Coroner's Court of Western Australia

Inquest into the Death of Jeffrey Lee STRETTLES

Inquest into the Death of Jeffrey Lee STRETTLES

Delivered on : 14 February 2022

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 8 August 2019 at St John of God Hospital, Midland Mr Jeffrey Strettles died from complications in association with advanced malignancy, end-stage liver disease and generalised sepsis in a man under medical palliative care.  He was 52 years old.

Immediately before his death, Mr Strettles was a person held in care as a sentenced prisoner in the custody of the Chief Executive Officer of the Department of Justice. An inquest into his death was therefore mandated.

Mr Strettles was initially admitted to Hakea Prison on 19 October 2017. On admission he was noted as having multiple pre-existing health issues, including liver cancer, liver cirrhosis, hepatitis C, peripheral neuropathy and depression. He was a smoker and had a long history of alcohol and polysubstance abuse. Mr Strettles advised staff he had a history of mental health issues and had attempted suicide in the past with the latest attempt only five days prior to his incarceration.  Mr Strettles was placed on the department’s At Risk Management System and remained on moderate ARMS until 31 October 2017, when he was identified as having no thoughts of self-harm.

On 22 November 2017, Mr Strettles was transferred to Acacia Prison. Medical records indicate that during his incarceration at Acacia and Hakea Prisons he attended the prison medical centres for various minor medical issues and received treatment for his hepatitis C, which was successfully treated and eradicated in July 2019.  Mr Strettles pre-existing health complications regarding his liver began to rapidly progress by June 2018.  On 26 June 2018, MRI results showed a new lesion on his liver and he was diagnosed with multifocal hepatocellular carcinoma.  On 23 April 2019, Mr Strettles was listed as Stage 3 terminally ill.  Although the treatment and care which he received at the medical centre in Acacia and tertiary hospitals were of a high order, Mr Strettles’ liver complications were too advanced for him to be cured.

Mr Strettles’ health continued to deteriorate and on 31 July 2019 he was transferred from Acacia Prison to St John of God Hospital, Midland with a fever and in a confused state. He underwent scans which revealed a destructive mass lesion on the right side of his brain, and he had developed end stage liver failure and sepsis. Mr Strettles’ condition did not improve and he was reviewed by the hospital palliative care team on 2 August 2019. Apart from palliative care, all treatment was ceased and the decision was made to keep him comfortable. On 5 August 2019, Mr Strettles was listed as Stage 4 terminally ill. He remained at St John of God Hospital, Midland until he died on 8 August 2019.

The Coroner was satisfied the medical care and treatment provided by the Department and hospitals that cared for Mr Strettles was of the same standard that a person living in the general community would expect to receive. The Coroner found Mr Strettles died of natural causes.

Catch Words : Death in Custody : Supervision, Treatment and Care : Royal Prerogative of Mercy : Natural Causes

Last updated: 19-Mar-2022

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