Inquest into the Death of Fabian Alec COFFIN
Inquest into the Death of Fabian Alec Coffin
Delivered on : 21 February 2025
Delivered at : Perth
Finding of : Coroner Jenkin
Recommendations : No
Orders/Rules : No
Suppression Order : N/A
Summary : Fabian Alec Coffin (Mr Coffin) died on 5 February 2024 at Fiona Stanley Hospital from complications of myocardial infarction and ischaemic heart disease. He was 51-years of age.
At the time of his death, Mr Coffin was a sentenced prisoner at Hakea Prison. On 18 August 2014, in the Supreme Court of Western Australia, Mr Coffin was made the subject of an order under the Dangerous Sexual Offenders Act 2006 (WA), and later the High Risk Serious Offenders Act 2020 (WA), (the Order) meaning he was detained for an indefinite term for “control, care and treatment”. The Order was regularly reviewed, with the next review due on 16 April 2024.
Mr Coffin saw a prison doctor on 1 February 2024, and complained of worsening intermittent chest pain for about three days. Although he denied experiencing any current chest pain and an ECG was normal, his oxygen saturation levels were low and the prison doctor decided to send Mr Coffin to FSH for further assessment.
On 2 February 2024, Mr Coffin underwent cardiac catheterisation and angiography, and was found to have severe disease in the left circumflex artery, and the right coronary artery. A stent was successfully inserted into his left circumflex artery, and the plan was to insert a stent into his right coronary artery during a subsequent procedure.
At about 1.20 am on 4 February 2024, Mr Coffin went into cardiac arrest. His restraints were removed and CPR (including use of a defibrillator) was commenced. A spontaneous return of circulation was achieved at about 2.15 am and Mr Coffin was taken to the catheterisation laboratory where a stent was inserted into his right coronary artery.
After the procedure, Mr Coffin was sedated and taken to the intensive care unit. At about 4.45 am on 5 February 2024, Mr Coffin went into cardiac arrest, and CPR was commenced. Although Mr Coffin appeared to revive, he experienced a further cardiac arrest at about 5.18 am, and CPR was recommenced. Despite concerted resuscitation efforts, Mr Coffin could not be revived, and he was declared deceased at 5.28 am on 5 February 2024.
After assessing the available evidence the coroner concluded that the supervision Mr Coffin received whilst he was incarcerated was of an acceptable standard, and that the treatment and care he received was commensurate with (and was likely better than) the care he would have received had he been in the community.
Catch Words : Death in Custody : Dangerous Sex Offender : Natural causes
Last updated: 14 March 2025