by ray jackson
on 6 march this year i posted a long explanation of the peter clarke death in custody in alice springs hospital having been held for too long in the alice springs gaol before being transferred for health reasons.
i am reposting because the initial request for at least 100 people to pledge $150 over a period of 3 months was very underwhelming in the generosity of those 100.
by mid-april only $550 had been raised. i have a copy of that statement and the funds donated are still sitting there. quite safe.
as advised previously the coronial inquest has now been moved to october, 2013, so we now have more time to raise the monies required for the 'peter clarke justice fund' details in main message.
i know times are hard but it is impossible for the clarke family to raise the required funds, so it takes people like you and i to fund the fight for justice.
please give what you can. but give!
fkj
----- Original Message -----
isja, on behalf of the peter clarke family, and especially ms kylie hampton, his daughter, has been advised by the nt coroner's office in alice springs that the death of mr clarke will be investigated over a 3 day period beginning on 25 june, 2013. isja, along with dr. carl hughes who is a forensic consultant of many years involvement in death in custody issues, has agreed to assist ms kylie hampton. isja will attempt to raise funds to allow her to be better legally represented during the coronial inquest to find the full and open truth of the tragic death of her father.
instead of rewriting the circumstances if mr clarke's death i paste below a previous post and the 2 letters to the nt authorities who failed to answer any of the very serious claims made by isja.
post/letter 1
.
peter clarke by family permission.
the attached correspondence to the nt chief minister, ministers knight, mccarthy and vatskalis and also to the nt coroner seeks to find an explanation of the death of peter clarke, an aboriginal man, who tragically passed away in the intensive care unit of alice springs hospital on 3 april 2012.
mr. clarke was finishing a sentence at the alice springs gaol and he was due for parole on 26 march 2012. on the 19 march 2012 peter became ill whilst in gaol and he was transferred by the gaol clinic to the hospital for better medical care. when he arrived at the hospital he was assessed by the emergency team and he was then sedated and put into the icu. he had been suffering respiratory distress but we, his family and this association, do not know the length of time he was in such distress prior to being sent to the hospital.
whilst he was heavily sedated in the icu nt corrective services saw a need to shackle him by the left ankle to the bed whilst also placing a corrective services officer in his room 24/7. why this was thought to be normal procedure is yet to be explained. peter was physically incapable of attempting to escape even if he had wanted to. the guard remained until he was finally sent away by the icu registrar, dr. raj, but the guard continued to visit peter to make sure, perhaps, that he had not absconded.
dr. raj had informed peter's family that he was suffering pneumonia,emphysema and a possible cancerous node in his left lung that showed in his scan on arrival. peter was not a fit man and it most certainly was not appropriate for him to be brutalised in this manner. the practice of shackling in australian gaols is totally offensive and more so when the practice is abused as it was in peter's case. recently the gaol system of south australia was vilified for its ridiculous and cruel shackling procedures, including the shackling of an inmate whilst she was giving birth! whilst such practices may have been normal procedure during the eighteenth and nineteenth centuries they most certainly have no place in modern custodial operations. the moreso when they are so commonly abused.
peter was due for parole on 26 march but did not recover from his illnesses and he died on 3 april 2012, still in an induced state and in the icu. his death, however, was not automatically identified as a death in custody as it should have been under royal commission recommendation 6 a/b. a recommendation that is recognised by every australian coroner and acted upon as and when necessary.
what was so different about peter's death then? prior to his hospitalisation he was finishing his bottom sentence and was looking forward to getting his parole. he went to hospital on the 19 march 2012, eight days before his release. sadly he never made it. he remained in his induced state for a further nine days before passing on. even though the superintendant of the gaol understood peter's death to be an automatic death in custody some authorities thought otherwise.
dr raj stated that he had rung the coroners office but we do not know if he actually spoke to the coroner personally or to one of his officers. perhaps the coroners constable? dr raj informed the family that peter would not be treated as a death in custody because from 26 march he had been paroled! he was in fact 'a free man.' how absolutely bloody ridiculous. he was still a person of interest to corrective services even if he'd been on parole. which he wasn't. the parole of an inmate from gaol creates a paper-trail and forms need to be signed by the inmate to make it official. if such paperwork had been finalised before peter went to hospital, nothing has been shown to, or given to the family to verify such an action.
it is most certain that peter did not receive a 'bedside' parole as he was too ill so regardless of any parole date being named, peter was most definitely under the care and control of the nt corrective services until such time that his health improved and he was able to sign the relevant documents to obtain his release.
the family requested that an autopsy be done and he was given a 'hospital' autopsy but no autopsy report has been given to the family. there are so many questions to be answered concerning peter's death that only the coroner can investigate the mutated procedures that stopped peter having an inquest. who is to be held responsible for the death of peter? the alice springs gaol and its medical clinic? is there something the alice springs hospital is attempting to hide relative to his treatment? was it in fact 'natural causes' caused by a degree of fatal errors at each stage that caused his demise?
we, the family and this association, do not have the answers but we expect that a full coronial inquest will and must be held to find out.
Daniel Knight
Minister for Justice and Attorney-General
Darwin. N.T. 0800
20 July 20, 2012
Daniel,
I write on behalf of the Family of Peter Clarke, an Aboriginal man, who tragically passed away in the Intensive Care Unit of Alice Springs Hospital on 3 April, 2012.
The facts of his pre-death history that are known to the Family and ISJA are as follows:
Mr. Peter Clarke was incarcerated at the Alice Springs Gaol for a bottom sentence of 3 ½ years and was being considered for parole, if granted by the Parole Board, to begin on 26 March, 2012.
On 19 March 2012 Peter became ill whilst in Gaol and after consultation the Gaol Clinic decided that he should be escorted by Corrective Service Officers to the hospital for better medical treatment to be given to him. Peter had been in respiratory distress and coughing up sputum for an unknown time prior to his transfer to hospital.
He was informed that he was to have an initial sedation but it is not known by his Family whether this sedation occurred at the Gaol clinic or at the hospital.
On arrival at the hospital, Peter was medically assessed by the Medical Emergency Team and he was transferred directly to the ICU and further sedated.
When Peter was visited by his Brother, Wayne Clarke, and his Sister, Ms. Gladys Appo, it was observed that Peter was shackled by his left leg to the hospital bed and a Correctional Officer was present during their visit. Why this correctional procedure was adopted in this situation has yet to be explained to the Family. Mr. Clarke was not only in a sedated state in ICU he was but 5 days away from him getting his Parole. This fact alone shows that he was not a flight risk and yet he was treated as a major criminal. Such action is truly reprehensible and must be investigated by your office. I shall have more to say on the unnecessary practice of shackling in a later post.
Wednesday, 21 March, 2012 Peter was continuing to be sedated, still guarded by Corrective Services and still shackled.
Friday, 23 March, 2012 Peter’s condition was not improving and a Hospital Doctor reportedly requested the Officer to leave the ICU bed of Peter and the ICU Staff would be responsible for his care and well being. It is assumed that the shackle was taken off his ankle at this time. Some time over the weekend of 24/25 March, 2012 the Officer returned to his position for some hours and he then left.
Monday, 26 March, 2012 was the date Peter may have been paroled had it been granted and had he not become ill on the Monday, 19 March, one week earlier.
Tuesday, 3 April, 2012 Peter Clarke’s conditioned worsened and he passed on. The ICU Registrar, Dr. Raj, told the Family that he had “spoken with the Coroner’s Office” He stated to the Family that the Coroner’s office did NOT regard Peter’s death as a Death in Custody. However, with the permission of the Family a Hospital Post Mortem was carried out. The Family is still waiting for a copy of the Hospital Post Mortem to be given to them.
Those are the facts that are known to the Family from the time of transfer from Alice Springs Gaol to the Alice Springs Hospital. What occurred between the above listed dates and the sad death of Peter can only be ascertained by obtaining his gaol and medical records and his hospital records.
Even though the ICU Registrar believed, after consultation with the Coroner’s Office, that Peter’s death was NOT a Death in Custody both the Family and this Association beg to differ for the following reasons.
I respectfully remind you of the Reportable Deaths to a Coroner being Recommendation 6 a and b which clearly identifies what parameters legally cover what constitutes a properly recognized Death in Custody, and especially for Aborigines and Torres Strait Islanders, who have died in police or gaol custody circumstances.
I am firmly of the opinion that every Coronial jurisdiction in Australia has accepted the identifiers put by the Royal Commissioners of the Aboriginal Deaths in Custody legal enquiries brought down in the 5 Volume Report and incorporating 339 Recommendations in 1991. I know that the Coroners of the NT follow this protocol as they do elsewhere around Australia.
Herewith is Recommendation 6 a and b: That for the purpose of all recommendations relating to post-death investigations the definition of deaths should include at least the following categories:
a. The death wherever occurring of a person who is in prison custody or police custody or detention as a juvenile;
b. The death wherever occurring of a person whose death is caused or contributed to by traumatic injuries sustained or by lack of proper care whilst in such custody or detention;
It is recognized of course that a Coroner can only investigate the veracity of the high-lighted words in b. and only after a Coronial Investigation has been held to allow for all of the required facts to be made known.
Recommendation 10 states: That custodial authorities be required by law to immediately notify the Coroner’s Office of all deaths in custody, in addition to any other appropriate notification.
The ICU Registrar, Dr. Raj stated to the Family that he had made enquiries to the Coroner’s Office but did he speak directly to the Coroner as explained above? If he did not then to whom did he speak? Did Dr. Raj, perhaps, receive some guidance in reaching his erroneous decision by conferring with a Correctional Officer, or the Hospital Director or some other peer staff, or perhaps even the Alice Springs Gaol? We do not know and as yet we need to find out.
I am informed by a Family member that on the day Peter died he was visited at his home by the Aboriginal Gaol Liaison Officer, known only to me as Natasha, who gave her sympathies to the Family member for the death of Peter, but more importantly for our argument here, also gave the sympathy of the Gaol Superintendant who had also offered the information that he considered the death of Peter as a Death in Custody!
On the same day the same Family member was contacted by the Alice Springs Hospital, possibly by the Aboriginal Liaison Officer, who stated that “the body can be picked up for burial as it is not a Death in Custody”.
The conflicting messages caused much confusion and pain to the Family and heightens their great need for answers.
We strongly contend that these facts require the further determination of a full Coronial Inquest.
Recommendation 11 states: That all deaths in custody be required by law to be the subject of a coronial inquiry which culminates in a formal inquest conducted by the Coroner into the circumstances of the death. Unless there are compelling reasons to justify a different approach the inquest should be conducted in public hearings. A full record of the evidence should be taken at the inquest and retained.We see no relevant circumstances to any different approach being made.
Recommendation 12 states: That a Coroner inquiring into a death in custody be required by law to investigate not only the cause and circumstances of the death but also the quality of the care, treatment and supervision of the deceased before his death.
This requirement of the Coroner allows for a close examination of not only the events whilst Peter was in the ICU but also, of course, his medical treatment whilst an inmate in the Alice Springs Gaol. It is noted that Peter was hospitalized in October, 2011, he also had a diagnosed history of being a Diabetic. Dr. Raj also informed Peter’s Daughter, Ms. Kylie Hampton, that he was suffering from pneumonia, emphysema and possible cancer in the left lung which showed on his CT scan. The treatment that Peter received from the Gaol Clinic is of the utmost importance and must be seriously considered by a Coroner.
What we do know is that prior to his transfer to Alice Springs Hospital Peter Clarke became ill but for how long prior to his transfer we do not know? We also do not know what treatment was sought and when it was sought? These matters need the legal attention of the Coroner.
The reason given to the Family of why Peter’s death was not a Reportable Death to a Coroner was that, somehow, he was paroled on Monday, 26 March, 2012. This is arrant nonsense bordering on criminal conspiracy! His Family and this Association absolutely disputes this false reasoning. On that Monday, 26 March, 2012, Peter was seriously ill and probably in an induced coma and therefore he was in no way possible to be fit enough to have a bedside parole performed. He was neither mentally nor physically able to partake in such an exercise concerning his parole and the legal circumstances of that parole. The man was dying but such facts do not concern the custodial establishments when they attempt to disown a Death in Custody in their bailiwick. This is not an isolated practice as other Corrective Service jurisdictions around Australia have attempted to pull the same stunt. These custodial entities, along with the police forces of this country, must accept, by legal force if necessary, that they have an innate Duty of Care to those under their responsibility.
Had Peter’s death been considered, honestly and fairly, as a legitimate Death in Custody, as it should have automatically been so identified, then the Family of Mr. Peter Clarke would not have to be expected to carry the onerous burden that their Father, Brother, Uncle – whatever his title – was of no consequence to a system that always counted him as an outsider all his life.
The Family and this Association demand that Mr. Clarke be treated with the same dignity as any other human being, with the full gamut of Human Rights that was his by Right. We demand that his tragic death at least be recognized as a Reportable Death in Custody with the consequence of being granted a full Coronial Inquest as soon as possible so the full details can be made known to all, but especially his Family.
Should your Office negate these calls for real Justice then would you please explain by return post why such disagreements can possibly exist?
FOR KOORI JUSTICE
Ray Jackson
President
Indigenous social Justice Association.
Cc Gerald McCarthy, Minister for Corrective Services.
Greg Cavanagh, Northern Territory Coroner.
Paul Henderson, NT Chief Minister.
Konstantine Vatskalis, Minister for Health.
letter 2
Konstantine Vatskalis
NT Minister for Health
Darwin. NT 0800
1 August, 2012
Konstantine,
Again I write on behalf of the Family of Peter Clarke, who died in the ICU of the Alice Springs Hospital on 3 April, 2012.
The Family has now had access to the clinical notes of Peter Clarke and, as a result, a number of issues arise
After looking at his medical records from the time he arrived at the Hospital on 19 March, 2012 there are several questions of treatment and diagnosis prior to his transfer from the Alice Springs Gaol to the Hospital, the treatment and diagnosis whilst in the ICU and the diagnosis arising from the Family’s request for an autopsy to be performed on Mr. Clarke.
The Family is most concerned that in the foreknowledge of his previous history of respiratory illnesses, including an earlier hospitalization for pneumonia, Peter may not have been identified and treated as a ‘venerable’ patient that would have required the gaol clinic staff to have a higher degree of suspicion that he was, in fact, generally more susceptible to chest infections that would have consequently required that he needed much more urgent treatment for him at the Hospital.
It is still unknown as to the level of ill health that Mr. Clarke was suffering from but on 19 March 2012 a Dr. Gordon Goodwin of the Alice Springs Gaol referred Peter to the Hospital at 3.43pm on that Monday afternoon. The Referral Note that accompanied Peter on his transfer stated that “Peter had frontal chest pains for a few days. The chest pain was not improving.” How long “a few days” is expected to cover is unknown but could entail a week or possibly longer. The usual ad hoc cheap health care was administered by the gaol clinic with the issuing of Panadol and an anti-inflammatory medicine of some kind.
This is most definitely an inadequate medical regime by the gaol clinic but one, sadly and dangerously, that is copied around the gaol systems of Australia in an effort to meet inadequate gaol health budgets. Peter was not given any anti-biotics at the gaol clinic as he should have been so treated.
Upon his eventual arrival at the Hospital at 6.10pm it was noted that he had been admitted previously in June, 2011 with a diagnosis of Pneumonia. I will return to this admission later.
The Emergency Department Nurse wrote that the symptoms provided by Peter were “a cough for 1 week, not productive.” Hence, a dry cough. Later that evening he was then diagnosed as having “severe pneumonia” and was immediately commenced on a course of anti-biotics. Blood culture tests were carried out and an x-ray showed widespread patchy pneumonia. Discussions were held on a possible underlying cause and the prospect of lung cancer was raised by the medical team. Peter was found to be oxygen deficient so oxygen was given and his pulse rate was found to be quite high. He was admitted to the ICU at 11am on Tuesday, 20 March, 2012. The ICU Consultant, Dr. Raj Goud, in his admission notes for Peter, raised the distinct possibility of a diagnosis of an “atypical pneumonia.” Such a critical diagnosis raises the possibility that Peter’s pneumonia MAY have been caused by an unusual bacteria or a fungus of some kind. More on this below.
During Peter’s time spent in the ICU we learn that he was continued treatment with anti-biotics and other supportive therapy that also included Physiotherapy and 24 hour nursing care. Despite all this care Peter still required to be intubated to allow him to breathe easier. Though there appeared to be some slight improvement to Peter’s condition it was never in doubt that he was, indeed, a very, very sick man. At one time he was thought to be possibly suffering from Endocarditis, inflammation of the heart membranes, but this was not proved. Nonetheless he was treated for this anyway, correctly in our view.
Chest x-rays suggested that some early improvement was observed and intubation ceased. Cardio-thoracic Surgeons were consulted however Peter was thought unsuitable for chest surgery. An internal examination of the upper chest, a Bronchoscopy, was carried out and ‘washings’ or samples taken for further diagnosis.
Again, the Family raises the more than obvious question that Peter’s outcome may have been quite different had he been admitted earlier to Hospital from the gaol. Especially as it must have been quite evident to gaol clinic staff over the weekend that Peter was becoming more ill. Was it simply more convenient to the staff rostered over the weekend to make Peter wait until the Monday before he was transferred to Hospital? If this was the case then it shows a very shabby attitude to their collective Duty of Care to Mr. Clarke.
It must be quite evident that had Peter been treated in a more positive and medically prescient manner then perhaps the Clarke Family would not be in mourning now.
On 23 March, 2012 a CT scan showed an irregular soft tissue lesion in the centre of his chest. The Radiologist surmised that the lesion was either a part of the ‘infective process’ or a bronchogenic carcinoma or lung cancer. In addition his lungs showed evidence of fluid and “consolidation” consistent with severe pneumonia. Sadly, despite aggressive and professional ICU treatment, Peter’s condition gradually deteriorated whereby Peter passed on peacefully at 6.10am on 3 April, 2012.
As has already been raised, if his treatment had of been effected earlier then a different outcome may have ensued.
After the ‘washings’ were taken from Peter’s chest they were cultured and after 2 weeks they were found to show “unusual culture.” After further consideration and consultation the bacteria was identified as being Mycobacterium Avium/Mycobacterium Intracellulare Complex. This identification raises several important issues for your Department, Minister.
The first concern is that such a bacterium Complex is qualified as being legally ‘Reportable’ to the Disease Control Section of your Department as this bacterial complex is known to be the cause of a serious infection in persons who are identified as being “immune suppressed.” This may well explain the ‘atypical’ nature of the pneumonia raised by Dr. Raj Goud previously. It must be remembered that Peter had spent his last three and a half years in the Alice Springs Gaol so such a bacterium, quite logically would most likely come from the gaol environment. If such is the case then it is most important that your Department monitor all who are currently in the gaol environment, officers and inmates, for the prevalence of the bacterium. Also it is of a high importance that testing also must be done to past inmates and, especially, those who have passed on since their release. The Clarke Family and their supporters are most desirous that no one else should die as Peter did.
The second concern is that the bacterial complex is widespread in water and soil and is usually not a major health concern. It is however known to have been found in shower-heads and this can cause an inhalable aerosol to occur. For this reason a gaol with communal showers or single showers with variable use by an unknown number of inmates, along with the well known general bad health of inmates, is a situation that should be seriously considered by you and your Department. The death of Peter must become an urgent clarion call for the health of all those who work within the NT gaol system. We urge you to act forthwith.
Another serious matter of major concern to the Family is the requirement to have an autopsy on Peter Clarke. The Family and this Association still maintain that Peter’s death occurred whilst he was still in the custody of the NT Corrective Services and therefore was an identifiable Death in Custody and as such an autopsy should have been performed within hours of his death and NOT some four days later and only because it was requested to the Hospital by the Family. There was an ‘administrative’ delay caused when the ICU Consultant Dr. Raj Goud, called the NT police. He was told that the ‘Coroner’s Constable’ would need to give permission for any autopsy to occur. This is absolute rubbish!! Dr. Goud should have been advised by the NT Police that the Duty Coroner was the correct person to be called as only they have the legal power and responsibility to adjudicate on such matters.
As an Association we strongly urge and recommend that your Department immediately direct all Hospital Medical Directors and their Staff of this basic requirement so such a legal error is not made again. This ridiculous breakdown of what should have been normal procedures has allowed for other strange problems.
The Family is very concerned, as are we, that the unreasonable delay in carrying out the Post Mortem on Peter may have prevented a full microscopic analysis of his body tissues. The Autopsy Report has still not been given to the Family. They were told that the Report needed to go to a Specialist in Adelaide for his/her opinions to be sought. Why this is so is unknown. The Family calls for the Post Mortem Analysis Report to be released immediately to them.
Why would such a Report need to go to a Specialist in Adelaide? What is the System attempting to hide? Whilst it is obvious these questions must be answered it is also possible that some of the several Authorities know of the real reason that Peter died? Are they attempting to hide something not only from Peter’s Family but also the wider public?
Peter Clarke’s Family has been told it could take up to a year before they are allowed to see it. Why? These questions, along with others, must be seriously examined by a NT Coroner in an open Inquest. It is rumoured that Peter’s death is now to be treated as an identified Death in Custody but if this is so then the Family have not been formally advised.
Minister, we await your reply with great interest.
FOR KOORI JUSTICE
Ray Jackson
President
Indigenous Social Justice Association
cc: Ms. Kylie Hampton, Daughter and Spokesperson.
Gerald McCarthy, Minister for Corrective Services.
Greg Cavanagh, NT Coroner.
Paul Henderson, NT Chief Minister.
Daniel Knight, Minister for Justice and Attorney- General
no reply of any substance was received by isja but the nt authorities did finally accept that the death of mr clarke was indeed a bona fide deaths in custody and would be treated as such, hence the pending coronial inquest.
isja, in pledging our support to kylie, recognise that we are not in a position to cover legal costs for our choice of barrister, john rowe, and ably supported by a instructing solicitor who have also been accepted by kylie. both dr. hughes and i believe and accept that with this legal team representing kylie and the clarke family to have most, if not all, of their questions properly answered by the inquest and that the appropriate findings based on real justice by the coroner will make changes to ensure that these omissions and mistakes do not cost another life.
the police are not involved in this case except in obtaining the brief for the coroner to base his decisions on after he hears 3 days of evidence. the culprits are the nt gaol system and its medical team at the alice springs gaol, the nt health department on its hospital procedures relative to general health issues and the death of patients still in a custodial situation and possible changes to the nt coronial system and operational procedures.
it will, of course, come as no great surprise that aboriginal families cannot in any form meet the high costs of being represented by excellent legal assistance. whilst the relevant aboriginal legal services are directed to represent death in custody families, due to severe underfunding they are restricted in resources by continuing government cuts. whilst the enthusiasm of their legal teams are well known that is not enough when they are faced by senior barristers with unlimited funds at their disposal. for justice to be obtained we need to at least attempt to have an equivalent of legal knowledge and cunning. for that we need to be able to pay the legal costs.
unfortunately representation on a pro bono basis is also not possible because the greater majority of legals will not do a death in custody case as there is no kudos in it and they need to take on the government and/or its departments. nt legal aid will not fund a legal team outside of the nt and the nt legals do not really want to take on the nt legal scene as they live and work there.
basically and cynically, you get the justice you can afford and this is where isja now puts up an argument for a financial pledge.
isja wants 100 (or more) individuals, organisations, groups to accept a pledge of giving $50 per month over a 3 month period. this equals $150 over that 3 month time frame. i have advised kylie to open up an account, details of which are given below.
i will put my pledge where my mouth is and pledge the $50 per month for march, april and may. pledges banked are to be used for all costs relative to the case of fred clarke only. i know i can trust kylie and the legal funds will not be misused for any other purpose. at the end of each month kylie will inform me of the balance of the account and any payments made.
the 100+ (maybe) will contact me when they accept the pledge so i can inform them of where we are at.
Westpac Bank
Account Designator: Peter Alexander Clarke Justice Fund
BSB: 034203
Account No: 333046
Branch Name: Mount Isa QLD
we live in a society that talks about justice for all but we know that for real justice you must pay. if you can assist our call for justice then i urge you to please do so.
fkj
ray jackson
president
indigenous social justice association
isja01@internode.on.net
(m) 0450 651 063
(p) 02 9318 0947
address 1303/200 pitt street waterloo 2017
we live and work on the stolen lands of the gadigal people.
sovereignty treaty social justice