Coroner's Court of Western Australia

Inquest into the Death of Colin Albert WINTER

Inquest into the Death of Colin Albert Winter

Delivered on : 11 January 2023

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Colin Albert Winter (Mr Winter) was a sentenced prisoner at the time of his death and was in the care of the Department of Justice. As he was a person held in care, his death was subject to a mandatory inquest. He was 71 years old.

Mr Winter had been in custody since 17 June 1986. During his long stint in jail he developed multiple and significant medical conditions. These included chronic obstructive pulmonary disease (COPD), ischemic heart disease, valvular heart disease, atrial fibrillation and an abdominal aortic aneurysm.  Mr Winter’s entrenched smoking habit was a major component in the development of a number of his medical conditions, most notably his COPD. He ignored repeated advice from his health service providers to stop smoking and improve his eating habits.

The health care provided to Mr Winter during his final years of imprisonment extended to a number of significant surgical procedures and he was treated by specialists in the areas of cardiology, haematology, respiratory, vascular, ENT, spinal and scoliosis.

On 15 November 2019, Mr Winter was admitted to Fiona Stanley Hospital (FSH) for treatment of an exacerbation of his COPD which was now regarded as severe. Although he was discharged 10 days later, he was readmitted on the same day due to the limited health care resources at Casuarina Prison’s infirmary. On 2 December 2019, Mr Winter was discharged, however prison medical staff determined he was too unwell to remain in prison and he was returned to FSH. That evening, he was discharged again from the ED at FSH.

Arrangements were then made for Mr Winter to be admitted to Bethesda Hospital for palliative care as he had end-stage COPD and significant ischemic heart disease. He was admitted on 4 December 2019 to that hospital with low oxygen levels, increased difficulty breathing, fatigue, worsening malnutrition and swallowing difficulty.  Mr Winter received end-of-life care with medication to keep him comfortable. He died on 19 December 2019 from end-stage COPD and atherosclerotic heart disease.  

The Coroner was satisfied that Mr Winter’s various medical conditions, including his COPD, were appropriately managed and that the standard of supervision, treatment and care he received whilst he was in custody was not only appropriate but was most likely better than he would have accessed in the community.  

Catch Words : Mandatory Inquest – Death in Custody -  Natural Causes  

Last updated: 4-Feb-2023

[ back to top ]