Coroner's Court of Western Australia

Inquest into the Death of Errol Warren BARTLETT-TORR

Inquest into the Death of Errol Warren BARTLETT-TORR

Delivered on : 22 May 2023

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations :

When a prisoner is escorted to a hospital for palliative treatment only, the documentation provided to the officers responsible for the hospital sit should clearly specify that the prisoner is to receive palliative care and is not expected to be returned to prison.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Bartlett-Torr was 87 years old when he died on 20 June 2021 at Bethesda Hospital. He was a sentenced prisoner and was in the care of the CEO of the Department of Justice (the Department) at the time of his death. As he was a person held in care, his death was the subject to a mandatory inquest.

Mr Bartlett-Torr commenced his term of imprisonment on 16 March 2020 when he was 86 years old. He already had a number of pre-existing illnesses which included a pacemaker insertion, atrial fibrillation, gastro-oesophageal reflux, hypertension and osteoarthritis. At Mr Bartlett-Torr’s initial prison medical assessment, he was noted to be very frail and unsteady on his feet. At that assessment, the only urinary symptom he reported was a longstanding poor urinary flow. Mr Bartlett-Torr did not disclose, either then or subsequently, that a recent blood test ordered by his general practitioner returned a high prostate-specific antigen (PSA) reading that required further urological investigation for prostate cancer. Nor did Mr Bartlett-Torr’s general practitioner refer to this PSA reading when he provided a patient health summary for Mr Bartlett-Torr that had been requested by the Department’s Health Services.  

This meant that the diagnosis of Mr Bartlett-Torr’s prostate cancer was not made until May 2021 when he was admitted to hospital, after complaining of major symptoms that included nose bleeding, abdominal pain and dizziness. By then the prostate cancer was at an advanced stage and Mr Bartlett-Torr’s prognosis was regarded as poor.

On 12 June 2021, Mr Bartlett-Torr was discharged from hospital to Casuarina Prison so he could be treated at that prison’s infirmary. He continued to have shortness of breath, chest pains, nausea and diarrhea. He remained very frail and confirmed his view he had expressed in hospital that he did not want any life prolonging treatment.

On 17 June 2021, Mr Bartlett-Torr was admitted to Bethesda Hospital (Bethesda) for palliative care and was prescribed medication to keep him comfortable. Mr Bartlett-Torr died three days later from metastatic carcinoma of the prostate with complications, and his death occurred by way of natural causes. 

The Coroner was of the view that Mr Bartlett-Torr’s various chronic and progressive medical conditions, including his prostate cancer, were appropriately managed by the Department and was satisfied that the standard of medical supervision, treatment and care that he received whilst he was in custody was appropriate. 

The Coroner, however, was not satisfied that it was necessary to restrain Mr Bartlett-Torr when he was transferred, and then admitted, to Bethesda. As he was a frail and elderly prisoner, who was terminally ill with significant mobility issues, the Department’s policies and procedures mandated that Mr Bartlett-Torr was not to be restrained unless a risk assessment determined otherwise.  However, no risk assessment was performed by the Department before Mr Bartlett-Torr was taken to Bethesda. Had such a risk assessment been carried out, it would not have recommended that restraints be used.  

Consequently, the Coroner found that the entirely inappropriate and unnecessary use of restraints on Mr Bartlett-Torr meant that he was dealt with in an inhumane manner in the final days of his life.    

The Coroner made one recommendation regarding the information that is to be provided to officers responsible for the hospital sit of a prisoner who has been admitted for palliative care.

Catch Words : Mandatory Inquest: Death in Custody: Natural Causes: Palliative Care: Restraints

Last updated: 3-Aug-2023

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