Inquest into the Death of Robert Fredrick PARNELL

Inquest into the Death of Robert Fredrick Parnell

Delivered on : 5 September 2024

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : Yes

On the basis that it would be contrary to the public interest, I make an Order under section 49(1)(b) of the Coroners Act 1996 that there be no reporting or publication of the name of any prisoner (other than the deceased) housed at Albany Regional Prison on or about 16 May 2022. Any such prisoner is to be referred to as “Prisoner [Surname Initial]”.

Summary : Robert Fredrick Parnell (Robert) died on 16 May 2022 at Albany Health Campus (AHC), from butane and propane toxicity.  He was 29-years of age.  At the request of his family, the deceased was referred to at the inquest and in the coroner’s finding as “Robert”.

At the time of his death, Robert was a sentenced prisoner at Albany Regional Prison (ARP) in the custody of the Director-General of the Department of Justice (Department).  On 19 May 2021, in the District Court of Western Australia at Perth, Robert was sentenced to a term of five years and six months imprisonment (with parole eligibility) for the offences of armed robbery, and pretending to be armed in a way that may cause fear. 

Robert’s medical history included Attention Deficit Hyperactivity Disorder, anxiety, depression, and cognitive/intellectual disability, and he had a history of polysubstance use including alcohol, tobacco, methylamphetamine, cannabis, heroin, and suboxone.  Robert also had a history of sniffing solvents and petrol, which reportedly started when he was about 13 years of age.

Whilst at ARP, Robert worked in the ARP kitchen as a cleaner.  At about 8.50 am on 16 May 2022, Robert left his prison cell and went to the ARP kitchen to start work.  He appeared to be his usual self, and during the shift he had several work-related interactions with his supervisor.

At about 4.00 pm, a prisoner told prison staff that someone was lying on the floor in the kitchen toilet.  Staff rushed to the toilet, and found Robert lying, unresponsive, inside the cubicle.  As Robert was moved to a changing area so that he could be given CPR, a plastic bag and a spray can of canola oil spray (which is used regularly in the ARP kitchen) was found in the cubicle.

It appears that in the period before he was discovered, Robert had sprayed the contents of the can of canola cooking oil spray into the plastic bag, before inhaling the propellants, namely butane and propane captured in the plastic bag.

Emergency services were called and ambulance officers arrived a short time later and took over CPR, before taking Robert to AHC.  Despite further resuscitation efforts, Robert could not be revived and was declared deceased at 5.21 pm on 16 May 2022.

The forensic pathologist who conducted a post mortem examination on Robert’s body noted that butane and propane “may cause respiratory depression, seizures, an abnormal beating rhythm of the heart (cardiac arrythmia) and sudden death”.

The coroner noted that a Commissioner’s Broadcast published on 26 August 2024, imposed appropriate controls on the use of aerosols within custodial facilities.  Significantly, the use of aerosol cooking spray is to be discontinued throughout custodial facilities in Western Australia, along with “any other aerosol cans that prisoners have direct access to and can be misused causing harm to themselves and or others”.

While the coroner considered that the terms of the Commissioner’s Broadcast satisfactorily addressed the hazards posed by the sniffing of propellants in aerosol cans by prisoners, the coroner was critical of the fact that it had taken the Department over two years to address the issue.

After carefully considering the available evidence, the coroner was satisfied that the standard of treatment and care Robert received during the time he was incarcerated was appropriate, and that his medical care was commensurate with community standards.

However, the coroner noted that on at least one occasion (and on the evidence of another prisoner at ARP, possibly on other occasions), Robert was able to inhale propellants from a can of canola cooking oil spray which he had removed from a storeroom in the prison kitchen.  The coroner concluded that even accepting the fact that the risk that prisoners might inhale propellants from cans of cooking oil spray was not appreciated at the relevant time, the coroner expressed the view that the standard of supervision Robert received, at least on 16 May 2022, was sub-standard.

Catch Words : Death in Custody : Inhalation of volatile substances : Accident

Last updated: 20-Sep-2024

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