Coroner's Court of Western Australia

Inquest into the Death of Karl Frederick Dominic HOLMES

Inquest into the Death of Karl Frederick HOLMES

Delivered on : 4 April 2024

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Karl Frederick Holmes died on 14 January 2023 at Fiona Stanley Hospital from complications of metastatic lung cancer. Mr Holmes was a serving prisoner at the time of his death, so an inquest was mandatory.

Mr Holmes was convicted after trial of a significant number of offences, eventually leading to a total term of seven years’ imprisonment with parole eligibility in June 2022. His earliest eligibility for release on parole was 8 February 2027.

Mr Holmes had been admitted to Bunbury Regional Prison in February 2022 after being convicted. At that time, he had a significant number of health issues, including a prior history of liver cancer and chronic obstructive pulmonary disease (COPD) on a background of cigarette smoking. He was noted to be in pain and to have limited mobility when he was assessed by a prison doctor on 14 February 2022, so he was prescribed pain medication and housed in a prison unit in close proximity to the medical centre. Some blood tests and other investigations were arranged, which suggested he might have lung cancer. It was felt likely to be a second primary cancer, rather than his liver cancer having metastasised. Following a lung biopsy on 5 May 2022, Mr Holmes’ diagnosis of lung cancer was confirmed. His lawyer was informed of his diagnosis, so that it could be raised at his sentencing hearing.

After being sentenced, Mr Holmes continued to receive regular medical treatment in prison for his lung cancer, as well as his pre-existing liver cancer and COPD, as well as ongoing pain. He was told in September 2022 that a new lesion in his lung had been identified on a scan. Mr Holmes indicated he did not want to make any decisions about ongoing treatment until the outcome of his criminal appeal, as he was not interested in receiving treatment for his cancers if his appeal was not successful. He had reduced the amount of his cigarette smoking significantly at that time, but was still smoking and had an ongoing heavy cough. Mr Holmes’ regular doctor discussed his case with two other prison medical officers, and they agreed if he did not accept further treatment, then he should be offered palliative treatment.

Mr Holmes had ongoing discussions with doctors within the prison and external specialists, but maintained his position that he did not want active treatment for his lung cancer, although he was willing to explore treatment options for his liver cancer. In November 2022, Mr Holmes contracted COVID-19. He was given antiviral treatment but it was acknowledged that his risk of death was increased as a result of the infection, although he eventually recovered.

On 5 January 2023, Mr Holmes had another medical review after having some more CT scans performed. He indicated he wanted to know the results of the scans before making any treatment decisions. He became unwell the following day and was transferred to Bunbury Hospital for treatment. The prison medical officer visited Mr Holmes in Bunbury Prison to discuss his CT scan results, prognosis and treatment goals. He was informed that based on the results of the scans, his prognosis was not good and the time for treatment had passed. It was suggested he should focus now on palliative care with the goal of remaining well and comfortable for as long as possible. Mr Holmes indicated he wanted to discuss end of life care options with his daughters, and visits were facilitated.

Mr Holmes was discharged from Bunbury Hospital on 12 January 2023. Although his preference was to remain at Bunbury Prison, he was transferred from hospital to Casuarina Prison due to his significant health care needs and the fact that Casuarina has the only Infirmary. His case was considered for recommendation for release on the Royal Prerogative of Mercy, but release was not recommended.

Mr Holmes was seen the next day by a prison medical officer in the morning and he appeared stable, but he rapidly deteriorated in the afternoon so he was transferred to Fiona Stanley Hospital. He was diagnosed with acute renal failure and infective exacerbation of his COPD. Mr Holmes was given palliative care until he died the following morning, being 14 January 2023.

A forensic pathologist formed the opinion Mr Holmes died from complications of metastatic lung adenocarcinoma, with terminal palliative care, in a man with multiple medical comorbidities. His death was due to natural causes.

The Deputy Coroner was satisfied that Mr Holmes’ medical treatment was of an extremely high standard prior to his death. The Deputy Coroner did raise some concern about the absence of prompt dental treatment for Mr Holmes and an issue in relation to his restraint on his transfer from Casuarina Prison to Fiona Stanley Hospital and overnight at Fiona Stanley Hospital until shortly before his death was also considered.

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

Last updated: 16-Apr-2024

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