Inquest into the Death of Terrance Patrick GILMORE
Inquest into the Death of Terrance Patrick GILMORE
Delivered on : 17 December 2025
Delivered at : Perth
Finding of : Acting State Coroner Linton
Recommendations : N/A
Orders/Rules : No
Suppression Order : N/A
Summary : Terrance Gilmore was a 76 year old man who died on 27 July 2022 at Fiona Stanley Hospital from complications of staphylococcus aureus septicaemia, bacterial endocarditis and kidney failure.
Mr Gilmore was a serving prisoner at the time of his death, so he came within the definition of a ‘person held in care’ under the Coroners Act 1996 (WA). As he was a person in care, his death was subject to a mandatory inquest.
An independent medical review of Mr Gilmore’s medical care raised some concerns about his early medical care in Bunbury, prior to being transferred to Fiona Stanley Hospital in Perth. No concerns were raised about his medical care once he was transferred to Perth. Accordingly, the primary focus of the inquest was Mr Gilmore’s early medical care to consider whether earlier intervention could have potentially altered the rapid progression of Mr Gilmore’s decline.
Mr Gilmore was an elderly man with a number of significant health issues when he came into prison for the first time at a later stage in his life. His health care was coordinated by the prison health staff, with appropriate input from external health providers, with a particular focus upon his diabetes and its complications. Mr Gilmore engaged willingly with his recommended treatment and generally seemed to be coping well until a second decline in his health in the middle of 2022.
Mr Gilmore was sent to Bunbury Hospital when it became apparent he might have an infection affecting his heart and possibly have suffered a heart attack. He was quickly admitted for intensive medical treatment. As part of an arrangement between Bunbury Hospital and SJOGH, which are co-located at the South-West Health Campus, Mr Gilmore was transferred to SJOGH so he could receive coronary care. There was evidence before the acting State Coroner to indicate that while there was a focus upon his infection and its complications, including the cardiac implications, it seems Mr Gilmore’s need for aggressive fluid management was overlooked, resulting in a worsening of his already impaired kidney function.
After Mr Gilmore was transferred to FSH, he received appropriate treatment for his kidney injury by commencing dialysis, but he succumbed to his other serious health issues and died.
The acting State Coroner was satisified that Mr Gilmore received a high standard of treatment, supervision and care while a prisoner at Hakea Prison and Bunbury Prison. After he was transferred to hospital, there were some issues with his restraints (although this was resolved before his death) and there were also some issues with his fluid management as part of his overall medical care, although this had no connection to his status as a prisoner.
Mr Gilmore had a number of significant co-morbidities, and the acting State Coroner was satisfied that, in the end, he died as a result of natural causes due to complications from an infection on a background of these known health issues.
Catch Words : Mandatory Inquest : Sentenced Prisoner : Supervision, Treatment and Care : Natural Causes
Last updated: 23 September 2026