Inquest into the Death of Frank MIKHAIL

Inquest into the Death of Frank MIKHAIL

Delivered on : 23 December 2024

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : N/A

Summary : Frank Mikhail (Mr Mikhail) died on 23 February 2023 at Acacia Prison (Acacia), from “bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pulmonary disease”.  He was 68-years of age.

On 22 June 2011 in the Supreme Court of Western Australia, Mr Mikhail was convicted of two counts of murder and sentenced to life imprisonment.

Mr Mikhail’s medical history included: post-traumatic stress disorder, depressive disorder, sciatica, scoliosis of the lumbar spine, gastritis, and severe chronic obstructive pulmonary disease related to his history of heavy smoking.

Whilst he was at Acacia Mr Mikhail regularly attended the medical centre for treatment of various minor ailments and conditions.  He would often do so without an appointment, or outside standard clinic times, and would often present in a demanding and argumentative manner.  Mr Mikhail also made frequent complaints about his medical care and expressed his belief that his “ongoing issues were not being resolved”.

At about 12.15 am on 29 January 20232, prison officers responded to an emergency call from Mr Mikhail who said words ot the effect that he was “coughing up blood” (known medically as haemoptysis).  Prison officers noted blood around Mr Mikhail’s mouth and on the floor of his cell, and he was taken to St John of God Midland Public Hospital (SJOG) by ambulance.

At SJOG, Mr Mikhail was diagnosed with an acute lower respiratory tract infection and prescribed two oral antibiotics.  He was returned to Acacia the same day, but before his discharge Mr Mikhail had a further episode of haemoptysis.  Although a nursing entry in the SJOG hospital notes states that this incident was reported to a doctor, the volume of blood and/or fluid coughed up is not mentioned, and it is unclear what action (if any) was taken.

After his return to Acacia, Mr Mikhail’s symptoms did not appear to resolve despite his dual antibiotic therapy.  On 8 February 2023, Mr Mikhail was seen by a doctor at the medical centre and was said to be “very unhappy”.  Mr Mikhail complained about his treatment saying he was “dying” and “coughing up shit”.  Mr Mikhail was diagnosed with “non-infective exacerbation of his COPD”, and prescribed a short course of prednisolone.  The prison doctor also ordered a chest CT to exclude any “sinister” cause for Mr Mikhail’s symptoms.

On 15 February 2023, Mr Mikhail presented to the medical centre and reported he was still coughing up some “dried blood”, and also that his sputum was coloured.  Mr Mikhail asked for “something to clear out the sputum” and also told the prison nurse he was “dying” and “had cancer”.  Mr Mikhail denied smoking, and on examination was found to have an occasional dry cough with “added right sided chest signs”.  The nurse who reviewed Mr Mikhail liaised with a prison doctor about Mr Mikhail’s treatment plan, and the EcHO medical notes record that Mr Mikhail was to continue his course of oral prednisolone.  The EcHO medical notes also state that Mr Mikhail was still awaiting a CT scan of his chest, which as noted had been requested by the prison doctor on 8 February 2023.

At about 12.05 am on 23 February 2023, Mr Mikhail was found in his cell lying on his back in bed with a pool of blood around his head.  Mr Mikhail was placed on the floor and CPR was commenced, and a prison nurse attached a defibrillator to his chest.  Ambulance officers arrived and took over resuscitation efforts but Mr Mikhail could not be revived, and was declared deceased at 12.57 am on 23 February 2023.

After carefully considering the available evidence, the coroner concluded that during the time he was incarcerated, the standard of Mr Mikhail’s supervision was appropriate.  Mr Mikhail was regarded as a well-behaved and courteous prisoner who maintained adequate levels of hygiene, and he received regular visits from his family.

After reviewing the expert medical evidence the coroner concluded that Mr Mikhail’s medical care and treatment was generally commensurate with community standards.  However, the coroner also found that between 29 January 2023 and the date of Mr Mikhail’s death, there were several missed opportunities where the “haemorrhagic lesion” in the upper lobe of his right lung (which was noted during a post mortem examination) could have been identified and treated.  Had it been realised that the source of Mr Mikhail’s bleeding was the lesion in his right lung, it is likely that several treatment options (including targeted radiotherapy, intravenous antibiotics, high dose corticosteroids, and/or a bronchial embolisation) may have been employed to address the bleeding.

The Coroner noted that the expert evidence suggested that had the bleeding in Mr Mikhail’s lung been identified and treated at an earlier stage, it is possible that Mr Mikhail’s lifespan (and the quality of his life) may have been improved.  However, the coroner noted that given the clinical imponderables in Mr Mikhail’s case (including his various co-morbidities) it was not possible to conclude (to the relevant standard) that Mr Mikhail would not have died even if the lesion had been identified and treated earlier.

Catch Words : Death in custody : Haemorrhagic lesion : Chronic Obstructive Airways Disease : Missed opportunities : Natural causes

Last updated: 7-Feb-2025

[ back to top ]