Coroner's Court of Western Australia

Inquest into the Death of Bradley James Raymond STINSON

Inquest into the Death of Bradley James Raymond STINSON

Delivered on :  2 November 2023

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 2 February 2022, Mr Bradley James Raymond Stinson (Mr Stinson) died at St John of God Midland Hospital (SJOGMH), from cardiac arrhythmia in the presence of arteriosclerotic cardiovascular disease, pulmonary thromboembolism and metastatic cancer of the pancreas. He was 66 years old. At the time of his death, Mr Stinson was a sentenced prisoner and in the care of the CEO of the Department of Justice (the Department). As he was a person held in care, Mr Stinson’s death was subject to a mandatory inquest.

After being held at Hakea Prison for just over a year, Mr Stinson spent his remaining eight years as a prisoner at Acacia Prison (Acacia).  In that time, he underwent regular health assessments and was diagnosed with a number of additional health conditions. These included COPD (chronic obstructive pulmonary disease), hypertension and mild coronary artery disease.

On 6 December 2021, Mr Stinson was taken from Acacia to SJOGMH after experiencing severe abdominal pain. A CT scan showed a primary pancreatic cancer that had spread to the liver and lungs. A subsequent liver biopsy confirmed adenocarcinoma of the pancreas. Mr Stinson was prescribed tapentadol and paracetamol to manage his pain and he was discharged from SJOGMH on 9 December 2021.  

On 12 January 2022, Mr Stinson had an outpatient appointment with a consultant at SJOGMH. He was informed he had an aggressive pancreatic cancer that was unable to be surgically removed. Mr Stinson was given a prognosis of six to nine months, or possibly two to three years with chemotherapy. Mr Stinson elected not to have chemotherapy.

On 22 January 2022, Mr Stinson had severe nausea and vomiting with generalised abdominal pain, and he was taken by ambulance to SJOGMH. A CT scan showed significant progression of the intra-abdominal cancer and ascites (fluid in the abdomen). Mr Stinson remained as an inpatient at SJOGMH and by 28 January 2022, he was receiving palliative care medications. He died in the early hours of 2 February 2022.

The Coroner was satisfied that the medical supervision, care and treatment provided to Mr Stinson when he was in prison and in a hospital setting was appropriate. The Coroner, however, was not satisfied it was appropriate to restrain Mr Stinson during his transfer to, and subsequent admission at, SJOGMH from 22 - 28 January 2022. The Coroner found that such restraints not only defied the Department’s relevant policies and procedures, but they were completely unnecessary given Mr Stinson’s age, frailty, terminal illness and limited mobility.    

Catch Words : Death in Custody : Terminally Ill Register : Restraints : Natural Causes

Last updated: 15-Nov-2023

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