Coroner's Court of Western Australia

Inquest into the Death of Hugh WARD

Inquest into the Death of Hugh WARD

Delivered on :30 March 2023

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

Recommendation No. 1

I recommend that when a prisoner is being received into custody, the Department of Justice (DOJ) should consider asking the prisoner to provide written consent for their nominated next-of-kin to be provided with information about their medical condition and/or its management.  I further recommend that DOJ consider applying this procedure to all prisoners who are likely to require ongoing medical treatment and/or intervention because of their age, cognitive ability, and/or medical conditions.

Recommendation No. 2

I recommend that the DOJ consider implementing a practice of including, within the 'Medical Alert' tab on a prisoner’s profile within the Total Offender Management Solutions system, any information relating to the prisoner's consent to provide third parties with information about their medical condition and/or its management

Recommendation No. 3

I recommend that when a prisoner is the subject of an enduring power of attorney or a guardianship order, the Department of Justice ensure that an alert is placed on the prisoner’s profile within the Total Offender Management Solutions system, to alert users to that fact.

Orders/Rules : N/A

Suppression Order : N/A

Summary: Mr Hugh Ward (Mr Ward) was 89-years of age, when he died on 5 October 2021 at Sir Charles Gairdner Hospital (SCGH) from complications of a stroke.  At that time, Mr Ward was a sentenced prisoner accommodated at Casuarina Prison (Casuarina).

Mr Ward’s medical history included atrial fibrillation, type-2 diabetes, high blood pressure and hearing loss.  When he was admitted to Casuarina, he was taking warfarin (an anticoagulant) to prevent blood clots as a result of his atrial fibrillation.

Mr Ward was accommodated in the infirmary at Casuarina because of his frailty and medical issues.  He was taken to hospital on several occasions for treatment of issues including: bleeding gastric ulcers, embolic strokes, and falls.

At about 3.30 pm on 4 October 2021, Mr Ward was found slumped over in his wheelchair in the infirmary.  The right side of his face was drooping and he had right-sided weakness and no grip strength.  He was taken to SCGH by ambulance, where CT scans showed blockages in multiple blood vessels in his brain (embolic stroke).  Mr Ward underwent a procedure to treat the blocked blood vessels (percutaneous thrombectomy) and although the procedure was uneventful, a follow-up CT scan showed a subarachnoid haemorrhage and associated swelling of the brain.

Mr Ward’s prognosis was poor and following discussions between his family and his treating team it was decided to treat him palliatively.  He was kept comfortable until his death on 5 October 2021 at about 9.30 pm.

The coroner was satisfied that the supervision, treatment and care that Mr Ward received while he was incarcerated was of a good standard.  The coroner made three recommendations aimed at improving communication with a prisoner’s next-of-kin.

Catch Words : Mandatory Inquest: Death in Custody: Natural Causes

Last updated: 14-Apr-2023

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