Coroner's Court of Western Australia

Inquest into the Death of Alex Carl MILLS

Inquest into the Death of Alex Carl MILLS

Delivered on : 6 August 2021

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Alex Mills was a sentenced prisoner at the time of his death on 16 May 2019.  He was transferred from Casuarina Prison about a week before his death to Fiona Stanley Hospital where he received palliative care until his death.  His death was due to sepsis from a bacterial infection that did not respond to antibiotics.

When Mr Mills came into custody, he was 76 years old with a long history of severe rheumatoid arthritis.  He had been on the steroid prednisolone as a treatment for many years.

Mr Mills clinical assessment also included known valvular heart disease, severe osteoarthritis in his shoulders and an ulcer on his right foot from which he suffered the bacteria staphylococcus aureus.  On 28 June 2018 Mr Mills was added to the terminally ill module stage 3 in the prison health system due to his multiple health issues and risk of an acute terminal event.

On 8 August 2018 Mr Mills presented to a nurse complaining of a large, painful bruise on the right side of his body that extended from his scapula to his waist.  He was sent to Armadale Hospital Emergency Department for review.  Mr Mills was noted to have a mass over the right postero-lateral chest wall, which was enlarging.  Blood tests showed anaemia and a raised white cell count.  A chest wall ultrasound reported a large, complex haematoma on the right posterolateral chest wall.  He was discharged with advice to have repeat blood tests in two to three days and to continue on his anticoagulant, despite the bleeding, as he was at high risk of a stroke if he stopped taking it.

He was reviewed by a prison doctor on 9 August 2018 and it was noted he was to be reviewed immediately if the bruise was increasing in size or other bleeding occurred.  Mr Mills was returned to Armadale Hospital ED on 10 August 2018 as the bruising was noted to have extended and he reported red stools.  Mr Mills was admitted and treated and then discharged back to prison on 11 August 2018 with advice to restart his steroid and withhold his anticoagulants for a week.  Mr Mills was referred for a colonoscopy, which revealed colonic polyps and haemorrhoids.

On 26 October 2018 Mr Mills was reviewed by a prison medical officer with complaints of a red, hot, tender left foot.  He was prescribed medication but there was little improvement in the following days and on 28 October 2018 Mr Mills requested to go to hospital as his entire lower left leg, from the knee down, was now hot and swollen.  He was sent Armadale Hospital ED that day, where he was admitted.  Tests were suggestive of infection.  Mr Mills was treated and discharged back to the Casuarina Infirmary on 7 November 2018 on an oral antibiotic.  A doctor saw Mr Mills at the Casuarina Infirmary and he was cleared to return to Karnet Prison, which was his preference.  On 19 November 2018 Mr Mills returned to Karnet Prison.

On 28 November 2018 Mr Mills’ legs were swollen and red again.  He was reviewed by a doctor and prescribed a course of antibiotic treatment and blood tests were ordered.  On 12 December 2018 Mr Mills self-presented to the health centre feeling unwell and requesting more antibiotics.  In late December 2018 there were some concerns about Mr Mills’ medication regime and effect on his blood pressure and heart, which resulted in some medication changes.

Mr Mills health appeared to have settled in early 2019 but he remained on the terminally ill register.  He had a discussion with a nurse about arranging a ‘not for resuscitation’ order and the relevant policy was explained to him.  On 4 March 2019 Mr Mills was reviewed by a nurse as he appeared unwell during the medication round.  He complained of groin pain and feeling generally unwell.  He was noted to look ‘unwell’ and he had lost weight.  His observations were taken and showed a high temperature and rapid heart rate.  His left lower leg was also noted to be hot and red.  He was sent to Armadale hospital for a medical review.  Mr Mills remained in hospital for treatment until on 19 March 2019 when he was discharged back to prison where he was regularly monitored.

On 7 May 2019 Mr Mill developed nausea and began vomiting.  He was taken by ambulance to FSH for assessment.  Mr Mills remained in hospital being treated and his treating team considered his prognosis was very poor.  He was transferred to the General Ward and made not for resuscitation.  Mr Mills was kept comfortable until his death on 16 May 2019.

The Deputy State Coroner was satisfied Mr Mills medical care comparable, or better, to what Mr Mills could have received in the community.

Catch Words : Death in Custody : Care, Treatment and Supervision : Natural Causes

Last updated: 28-Oct-2021

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