Coroner's Court of Western Australia

Inquest into the Death of Francis Robert Ward

Delivered on 22 October 2014 at Perth.

Finding of Deputy State Coroner.


The deceased was a sentenced prisoner at Casuarina Prison at the time of his death on 8 September 2013. The deceased was 90 years of age.

The inquest focused on the quality of the supervision, treatment and care the deceased received while in custody. The Coroner found the deceased had a number of comorbid medical conditions and was at high risk for mechanical falls.

On 17 August 2013 the deceased was examined at Royal Perth Hospital and was found to have a large acute subdural haemorrhage overlying a prior subacute/chronic subdural collection. The deceased returned to Casuarina Infirmary for palliative care.

The Coroner found the deceased died as a result of pneumonia in a man with traumatic brain injury and that death occurred on 8 September 2013. The Coroner found death arose by way of Accident.

The Coroner found the deceased’s supervision, treatment and care were adequate and reasonable.

Catch Words

Death in Custody : Pneumonia : Traumatic Brain Injury : Accident.

Last updated: 15 July 2022

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