Record of Investigation Into Death (With Inquest)

Corners Act 1995
Coroners Rules 2006
Rule 11

I, Timothy John Hill, Coroner, having investigated the death of

Phillip John Salter

WITH AN INQUEST HELD AT Launceston Coroners Court

in Tasmania on the 12 and 13 December 2012

Find That:

 ( a)  Phillip John SALTER died on  the 19 June 2010 at the Launceston General Hospital,  Charles Street,  Launceston. 

 ( b) Phillip John SALTER  was born in Launceston, Tasmania on the 3 September 1959 and was aged 55 years.

  (c) Phillip John SALTER  was a single person whose occupation at the date of death was a retired truck driver.

 (d) I find that the deceased died as a result of complications of acute myeloid leukemia.

 (e) At the time of the deceased person’s death he was being treated by a medical practitioner.


1.    Phillip John SALTER died at the Launceston General Hospital on 19 June 2010.  He died of complications of acute myeloid leukaemia (AML).  Prior to him being admitted to the Launceston General Hospital, Mr Salter had been held in custody at the Launceston Reception Centre, a division of Risdon Prison.  This inquest is part of a coronial investigation conducted under the Coroners Act 1995 (“the Act”).  A coroner has jurisdiction to conduct an inquest into death where a person has been held in custody.  I am required to find, if possible, when and where he died, how his death occurred, the cause of his death and to identify any person who contributed to the cause of death.

2.    The primary focus of an inquest is to seek out and record the facts concerning the death of a person.  It is a fact finding exercise of an inquisitorial nature.  The facts which are relevant are those which may enable findings about the matters the Act requires the coroner to, if possible, determine. 

3.    Following an investigation conducted with the assistance of Tasmania Police an inquest was held in Launceston  commencing 12 December 2012.  It occupied 2 days of hearing time.  Affidavits and statutory declarations from a number of witnesses were tendered.  Six witnesses attended the inquest and gave evidence. Mr Christopher Dockray appeared as Counsel assisting the Coroner. Mr Terry Foulds appeared as Counsel for the Crown or more particularly the Department of Health and Human Services. Mr Salter’s children Shantelle and Michael attended the inquest and were offered the opportunity to cross-examine each of the witnesses and present evidence. They chose not to do so.

Events Preliminary to the Death:

4.   Mr Salter had been in a relationship with Juanita Joy Paterson. The couple had married on 26 April 2009. The relationship lasted for approximately four years and ended on the 13 November 2009.  They did not have any children, however both had children from previous relationships.

5.   On 23 October 2009 Mr Salter was issued with a Police Family Violence Order as a result of a Family Violence incident that occurred between Ms Paterson and himself.  A condition of that order was that Mr Salter not directly or indirectly threaten, harass, abuse or assault Ms Paterson. The order did not prohibit contact between them.

6.   Ms Paterson commenced a new relationship with Craig Allen Pinchin.  As a result of Ms Paterson and Mr Pinchen’s circumstances, Mr Salter allowed the pair to move in with him at 3321 West Tamar Highway, Sidmouth, the residence that he had previously shared with Ms Paterson.

7.    Mr Salter suffered from acute myeloid leukemia. He had been diagnosed with this illness in 2008. It would appear that he was initially amenable to treatment but on the evidence he had decided to refuse further treatment in or about September 2009. 

8.   Mr Salter’s medical records from his GP, the Launceston General Hospital and the Holman Clinic have been tendered as evidence.  These records indicate that Mr Salter’s most recent leukaemia chemotherapy was in September 2009.  This treatment achieved a remission and subsequently Mr Salter refused further treatment.

9.   In early 2009 Mr Salter showed signs of relapse.  In February 2009 he was informed by his treating specialist Dr Szur that he was a candidate for a bone marrow transplant from his sister however he declined to accept this treatment. Six months later this course of treatment was again suggested to Mr Salter however he continued to decline.

10.   On or about 31 March 2010 Mr Salter told his treating haematologist Dr Beamish that he did not want any treatment for the time being however he would continue to attend his appointments and have his blood tests. 

11.   On Sunday 13 June 2010 Mr Salter, Ms Paterson and Mr Pinchin were at the home when Mr Salter and Ms Paterson began to argue. The verbal argument escalated into a physical altercation between the pair. As a result of this altercation Ms Paterson made a complaint to police of assault and a breach of the Police Family Violence Order. This complaint was made to a police officer at the Exeter Police Station.

12.   Later in the day of 13 June 2010, members of Tasmania Police attended the address of Mr Salter and he voluntarily accompanied them to the Launceston Police Station where he participated in an electronically recorded interview with police. Following that interview Mr Salter was arrested, charged and detained in custody to appear in court.

13.   Sgt Matthew Stewart gave evidence at the inquest. Mr Salter was presented to him by the arresting officers. He completed Part A of a form titled Admission To Watch House Facility. That document was tendered. He gave evidence that Mr Salter did not express any concerns to him at the time. He did not identify any injuries to him and did not appear to be affected by alcohol or drugs. As part of the process he asked Mr Salter whether he was taking any medication and was told that he wasn’t. The allegations were detailed to him by the arresting officers and Mr Salter appeared to understand. It seems that Const Eaton (one of the arresting officers) did not mention to Sgt Stewart that Mr Salter had told him in the car that he suffered from cancer. He said that if he’d been told that Mr Salter was unwell he would have made further enquiries. He said Mr Salter could have been taken to the hospital or an ambulance could have been called wheupon he would have received further advice. This of course did not occur and Mr Salter was placed in the cells to await his court appearance the following morning.

14.   Based on the evidence presented before me, I am satisfied that the arrest of Mr Salter was lawful and that his detention to appear in court was lawful in accordance with the provisions of the Family Violence Act 2004.

15.   Mr Salter was seen in the Reception prison by Registered Nurse Danial Fassett on the morning of the 14th June 2010. Mr Fassett spoke to him and completed what is known as a Tier One Report. A copy of the report was tendered. During that discussion it is apparent that Mr Salter identified to Mr Fassett that he had a number of medical conditions namely asthma, bronchitis, cancer and depression.

16.   Mr Fassett gave evidence at the inquest. He said that Mr Salter did not seem unduly stressed or in distress and presented “as a likeable fellow who was a bit down on his luck”. He took a history and some observations which apparently were unremarkable. He said that Mr Salter told him that he had leukemia and had had treatment but had refused his last course as he was unwell. He said that Mr Salter presented as reasonably well and he felt confident that his assessment was an accurate one. He said that if he had known that Mr Salter was suffering a relapse he would have had him taken to the hospital for a hands on assessment.

17.   Mr Fassett gave evidence that in his view the Tier One form was adequate for the purpose. He had no further dealings with Mr Salter.

18.   Monday the 14 June 2010 was a Public Holiday and Mr Salter appeared before a Justice of the Peace in an out of hours court session. His application for bail was refused and he was remanded in custody to appear before a Magistrate on 15 June 2010. As Mr Salter had been charged with a Family Violence offence the question of his bail both before the Justice and subsequently before the Magistrate was governed by the provisions of Section 12 of the Family Violence Act 2004. That section provides:-

12. Bail

(1) A person charged with a family violence offence is not to be granted bail unless a judge, court or police officer is satisfied that release of the person on bail would not be likely to adversely affect the safety, wellbeing and interests of an affected person or affected child.

(2) Without limiting the matters to be taken into account in considering whether or not to grant bail to a person, a judge, court or police officer must have regard to the following:

(a) any available risk screening or rehabilitation program assessment;
(b) the person's demeanour;
(c) the result of any available safety audit;
(d) the availability of suitable accommodation for the person and any affected person or affected child;
(e) any other matter the judge, court or police officer considers relevant. 

(3) Section 34 of the Justices Act 1959 does not apply to a person charged with an offence under section 35 of this Act.

19.   On 15 June 2010 Mr Salter appeared before Magistrate Pearce in the Launceston Magistrates Court. He was represented by counsel. An application for bail was made however this was refused due to considerations regarding the safety and welfare of Ms Paterson.  Mr Salter was again remanded in custody until 18 June 2010 at 2.15pm.

20.   Registered Nurse Jane Elkin also gave evidence. Her first involvement with Mr Salter was on the 15 June. She had by then seen the Tier One report. She said that Mr Salter presented as reasonably well. He told her that he was “ok” and that he didn’t want any medication. She only spent a couple of minutes with him before the video link up with Dr Donaldson. She recalled the doctor talking to Mr Salter and saying that she would follow the matter up with Dr Beamish. Mr Salter signed a release so further information could be obtained from the Holman Clinic. She said that those notes arrived the following day and she scanned them. She “thought” that “bloods” were ordered although she was unable to recall any direction being given to take Mr Salter to the hospital for this purpose.

21.   Dr Frances Donaldson is a medical practitioner employed full time at the Risdon Prison. She saw Mr Salter over a video link at 8.30am on 15 June 2010. She gave evidence that Mr Salter did not give her any indication that he was unwell. She said that she made up her mind to speak to Dr Beamish but she said that Mr Salter made it clear that he wasn’t really interested in any extra care.

22.   Dr Donaldson discussed Mr Salter’s case with Dr Beamish. He told her that it was a complicated case. She told Dr Beamish that she would have preferred for Mr Salter to go to Hobart however Dr Beamish preferred that he stay in Launceston and said that he wanted him to have a blood test.

23.   On the evidence an attempt was made to take a blood sample from Mr Salter on 16 June 2010 however taking the sample proved difficult. Mr Salter did not want to go to the hospital.

24.   Exactly what else happened on the 16 June and throughout the day on the17 June 2010 is unclear because there are no records covering that period. Mr Salter was seen by Ms Elkin at lockdown on the 17 June 2010. She noted that he appeared to be as stable as he had been the previous day.

25.   Counsel assisting, Mr Dockray,  submitted to me that had the blood sample been taken on the 16 or 17 June (and presumably analysed as a matter of urgency) it would more likely than not have revealed that Mr Salter required immediate hospitaslisation.

26.   Ms Elkin was on duty on the morning of the 18 June. She saw Mr Salter in the interview room between 7.30 and 8 o’clock. He told her that he had had a fall and he had a graze to his head which was oozing blood. He also told her that he was passing blood in his urine. He gave a urine sample and she observed that “it looked nasty-there was a lot of blood in it”. She concluded that there had been a dramatic change in his health and that he needed medical care as soon as possible. It was at this stage that arrangements were made to bring Mr Salter’s court appearance forward from 2.15 to 11.30am.

27.   Mr Salter appeared before the court on 18 June 2010 at 11.30am and was immediately bailed.  Upon receiving bail, he was transported to the Launceston General Hospital by a staff member of the Launceston Reception Centre. 

28.   Mr Salter was admitted to the Launceston General Hospital at approximately noon on 18 June 2010. He was complaining of chest pain and had difficulty breathing. He was pale and ill. He was coughing blood and passing bloody urine. His pulse was elevated and his blood pressure was low. He was transferred to ICU shortly after midnight.  Dr Ulman examined the LGH case file. The following is an extract from his report.

            “ The ICU case file shows that his temperature returned to normal but his breathing rate                          
             and pulse rate remained high and his blood pressure remained low. Blood tests showed
             evidence of infection, kidney failure and impaired liver function-as well as relapsed
            leukaemia including low haemoglobin and a low platelet count.
                By 8:53 a.m on 19.6.10 his prognosis was deemed poor and his treatment ‘was reduced
            to comfort care’.
               Accordingly, at about 3:00 p.m on 19.6.10 he was transferred from the ICU to a general
             He was found dead at about 7:10 p.m on 19.6.10 and he was certified dead at 7:40

29.   A post mortem examination was carried out upon Mr Salter by forensic pathologist Dr Christopher Lawrence on 22 June 2010. Dr Lawrence found the cause of death to be Complications of acute myeloid leukaemia. Dr Lawrence stated;

 “Autopsy reveals consolidation of the lungs, an intracerebral haemorrhage due to the acute myeloid leukaemia and sepsis due to acute myeloid leukaemia.  There are extensive superficial bruises due to the previous assault.  The extent of these bruises is due in large part to his acute myeloid leukaemia because of a low platelet count, which makes him more inclined to bruise than normal.  The assault does not appear to have played a direct role in the death”

30.  I received evidence from Dr Ross Ulman who was engaged  by counsel assisting me, Mr Dockray.  Dr Ulman is a consultant physician. He had been provided with the relevant medical records relating to Mr Salter and his subsequent death and had been asked to provide an expert and independent opinion on the cause of death and the impact of the events leading up to his death.

31.    Dr Ulman was clearly of the view that the assault suffered by Mr Salter on the 13th June 2010 played no direct part in his death. He could see no causal relationship between Mr Salter being in custody and his death.

32.    Dr Ulman was critical of the Admission document. He described it as rudimentary. In his opinion the TIER 1 document needed to provide more scope for amplification.

33.    Dr Ulman’s evidence was to the effect that Mr Salter should have been monitored more closely. He said that his blood pressure, pulse and temperature should ideally have been monitored two or three times a day. It may be that these observations would not have shown anything but they should have been done nonetheless.

34.    Submissions were also made on behalf of Mr Salter’s children Shantelle and Michael who had attended the the inquest. As stated above neither had sought to give or adduce any evidence or cross-examine any of the witnesses but there were some points they wished to raise.

35.    They were critical of the failure to take their father to the hospital at an earlier time. They suggested that he may well have been able to receive treatment if this had been done.

36.    Clearly Mr Salter would have received palliative care at the hospital had he been taken there earlier but all the medical evidence suggests that he only had a very short time to live at that stage. A blood test may well have shown a low platelet count and that he was very ill but, of course, that was known to be the case in any event.

37.    They submitted that it is unclear whether Mr Salter had refused treatment or simply postponed it. This does not accord with the evidence and I am satisfied on all the evidence particularly that provided by Dr Beamish that Mr Salter had indeed decided not to resume treatment. There is certainly no evidence which would support a finding to the contrary.

38.    Clearly, if Mr Salter had been taken to the hospital at an earlier stage then he would not have suffered a fall in the prison on that morning but there is no evidence to show that the fall in itself hastened his death. Nor is there any evidence to suggest a causal link between the assault he suffered on the 13 June and the fall on the morning of the 18 June.

Comments and Recommendations:

39.   The documentation maintained at the Launceston Reception Prison was, in my view, inadequate. Certainly it was in Mr Salter’s case. As Mr Dockray submitted it is not possible by reference to those records to objectively assess Mr Salter’s status until the morning of the 18 June.

40.   I accept the evidence of Dr Ulman that whilst some treatment may have made Mr Salter’s life more bearable it would not have prolonged it.

41.    Once a person is taken into the custody of the Department of Corrective Services it becomes the responsibility of the Department to ensure that person’s wellbeing is maintained. This responsibility is even more important when the person has a serious medical condition such as Mr Salter did and it would be appropriate to formulate a policy for such cases.

42.    Ideally persons in custody suffering serious illness ought be monitored at regular and frequent intervals and proper records maintained of the results of those observations. The gap in Mr Salter’s records is clear proof that such procedures were not adopted in his case.

43.   I agree with Dr Ulman’s opinion that:- 

a) the Admission to Watch House Facility form should be expanded to make it more flexible and provide space for more detail to be included in cases where a person has identified health issues, and

b) an Incident Form should be introduced so that events such as Mr Salter’s fall, which can obviously have adverse medical implications, are properly recorded.

44. I would recommend that the Department of Corrective Services adopt such practices.
Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.

This matter is now concluded.

Dated:  The 29 April  2013 at Launceston in the state of Tasmania.

These findings have been amended in relation to the inacurrate number paragraphing.

Timothy John Hill