Ivan Milat
| Findings of the Inquest into the Death of Ivan Milat | |
| author | Derek Lee |
| Release date | 2021 |
| Pages | 9 |
The following is a reworded factual summary of the coronial inquest report concerning the death of Ivan Milat.
Introduction
At the time of his passing, Ivan Milat was 74 years old and held in custody at Long Bay Hospital, part of Long Bay Correctional Centre. He was serving a life sentence for several grave crimes, sentenced on July 27, 1996.
In the early morning of October 27, 2019, Milat was discovered unresponsive in his cell without vital signs. Due to existing do-not-resuscitate instructions, no revival efforts were made, and he was declared deceased.
Purpose of the Inquest
Under the Coroners Act 2009, coroners must examine all reportable deaths to determine the identity, date, place, cause, and manner of death.
When individuals are detained legally, the state takes on their care. Section 23 of the Act requires an inquest for deaths in custody to meet community expectations for a thorough, independent review.
The investigation found no indications that Milat received inadequate care or treatment while incarcerated.
Background on Ivan Milat
Inquests emphasize both life and death, highlighting the value of human existence and the effects of loss on loved ones.
Milat was one of 14 siblings born to Steven and Margaret Milat. Raised in Liverpool, New South Wales, he attended high school in Fairfield but left after Year 8 to start casual welding jobs.
He had various short-term relationships in adulthood. After a trip to New Zealand, he returned to Australia and worked for state agencies.
His brother William noted Milat's interests in camping, shooting targets, riding motorbikes, and reading.
William kept in touch with Milat during his imprisonment and felt deeply impacted by his death, describing their bond as strong.
Custodial Record of Ivan Milat
Milat's initial police contact was in 1962. From then until 1974, he faced charges for property crimes and sexual offenses. On May 22, 1994, he was arrested for nine charges, including seven murders, and held in remand by Corrective Services New South Wales (CSNSW).
Convicted on July 27, 1996, at the Supreme Court of New South Wales, he received a life sentence.
He was placed in various facilities, primarily Goulburn Correctional Centre until 2019.
On May 13, 2019, due to worsening health, he moved to Long Bay Hospital.
Health Background of Ivan Milat
Upon entering custody, Milat had no significant health issues, as confirmed by his brother William.
On October 5, 2018, he reported gastrointestinal problems like painful swallowing. A doctor prescribed medication for upper digestive issues. He tested positive for Helicobacter pylori on November 30, 2018, and received treatment. He was monitored regularly at Goulburn.
Symptoms persisted, leading to a referral for gastroenterology tests. He refused a colonoscopy but agreed to a gastroscopy, though he canceled the January 18, 2019, appointment against advice. Records show he often declined procedures.
He continued at Goulburn with weight loss and swallowing issues monitored.
An advance care directive was discussed and signed on February 1, 2019, updated on August 21, 2019, to refuse intensive care, surgery, or resuscitation.
He was referred again to Prince of Wales Hospital but refused the February 25, 2019, visit.
From February to May 2019, symptoms worsened: weight loss, throat pain, reflux, and swallowing difficulties. He received symptom relief but rejected a soft diet.
On May 1, 2019, he consented to a gastroscopy and preparatory tests. On May 8, a doctor noted progression and urgently referred him to Prince of Wales Hospital.
Admitted from May 13 to 27, 2019, he underwent a gastroscopy on May 14, CT scans of neck, chest, abdomen, pelvis, a PET scan, and a lymph node biopsy on May 17 showing metastatic adenocarcinoma.
On May 21, 2019, a palliative esophageal stent was placed to aid swallowing. He received palliative radiation, completed June 7, 2019.
On June 6, 2019, the palliative care team at Long Bay's Medical Subacute Unit (MSU) reviewed him, coordinating with Prince of Wales for comfort care during oncology.
On June 27, 2019, oncology offered palliative chemotherapy for incurable metastatic esophageal cancer, aiming to extend life by months with a 30-40% response rate.
From May to October 2019, he had six MSU admissions, with ongoing treatment at Prince of Wales. His final admission was October 22 to 27, 2019.
Events on October 27, 2019
On October 26, 2019, Milat was observed hourly by MSU nurses. His cell faced the nursing station.
During evening rounds, he requested anxiety and pain medication, given around 9:30 pm. He was left sitting in bed with lights on.
Hourly checks continued. At 3:00 am on October 27, staff from CSNSW and Justice Health saw him appearing asleep.
At 4:05 am, he was observed not breathing.
Nurses used an oxygen saturation device, detecting no heartbeat or oxygen. No pulse, heart sounds, or breathing were found; pupils were fixed and dilated. Due to the do-not-resuscitate order, no CPR started, and he was pronounced dead at 4:07 am.
Cause of Death for Ivan Milat
Milat was taken to the Department of Forensic Medicine. Dr. Rianie Janse Van Vuuren conducted a postmortem on October 30, 2019.
Imaging revealed large pericardial and pleural effusions, coronary calcification, lymphangitis carcinomatosa signs, and bone metastases.
The July 8, 2020, autopsy report concluded the cause as metastatic gastro-esophageal adenocarcinoma.
Additional Issues in the Coronial Review
William Milat's statement expressed no issues with custody care but noted learning of the death from media at 5:00 am on October 27, 2019, before official notification at 7:00 am by New South Wales Police Force (NSWPF).
Investigation showed Eastern Beaches Police Area Command received notice at 4:40 am, arriving at MSU by 5:05 am. An officer inquired about next-of-kin notification; details were given, and Camden PAC arranged it for 7:00 am.
Meanwhile, CSNSW Media Officer Jodie Minus was informed at 4:26 am. She received media calls from 4:49 am to 5:32 am, surprised by the speed given Milat's notoriety.
At 5:40 am, CSNSW emailed a statement confirming the death to media, before William's notification.
Section 13.3 of CSNSW Custodial Operations Policy and Procedures (COPP) required immediate police reporting of custody deaths, with NSWPF handling next-of-kin notification. No policy then required confirming notification before media releases.
Michael Duffy, CSNSW Media Director, stated this was unprecedented; usually, time allowed for notifications.
Post-event, COPP was updated: media inquiries on custody deaths are confirmed only after verifying next-of-kin notification.
Summary
Based on Justice Health, CSNSW records, and postmortem, Milat died from natural progression of disease. Symptoms from October 2018 were investigated appropriately. Upon decline, he transferred to MSU. After terminal diagnosis at Prince of Wales, palliative care was provided.
Evidence shows adequate medical and custodial care; no contributions to death from care aspects.
CSNSW changes ensure proper next-of-kin notification before media confirmations, preventing media-first notifications.
Coronial Determinations
I acknowledge Coronial Advocate Brooke Notley's assistance and Plain Clothes Senior Constable Luke McNaughton's investigation work.
Under section 81(1) of the Act:
Identity: The deceased was Ivan Milat.
Date: October 27, 2019.
Place: Long Bay Hospital Medical Subacute Unit, Long Bay Correctional Centre, Malabar, NSW 2036.
Cause: Metastatic gastro-esophageal adenocarcinoma.
Manner: Natural causes in lawful custody during imprisonment.
On behalf of the court, condolences to Milat's family.
Inquest closed.
Magistrate Derek Lee
Deputy State Coroner
February 16, 2021
Coroners Court of New South Wales
Non-Publication Directives
Under section 74(1)(b) of the Coroners Act 2009, the following is not published:
1. Names, addresses, phone numbers, and personal details of visitors to Milat in custody (except professionals or legal reps).
2. Names, details, and Master Index Numbers of other CSNSW inmates.
3. Direct contacts or serial numbers of CSNSW officers.
4. Case Management File notes on security intelligence for escape attempts.
5. CCTV or handheld video footage and stills.
6. Specific parts of CSNSW COPP 13.3 Deaths in custody: (a) Page 6, subsection 2.4, third sentence; (b) Page 12, subsection 6.1, Aboriginal Strategy and Policy Unit contact.
Under section 65(4), note on file: CSNSW documents access applications under 65(2) require CSNSW submission opportunity.[1]
