Coroner's Court of Western Australia

Inquest into the Death of Alexander Robert EATTS

Inquest into the Death of Alexander Robert EATTS

Delivered on :27 March 2020

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Alexander Eatts died on 5 July 2022 at St John of God Midland Public Hospital (SJOGH). Mr Eatts was a serving prisoner at the time of his death, so an inquest into his death was mandatory.

Mr Eatts had been sentenced to a lengthy term of imprisonment on 19 October 2012. An appeal against his convictions and sentence was later dismissed. His earliest eligibility date for release on parole was 8 August 2026. He served the majority of his prison term at Acacia Prison.

Mr Eatts had been a heavy smoker earlier in his life and he was diagnosed with severe chronic obstructive pulmonary disease. He was also diagnosed with congestive cardiac failure, hypertension and a number of other chronic health conditions. It appears his conditions were relatively stable for a number of years, but from July 2020, Mr Eatts’ health began to decline. He was seen regularly by nursing and medical staff to monitor his cardiac and COPD issues, and also saw a dentist to get new dentures fitted.

In May 2021, Mr Eatts was treated at SJOGH for pneumonia. He was discharged back to Acacia on 14 May 2021. By this time, he was generally using a wheelchair to mobilise and was on oxygen supplementation. His health continued to be regularly monitored over the next year and was given appropriate medical attention, as required. On 7 June 2022, Mr Eatts was escalated to Stage 2 on the Terminally Ill register due to his reduced ability to mobilise and additional supplemental oxygen requirements.

On 26 June 2022, Mr Eatts was seen by a prison nurse and he reported he felt “shocking” and was unable to pass urine. Arrangements were made for Mr Eatts to be reviewed by a prison doctor and the next day he was transferred to SJOGH by ambulance. He was admitted to hospital that day and the next day he was escalaged to Stage Four on the Terminally Ill Register as his death was believed to be imminent as he was in the end-stages of COPD and was exhibiting heart failure and multi-organ failure. Palliative care options were discussed and Mr Eatts’ next of kin were notified and family visits approved.

By 1 July 2022, his condition had improved a little, but he indicated he did not want any further attempts to cure him and advised his daughter that he was ready to go and was at peace with himself. On 4 July 2022, it was recorded that Mr Eatts had declined any further active treatment. A request was made by a doctor for his restraints to be removed, which was completed soon after. A briefing note was provided to the Minister for Corrective Services that day in relation to the Royal Prerogative of Mercy, but Mr Eatts was not recommended for release.

The following day, security officers who were watching Mr Eatts noticed his breathing had stopped and they notified SJOGH staff, who confirmed his death at 4.57 am.

A post mortem examination established that Mr Eatts died as a result of complications, including multi organ failure and pneumonia, of chronic obstructive pulmonary disease, with terminal palliative care, in an elderly man with COVID-19 infection. The forensic pathologist expressed the opinion the death was due to natural causes. It was unclear from the evidence whether Mr Eatts contracted COVID-19 at Acacia Prison or while in hospital. He was fully vaccinated, but it obviously does not prevent infection, only reduce its severity, and Mr Eatts was particularly vulnerable given his other health conditions.

The Coroner was satisfied Mr Eatts received a high standard of treatment, supervision and care, commensurate with what he would have received in the community. He died as a result of the progression of his pre-existing illnesses and his death was due to natural causes.

Catch Words : Mandatory Inquest : Death in Care : Natural Causes

Last updated: 16-Apr-2024

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