Coroner's Court of Western Australia

Inquest into the Death of Herbert William MACKAY

Inquest into the Death of Herbert William MACKAY

Delivered on :12 January 2024

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 3 April 2021, Herbert William Mackay died as a result of complications associated with metastatic adenocarcinoma of the lung (lung cancer) at Fiona Stanley Hospital.  He was 45 years old and at the time of his death, he was being held in custody at Casuarina Prison, in accordance with an Indefinite Detention Order made under the High Risk Serious Offenders Act 2020 on 23 December 2020. 

Mr Mackay first displayed respiratory related symptoms in December 2020 when he was seen at the Casuarina medical centre, and medical investigations were promptly commenced, with a referral to Fiona Stanley Hospital.  Those investigations showed that Mr Mackay had lung cancer and that it was at an advanced stage.  Curative treatment was not possible, and his symptoms were managed at the Casuarina Infirmary and Fiona Stanley Hospital.  

In commenting on the quality of Mr Mackay’s supervision treatment and care, the State Coroner took account of a number of matters including the multiple transfers to Fiona Stanley Hospital, and the processes regarding the usage and removal of prisoner restraints.

The State Coroner was satisfied that the treatment of Mr Mackay was fair, reasonable and appropriate, having regard to his supervision, the availability prisoner treatment programs, and the treatment and care that he received in connection with his medical condition.  She accepted that this medical condition, and its seriousness, could not reasonably have been identified at an earlier stage during his incarceration.

The State Coroner noted, with approval, the proposed discussions between clinicians from Casuarina Infirmary, and clinicians from Fiona Stanley Hospital, aimed at reaching a greater understanding of the issues, when prisoners are discharged from hospital back to prison.  The State Coroner also noted, with approval, the Department of Justice’s plan to move towards smoke-free prisons in Western Australia.

Catch Words : Death in Custody : Natural Causes : lung cancer : smoke free prisons : restraints.


Last updated: 25-Jan-2024

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