Coroner's Court of Western Australia

Inquest into the Death of Lindsay WOODS

Inquest into the Death of Lindsay WOODS

Delivered on : 9 August 2024

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

Recommendation No. 1

In order to enhance the care and treatment provided to Aboriginal patients housed at the Frankland Centre, the North Metropolitan Health Service should consider engaging the services of sufficient numbers of Aboriginal Liaison Officers to service the Frankland Centre.

Orders/Rules : No

Suppression Order : N/A

Summary : Lindsay Woods (Lindsay) died on 19 February 2022 at Sir Charles Gairdner Hospital (SCGH) from metastatic high-grade neuroendocrine carcinoma.  He was 48 years of age.  At the time of his death, Lindsay was accommodated at the Frankland Centre, and was the subject to a custody order made under the Criminal Law (Mentally Impaired Accused) Act 1996 (WA).

Lindsay’s medical history included ischaemic heart disease, and poorly controlled type-2 diabetes.  In 1991, he sustained a significant head injury after the stolen car he was travelling in crashed while being pursued by police.  Lindsay was subsequently diagnosed with chronic paranoid schizophrenia, antisocial personality disorder, and polysubstance abuse disorder.  Later Lindsay’s diagnosis was amended to “organic psychosis”, indicating a mental illness caused by his acquired brain injury.  Lindsay also had cognitive deficits (frontal lobe impairment) secondary to his head injury.

Lindsay had a long history of polysubstance use including solvents, alcohol, cannabis, and methylamphetamine, and a documented history of “self-harm and auditory hallucinations to kill”.  Lindsay had numerous admissions to psychiatric facilities, with his first to Graylands Hospital (Graylands) in 1991 following his head injury.  Between 2005 and 2022, Lindsay had 13 inpatient admissions, including a three year admission to Graylands from 2006 until 2009.

On 26 November 2020, the State Administrative Tribunal appointed the Public Advocate as Lindsay’s limited guardian for a period of five years.  The limited guardian’s role was to make treatment decisions for Lindsay; to seek legal advice and representation in respect of Board hearings he was involved in; and to investigate options for Lindsay’s future accommodation and services.

On 21 January 2022: Lindsay complained of not being able to get out of bed, and told staff “I’m crippled, my back, I can’t move”.  Lindsay’s blood pressure was low and a Code Blue medical emergency was activated, and he was taken to SCGH by ambulance.

After he was admitted to SCGH, Lindsay underwent CT scans of his abdomen and pelvis, and a PET scan.  He also had an ultrasound guided biopsy of his right cervical lymph nodes, and was subsequently diagnosed with metastatic high-grade neuroendocrine carcinoma.  On 14 February 2022, Lindsay’s delegated guardian was advised of his diagnosis, and that he was not a candidate for chemotherapy.

On 16 February 2022, after discussions between the palliative care physician at SCGH, and Lindsay’s delegated guardian, approval was given for Lindsay to be treated palliatively.  Lindsay was kept comfortable, but his condition deteriorated, and he was declared deceased on 19 February 2022.

The Coroner concluded that the standard of care and treatment Lindsay received at the Frankland Centre was of a very good standard.  Lindsay was regularly reviewed by various specialists, and when he complained of severe back pain he was promptly transferred to SCGH where it was confirmed he had an aggressive form of cancer.  Nevertheless, the coroner accepted the submission made on behalf of Lindsay’s family that: “there should have been more culturally safe care available to him at the Frankland Centre”.

In relation to the treatment of Lindsay’s cancer at SCGH, the coroner concluded that Lindsay received a very good standard of care.  The coroner did not consider that Lindsay’s cancer could have been detected any earlier than it was.

The coroner made one recommendation concerning the employment of Aboriginal Liaison Officers at the Frankland Centre.

Catch Words : Custody Order : Frankland Centre : metastatic high-grade neuroendocrine carcinoma: Natural Causes


Last updated: 11-Sep-2024

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