Coroner's Court of Western Australia

Inquest into the Death of Ian HEAD

Inquest into the Death of Ian HEAD

Delivered on :  23 February 2024

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Head died was serving a prison sentence when he died overnight on 24 to 25 August 2022. He died from natural causes, having contracted Covid-19 on a background of pre-existing airways disease and other co-morbidities.

At the time of his death, Mr Head was housed in a four person cell in Juliet Block at Acacia Prison. His cellmates recalled he had been unwell with diarrhoea for a couple of days prior, which had been making him feel despondent. Mr Head blamed the diarrhoea on some soup he had eaten, but in hindsight it was likely to have been a symptom of Covid-19. However, as Mr Head did not seek medical attention, his illness was undiagnosed and he did not receive the support that might have assisted him to fight the virus and recover.

Mr Head was up to date with his Covid-19 vaccinations while in prison and had recently recovered from a bout of the virus only a few weeks before. This may have impacted on the severity of his illness the second time. In addition, the ongoing diarrhoea may have weakened him and may him more susceptible to a sudden cardiac arrhythmia.

On the evening of 24 February 2022, Mr Head seemed in reasonable spirits when he spoke to his cellmates before going to sleep. Overnight, checks were made by prison officers of the cell, but it seems the checks were cursory and it was not identified that Mr Head might be unwell or unresponsive. The next morning, the cell was opened and a head count conducted, that was supposed to also include a welfare check, but due to staff shortages that had led the cell opening procedure to run late, it was again not identified by prison officers that Mr Head was unresponsive. Not long after the cell was opened, one of Mr Head’s cellmates went to wake him so he could get ready for work, and found Mr Head unresponsive. Prison officers were notified and they immediately went to Mr Head and commenced CPR. A doctor and nurse also attended with a defibrillator, which indicated no shock should be administered. Despite Mr Head showing signs he had been deceased for some time, including evidence rigor mortis and livor mortis and a very low body temperature, the doctor determined it was appropriate to continue CPR until the arrival of ambulance officers. SJA officers attended and confirmed Mr Head’s death.

A post mortem examination found Mr Head died from cardiac arrhythmia in an elderly man with chronic obstructive pulmonary disease with Covid-19 infection, hypertension and kidney impairment. His death was consistent with natural causes.

The inquest hearing explored the quality of the care, treatment and supervision provided to Mr Head prior to his death, as is required under the Coroners Act. It was noted that Mr Head had been receiving regular medical reviews while he had been housed at Hakea Prison, but this had ceased upon his transfer to Acacia Prison in April 2022. He was due to have a medical review, including bloodwork, on 30 April 2022, but this date was administratively extended to June 2022. Mr Head did receive a flu vaccination and when he tested positive for Covid-19 in June 2022, he was also given a Covid-19 booster vaccination. He saw nurses over this time and was encouraged to cease smoking, had his blood pressure checked and given medication for an itchy rash. He was scheduled to have blood samples taken and to see a doctor in July 2022, but Mr Head did not attend the appointment. He also did not attend a rescheduled appointment with a doctor on 3 August 2022, although the reason for his non-attendance is unclear. There was a plan to follow up Mr Head and arrange another medical appointment, but he died before this occurred.

The Coroner noted that there were pressures on the healthcare systems at the relevant time due to the Covid-19 epidemic. There had been an outbreak in a different unit block on 11 August 2022, and it seems likely the outbreak had spread to Mr Head’s unit block immediately prior to his death, but this had not yet been identified. If Mr Head had been diagnosed, then he might have been able to be given more support to improve his chances of surviving the second bout of infection, but it cannot be said for certain that he would have survived even if that had occurred. However, the lack of medical review or even a comprehensive nursing review of Mr Head in the months leading up to Mr Head’s death was a missed opportunity to ensure his various health conditions were being managed effectively. Information was sought from Acacia Prison management as to the current GP to patient ratio at Acacia Prison after the inquest hearing.

In addition, the Department of Justice’s internal review found the policy and procedures for formal head counts and the unlock process were not adhered to on the day of Mr Head’s death, which was a missed opportunity to identify at an earlier stage that Mr Head was in extremis. In response, the Department had recommended to Acacia Prison’s management (noting the prison is managed by Serco Australia for the Department) to amend and reinforce it’s policies and procedures for head counts and welfare checks.

In relation to the resuscitation attempts, it was noted that there was compelling evidence before the prison doctor that might have allowed the doctor to make a determination that Mr Head was deceased and resuscitation efforts to cease, prior to the arrival of SJA officers. However, evidence was given at the inquest that prison health staff do not always feel comfortable making that call, given the death will be the subject of a coronial investigation and mandatory inquest and there is a concern individual staff might face criticism if all efforts are not made to try to resuscitate the prisoner, even if those efforts will be futile. The Court was advised that the Department of Justice is currently reviewing the policies relevant to resuscitation of prisoners, including in relation to advanced health directives, to ensure that the policies and training are consistent with practices in the community, as much as practical.

Given the issues raised have already been considered internally, and steps are being taken to address them, the coroner did not make any recommendations.

The Coroner found that Mr Head died from a sudden cardiac arrhythmia after he contracted Covid-19 infection on a background of his pre-existing co-morbidities. He died as a result of natural causes.

Last updated: 9-Apr-2024

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