Coroner's Court of Western Australia

Inquest into the Death of Frank Kenneth MAJOR

Inquest into the Death of Frank Kenneth MAJOR

Delivered on : 25 July 2023

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

Recommendation No. 1

I recommend that the Department of Justice amend the “Transfer and Discharge” module in the Total Offender Management Solution system (TOMS) so that the “Restraints Required” tab defaults to “No” for all prisoners being managed on the Terminally Ill register in TOMS.  The aim of this amendment is to ensure that before a terminally ill prisoner leaves a prison for an external appointment, a movements officer (or other relevant person) will be required to carefully review TOMS to determine whether the prisoner is required to be restrained during the relevant movement, and if so, what restraints are required.

Orders/Rules : No

Suppression Order : N/A

Summary : Mr Frank Kenneth Major (Mr Major ) was 75-years of age when he died at Bethesda Hospital (Bethesda) from complications of metastatic prostate cancer and end-stage chronic obstructive pulmonary disease, with terminal palliative care 10 October 2021.

At the time of his death Mr Major was a sentenced prisoner at Casuarina Prison (Casuarina), having been received into prison on 30 January 2015.  In November 2018, a routine blood test found Mr Major’s prostate-specific antigen (PSA) level was raised, and following an MRI in February 2019, he was diagnosed with metastatic prostate cancer, meaning the cancer had spread.  He was treated with radiotherapy and chemotherapy and managed in the infirmary at Casuarina, where he was regularly reviewed by prison nurses and medical officers. 

On 25 April 2021, Mr Major was identified as a Stage 1 terminally ill prisoner, due to the progression of his prostate cancer, and he was escalated to Stage 4 on 30 September 2021, when his medical condition deteriorated.  On 1 October 2021, Mr Major was transferred to Fiona Stanley Hospital with laboured breathing.  Later the same day, he is admitted to Bethesda for end-of-life care.

At about 3.10 pm on 10 October 2021, security officers supervising Mr Major at Bethesda noticed he appeared to have stopped breathing.  The officers alerted nursing staff, who conducted end-of-life checks, and confirmed that Mr Major had died.

The coroner concluded that the management of Mr Major’s prostate cancer was of a very good standard.  Further, with the exception of the inappropriate application of restraints during hospital transfers on three occasions, the coroner concluded that Mr Major’s supervision, treatment and care was of an acceptable standard.

The coroner made one recommendation aimed at improving the assessment of the need for restraints during the external movement of terminally ill prisoners.

Catch Words : Death in Custody : metastatic prostate cancer: restraints for terminally ill prisoners :: Natural Causes

Last updated: 2-Oct-2023

[ back to top ]