his blood tests with him in person, to have further discussion about the on-going management of his left shoulder problems and for the further investigation of his sleep apnoea.  Too, it was intended to consider any issues that may have arisen on review of his GP notes which had been sought.

Mr Webb failed to attend for his examination on 29 June.  He did not give an explanation for his non-attendance.  He was recorded as a “no show” and another appointment was made for him to see Dr Wake the following day.

Mr Webb did not receive any medical treatment in the prison following his examination by Dr Wake on 1 June.  However, on four occasions he did complain to nursing staff of headaches and on each occasion he was given two Panadol tablets.  This occurred on 6, 19, 23 June and lastly at 8.00 am on 29 June.  It was Dr Wake’s evidence that this level of paracetamol consumption over a month was not a cause for concern noting that the permitted dosage for Panadol is 8 tablets per day. 
 

 Mr Webb's Medical Records:

On 26 May 2010 the prison forwarded by facsimile a request to the Glenorchy Medical Centre for it to provide a medical summary for Mr Webb.  On 28 May Dr Beltz faxed to the Department of Justice and Community Services a copy of the prison’s facsimile having endorsed on it that Mr Webb had not been seen at the Centre for 12 months and that the only medication which had been previously prescribed to him was Somac for relief of reflux.  Dr Belz says that he did not inform the prison of Mr Webb's visit to Dr Miller on 23 June 2009 because he did “not consider it relevant.”  He further said that had the prison requested all of Mr Webb’s notes that they would have been provided. 

It was the evidence of Dr Wake that the prison has no record of receiving the reply facsimile from Dr Belz on 28 May.  However, had it been sighted by him it would not have changed his medical management of Mr Webb“as it contained limited information.  Specifically he noted that the response “would not have been helpful in alerting me to the possible diagnosis of epilepsy.” 

It was Dr Wake’s further evidence that the medical summary requested of the Glenorchy Medical Centre should have complied with the requirements for a medical summary as stipulated by the Royal Australian College of General Practice.  Such a summary would have incorporated detail of Dr Miller’s consultation with Mr Webb on 23 June 2009.  Dr Wake said that this information, had he been aware of it, would have strongly suggested to him that Mr Webb was suffering from grand mal epilepsy.  It was his evidence that he would have immediately advised Mr Webb of his provisional diagnosis and made recommendations for its management.  This would have included his referral to a neurologist or physician for specialist input coupled with repeat EEG and CT investigations along with an MRI.  More immediately he would have recommended commencement of medication designed to reduce the frequency of seizures.  Too, he would have suggested that Mr Webb participate in an epilepsy care plan tailored to address lifestyle factors relevant to epilepsy. 

Dr Wake estimated that in about 50% of cases requests made of medical practitioners to provide the prison with a medical summary of a prisoner were not complied with by the time Dr Wake carried out his first medical review of that prisoner. 

It seems that since Mr Webb’s death the Royal has permitted the prison to have access to its digital medical records.  Similar access to prisoners’ medical records at the State’s other hospitals and at general practices would, Dr Wake made clear, significantly improve his care and treatment of prisoners. 

Findings/Recommendations/Comments as Required By The Coroners Act 1995:

I am satisfied and so find that Zane David Webb died at an unknown time but before 7.00 am on Wednesday 30 June 2010 in Cell 3 of Gordon A Unit which is a division of Her Majesty’s Prison at Risdon.  I am satisfied and find that the cause of Mr Webb’s death was sudden, unexpected death in epilepsy.  I am further satisfied that no person contributed to Mr Webb’s death.
 
At the time of his death Mr Webb was a person held in custody within the meaning of s3 of the Act and I am thus required by s28(5) to report upon the care, supervision and treatment of Mr Webb whilst he was held in custody.  This obligation leads me to report that I am satisfied on the evidence that the care, supervision and treatment afforded to Mr Webb whilst he was in in custody was at all times proper and appropriate. 

It’s necessary that I comment upon the medical information which Dr Belz says that he provided to the prison but, if received, was not sighted by Dr Wake.  That information was particularly scant and unhelpful.  It should, in my view, have included detail of Dr Miller’s consultation with Mr Webb on 23 June 2009.  I accept that had that detail been included in the advice, and Dr Wake had seen it, then it would have alerted Dr Wake to the real possibility that Mr Webb was suffering from epilepsy.  I accept that this in turn would have led Dr Wake to recommend to Mr Webb that he commence taking medication and that he participate in further investigation of his condition. 

The evidence in this matter falls well short of permitting a finding that Mr Webb’s death would have been avoided if Dr Wake had appreciated the possibility that Mr Webb was suffering epilepsy.  Nevertheless, the circumstances of this case very starkly illustrates the need for Dr Wake and his staff to have timely access to general practice medical records if they are to provide optimal care to those prisoners whose medical wellbeing is their responsibility.  This leads me to recommend that the Tasmanian Faculty of The Royal Australian College of General Practitioners liaise with the prison’s medical staff with a view to putting in place processes to better ensure that its members’ patient records for prisoners are made promptly available to authorised personnel at the prison upon request. 

Evidence was received at the inquest that Mr Webb’s parents did not learn of their son’s death until about 11.00am on 29 June, that is about four hours after his body was discovered, and that they were not provided with any information upon the cause or circumstances of the death until they retained legal counsel who was able to assist in obtaining some information for them.  Too, it seems that no offer of counselling was made to them by prison authorities.  It was the gist of Dr Wake’s evidence that prison personnel, including himself, consciously avoid having contact with the family of prisoner who has died in their care because of the fear that it may compromise any subsequent legal proceedings, including this inquest. 

Counsel for the family has urged me to recommend that the prison put in place protocols to ensure that family members are promptly informed of a prisoner’s death, that they have information of its cause and circumstances and that counselling is available, if requested.   It is my view that it is beyond my jurisdiction to make recommendations upon these matters as they are not sufficiently proximate to the actual cause of Mr Webb’s death.  (see Harmsworth v State Coroner [1989] 989 andR v Doogan; ex parte Lucas-Smith [2005] ACTSC 74.)  Nevertheless, it is trite to say but proper human decency does require families of a deceased prisoner to be promptly informed of the death, to be timely appraised, as far as reasonably possible of its cause and circumstances and to be given support.  A concern for any legal consequences that may follow from a death should not prevent these actions being taken.  Finally, families of deceased persons should be aware that it is commonplace for the Coroner, on request, to make available to the immediate family of a deceased person, the post mortem-report as soon as it becomes available.  In this instance Dr Ritchie’s report was completed within two months of Mr Webb’s death. 

I conclide by extending my aincere condolences to Mr Webb's fanily.

 

Dated at Hobart this 21 day of January 2013

 

Rod Chandler
CORONER