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Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Inquest Findings

Home →Inquest Findings→Inquest Findings 2022→Roman, Robert William

Inquest into the Death of Robert William ROMAN

Inquest into the Death of Robert William ROMAN

Delivered on :4 February 2022

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Roman was a 55 year old man who died on 10 May 2018 at Rockingham General Hospital as a result of a subdural haematoma in a man with diabetes mellitus and chronic kidney disease (requiring dialysis).  He had an extensive past history of type 2 diabetes, end stage renal failure, ischaemic heart disease and chronic obstructive pulmonary disease.

At the time of his death, Mr Roman was a sentenced prisoner at the Casuarina Prison and is therefore a ‘person held in care’ within the means of the Coroners Act 1996 (WA) in which a coronial inquest is mandated, in order for the coroner to comment on the supervision, treatment and care provided to Mr Roman while in prison and the circumstances surrounding the death.

Mr Roman was transferred on a regular basis from prison to his appointments at the Fresenius Dialysis Clinic for his dialysis treatment for end stage renal failure.  During his scheduled dialysis appointment on 10 May 2018, Mr Roman became progressively unwell and unexpectedly collapsed.  After being transferred by ambulance to the Rockingham General Hospital, it was discovered Mr Roman suffered a brain bleed and was unable to be revived.

Although the Department of Justice has made some improvements since Mr Roman’s death surrounding support to families of prisoners receiving timely notification of the deterioration in a prisoner’s health, the main focus of the inquest was the care provided to Mr Roman.  After reviewing all the evidence, the State Coroner was satisfied the care provided to Mr Roman was appropriate considering his complex medical needs and found death occurred by way of Natural Causes.

Catch Words : Dialysis Treatment : Death in Custody : Natural Causes


Last updated: 19-Mar-2022

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