Coroner's Court of Western Australia

Inquest into the Death of Leslie SHORTTE

Inquest into the Death of Leslie SHORTTE

Delivered on : 15 September 2022

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : N/A

Orders/Rules : N/A

Summary : Mr Leslie Shortte (Mr Shortte) died on 3 March 2020 at Bethesda Health Care from comlications metastatic squamous cell carcinoma (terminal palliation).  At the time of his death, Mr Shortte was a sentenced prisoner and was 71-years of age.

On 29 August 2006, in the Supreme Court of Western Australia at Perth, Mr Shortte was convicted of the wilful murder of his second wife.  He was sentenced to life imprisonment and ordered to serve a minimum of 17-years imprisonment before being considered for parole.

During his incarceration, Mr Shortte was managed on the At Risk Management System on several occasions, he occasionally saw prison counsellors.  These interactions tended to occur around significant dates, such as the death of his dog, his wedding anniversary and the date of his wife’s murder.

Mr Shortte was a life-long heavy smoker of cigarettes and, in the community, he was a heavy drinker who consumed alcohol on a daily basis.  Despite this, Mr Shortte had no recorded medical conditions on his admission to prison.

Mr Shortte was regularly seen in prison medical centres (PMC), although departmental records show he routinely declined recommended diagnostic tests and/or referrals to specialist medical practitioners.  On 21 March 2019, Mr Shortte saw a prison medical officer about a lesion on his shoulder.  He was diagnosed with a basal cell carcinoma and the lesion was surgically removed on 2 April 2019.

By the time Mr Shortte was reviewed by a prison doctor on 30 April 2019, a biopsy had determined that the lesion on his shoulder was in fact a squamous cell carcinoma, a lesion with a known high-risk of spreading.  In accordance with a system in place at the time but subsequently abandoned, Mr Shortte was handed a slip of paper for an appointment to further excise his shoulder lesion.  However, it appears that Mr Shortte failed to hand the slip to the receptionist at the prison medical centre and in any event, the appointment was never booked and Mr Shortte was not subject to any follow-up.

When Mr Shortte presented to the prison medical centre again on 17 August 2019, he said he had forgotten about his previous appointment although in fact, one was never booked.  A further appointment was booked for 10 September 2019, but when he failed to attend no follow up action was taken.

Mr Shortte next presented to the prison medical centre on 20 November 2019.  By that stage, he had a large solid mass at the right-hand base of his neck.  Although an ultrasound was requested by the prison medical officer, it was not immediately conducted.  Mr Shortte was admitted to hospital on 2 January 2020 and diagnosed with an invasive squamous cell carcinoma of the neck with secondary tumours.  He started radiotherapy, but this was discontinued when he became unwell.

Mr Shortte’s condition deteriorated and he was transferred to Bethesda Health Care and treated palliatively until his death on 3 March 2020.

The coroner was satisfied that satisfied that Mr Shortte was appropriately managed whilst he was incarcerated.  However, the coroner identified a number of deficiencies in Mr Shortte’s treatment whilst he was incarcerated, including a failure to follow up key appointments that Mr Shortte did not attend.  The coroner found that these errors lead to the inevitable conclusion that, when considered holistically, Mr Shortte’s treatment whilst he was in prison was suboptimal.  However, the coroner found there was no evidence that Mr Shortte’s clinical journey would necessarily have been any different, had these errors not been made.

Catch Words : Death in Custody : Treatment Decisions: Natural Causes

Last updated: 13-Dec-2022

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