Coroner's Court of Western Australia

Inquest into the Death of Marshall Ruben EDGILL

Inquest into the Death of Marshall Ruben EDGILL

Delivered on :6 September 2021

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : At the time of Mr Edgill death he was a sentenced prisoner in the care of the Department of Justice.  Mr Edgill died at Albany Health Campus on 7 May 2017.  He was 38 years of age.

Mr Edgill was sentenced on 5 February 2017 after his parole was suspended and placed in Hakea Prison.  On 18 February 2017 at Mr Edgill’s request to be closer to his family, he was transferred to Albany Regional Prison to serve the outstanding breach of his parole.  Mr Edgill was due for release on 10 June 2017.

On 7 May 2017, during the afternoon prison muster, prison officers were alerted by Mr Egill’s cell mate, that Mr Edgill was in his cell on the top bunk bed and not breathing.  Prison Officers entered the cell and failed to get a response from Mr Edgill.  They called a code red medical emergency.  Prison staff lifted Mr Edgill off the top bunk and placed him in a recovery position on the floor of the cell.  When they could not get a response, they moved Mr Edgill out of the cell and commenced CPR.

Prison medical staff attached a defibrillator and oxy viva to administer breaths to Mr Edgill.  An ambulance was called and transferred Mr Edgill to the Albany Hospital where resuscitation efforts were unsuccessful.

The Coroner found that Mr Edgill had numerous interactions with hospital and prison health services.  He had a history of asthma, obesity and hypertension.  He also had issues with anxiety and depression during his various periods of incarceration.  It is clear he had poor compliance with treatment and lifestyle advice provided to him by hospital and prison medical staff.

The Coroner was satisfied with the care, supervision and treatment which Mr Edgill received while he was in custody, although the Coroner did identify the failure of the Department to have Mr Edgill seen by a prison medical officer for a medical assessment during his last two periods of incarceration.  This failure was acknowledged by the Department and the Coroner was satisfied that the Department have taken adequate steps to improve their services.

Catch Words : Death in Custody : Sentenced Prisoner : Care, supervision and treatment : Natural Causes

Last updated: 19-Mar-2022

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