Coroner's Court of Western Australia

Inquest into the Death of John Henry WATERFALL

Inquest into the Death of John Henry WATERFALL

Delivered on : 21 September 2023

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : N/A

Summary : Mr John Henry Waterfall (Mr Waterfall) was 76-years of age when he died at St John of God Midland Public Hospital (SJOG) on 16 December 2021 from bronchopneumonia with multiple organ failure in the setting of advanced metastatic prostatic adenosquamous carcinoma (medically palliated).

At the time of his death Mr Waterfall was a sentenced prisoner at Acacia Prison (Acacia), having been received there on 6 March 2019.  Although Mr Waterfall was well known to prison health services during his incarceration, he frequently declined recommended investigations and treatment.  He also periodically refused to attend internal and external health appointments, although from 2020 his blood pressure was regularly checked.

On 10 December 2021, Mr Waterfall was reviewed by a prison medical officer.  His medical condition had deteriorated, and he appeared frail and had lost weight.  After encouragement, Mr Waterfall agreed to be assessed at hospital and he was transferred to SJOG by ambulance.

Mr Waterfall underwent X-rays, CT scans and blood tests which confirmed he had metastatic disease.  Although the primary cancer was unclear, it was thought that his primary tumour was in his prostate.  After discussions with his treating team, Mr Waterfall declined any further investigations or management, and instead he expressed a strong preference for palliative care.

At 12.10 pm on 16 December 2021, officers from Ventia, the company the Department of Justice (DOJ) uses to supervise prisoners admitted to hospital) noted that Mr Waterfall appeared to have stopped breathing.  Clinical staff were alerted, and Mr Waterfall was declared deceased at 12.19 pm.

On 10 December 2021, Mr Waterfall was identified as a Stage 3 terminally ill prisoner on the basis of his likely diagnosis of metastatic prostate cancer.  On 16 December 2021, Mr Waterfall was escalated to Stage 4, and as noted, he died the same day.

During his transfer to hospital and whilst he was an inpatient at SJOG, Mr Waterfall was improperly restrained, contrary to department policy.  The coroner noted that DOJ is planning amendments to its policies and procedures relating to the restraint of terminally prisoners.  On that basis the coroner determined that it was not necessary for any recommendations to be made in this case, but the coroner strongly urged DOJ to complete the consultation and approval process in relation to the proposed changes to prisoner restraint procedures, so that the changes could be implemented as quickly and efficiently as possible.

With the exception of the restraint issue, the coroner concluded that the standard of supervision, treatment and care that Mr Waterfall received whilst he was incarcerated was of an acceptable standard.

Catch Words : Death in Custody : Metastatic disease : Improper use of restraints : Natural Causes

Last updated: 6-Oct-2023

[ back to top ]