Inquest into the death of Raymond Sydney CHEEK
Inquest into the Death of Raymond Sydney CHEEK
Delivered on : 24 September 2024
Delivered at : Perth
Finding of : Coroner Urquhart
Recommendations :N/A
Orders/Rules : N/A
Suppression Order : N/A
Summary : Raymond Sydney Cheek (Mr Cheek) was 89 years old when he died on 19 September 2021 at Fiona Stanley Hospital (FSH) from complications in association with a gastrointestinal illness. At the time of his death, Mr Cheek was a sentenced prisoner and was in the care of the CEO of the Department of Justice (the Department). As he was a person held in care, Mr Cheek’s death was subject to a mandatory inquest.
Mr Cheek commenced his term of imprisonment on 6 August 2021. He already had extensive pre‑existing health conditions which included chronic renal failure, type-2 diabetes requiring insulin, hypertension, and heart disease managed by a permanent pacemaker. In addition, he had poor mobility and an inability to attend to many daily activities. On 7 August 2021, Mr Cheek was placed within the infirmary at Casuarina Prison (Casuarina) for management of his health conditions.
From 7 September 2021, Mr Cheek experienced hypoglycaemic (low blood glucose) episodes due to his diabetes. To manage those episodes, a prison doctor decreased Mr Cheek’s morning insulin dose by half. However, on 11 September 2021, a prison nurse administered the previous higher amount of insulin in error and Mr Cheek subsequently had hypoglycaemic episodes until the afternoon of that day.
On the morning of 12 September 2021, Mr Cheek experienced another hypoglycaemic episode and had very bad diarrhoea. He was later found collapsed on the floor and a call was made for an ambulance to attend. After an assessment by ambulance officers, Mr Cheek was taken to FSH.
Mr Cheek was admitted to FSH where he was diagnosed with a severe kidney injury. Despite active treatment, his health did not improve. On 18 September 2021, FSH doctors held discussions with Mr Cheek’s next of kin and prison doctors regarding his very poor prognosis. It was agreed Mr Cheek would be transitioned to palliative care and he was kept comfortable before he died on 19 September 2021.
Having received a report from a consultant endocrinologist, the Coroner was satisfied that the incorrect insulin dose given to Mr Cheek on 11 September 2021 did not contribute to his death. With the exception of this incorrect insulin dose, the Coroner was satisfied that the supervision, treatment and care provided to Mr Cheek by health service providers at Casuarina was appropriate. The Coroner was also satisfied with the treatment and care Mr Cheek received from the medical staff at FSH.
The Coroner, however, was not satisfied that it was necessary to restrain Mr Cheek when he was transferred, and then admitted, to FSH. As he was a frail and elderly prisoner, who was terminally ill with significant mobility issues, the Department’s policies and procedures mandated that Mr Cheek was not to be restrained unless a risk assessment determined otherwise. However, the Coroner was satisfied no risk assessment was performed by the Department before Mr Cheek was taken to FSH. Had such a risk assessment been carried out, it would not have recommended that restraints be used.
Consequently, the Coroner found that the entirely inappropriate and unnecessary use of restraints on Mr Cheek meant that he was dealt with in an inhumane manner in the final seven days of his life.
As the inappropriate use of restraints on terminally ill prisoners admitted to hospital has already been the subject of comment and recommendations in previous inquests, the Coroner was satisfied the Department has already introduced measures since Mr Cheek’s death to minimise the risk of this occurring again.
Catch Words : Death in Custody : Treatment, Care and Supervision : Use of Restraints : Insulin‑dependent diabetes : Natural Causes
Last updated: 6-Nov-2024
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