Coroner's Court of Western Australia

Inquest into the Death of Edward Ivan AFRICH

Inquest into the Death of Edward Ivan AFRICH

Delivered on : 17 April 2023

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Edward Ivan Africh (Mr Africh) was 64 years old when he died on 18 February 2019 at Fiona Stanley Hospital (FSH). He was a sentenced prisoner and was in the care of the CEO of the Department of Justice at the time of his death. As he was a person held in care, his death was subject to a mandatory inquest.

Mr Africh commenced his term of imprisonment on 15 February 2018. He already had a number of significant pre-existing illnesses which included atrial fibrillation, alcohol-related liver disease, interstitial lung disease and emphysema. While in custody, he was further diagnosed with chronic myelomonocytic leukaemia, right side heart failure and worsening emphysema.

Although he spent the majority of his incarceration at Acacia Prison (Acacia), Mr Africh was transferred to Casuarina Prison (Casuarina) in December 2018 so he could be treated in the infirmary at Casuarina.  

On 15 February 2019, Mr Africh complained of feeling unwell. His oxygen saturation levels were very low, he had difficulty breathing when walking and was very frail. A prison doctor assessed that Mr Africh may be having heart failure and arrangements were made to have him urgently transferred by ambulance to FSH. Following his admission to FSH, Mr Africh was diagnosed with pulmonary oedema secondary to decompensated heart failure and possible chest sepsis. He also had an acute kidney injury and fluid around the lungs.

Mr Africh did not respond to treatment, and he remained extremely unwell. On 18 February 2019, the haematology team at FSH determined that Mr Africh’s care should become palliative only. Active treatment was ceased and Mr Africh was prescribed medication to keep him comfortable. He died that evening from bronchopneumonia and sepsis with chronic obstructive pulmonary disease, and his death occurred by way of natural causes.

The Coroner noted the complexity of Mr Africh’s various medical conditions, which would have made it challenging to manage even outside of a prison setting. Although Mr Africh was placed in a four-person cell at Acacia that held prisoners who smoked (which would have aggravated his emphysema), the Coroner accepted there were satisfactory explanations for that placement. The Coroner was generally satisfied that the medical supervision, care and treatment provided to Mr Africh in prison was appropriate.

The Coroner, however, was not satisfied that it was necessary to restrain Mr Africh in the manner he was once he had been placed in a bed at FSH on 15 February 2019. Given his frailty, extremely poor health, lack of mobility and minimum-security status, the Coroner found that the prospect of Mr Africh breaching security if he was to be unrestrained was negligible. Accordingly, it was entirely inappropriate to keep Mr Africh restrained until the morning of the day he died.      

Catch Words : Mandatory Inquest: Death in Custody: Natural Cases: Physical Restraint: Palliative

Last updated: 27-Apr-2023

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