Coroner's Court of Western Australia

Inquest into the Death of Ohm SATHITPITTAYAYUDH

Inquest into the Death of Ohm SATHITPITTAYAYUDH

Delivered on :15 December 2021

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

To help reduce demand for synthetic cannabinoids (such as Kronic) in the prison system in Western Australia, the Department of Justice (the Department) should consider proactively delivering targeted education to prisoners aimed at raising awareness of the unpredictable and potentially lethal consequences of using these substances.

To ensure that the education being delivered is as accessible and relevant as possible, the Department should consider consulting with prisoners as well health, education and communications professionals in the development of the education materials and should consider asking Peer support Prisoners to help health professionals deliver this education.

Orders/Rules : N/A

Suppression Order : Yes

On the basis that it would contrary to the public interest, I make an Order under section 49(1)(b) of the Coroners Act 1996 (WA) that there be no reporting or publication of any document or evidence that would reveal any information about the methods of detecting illicit drugs, including synthetic cannabinoids, with respect to persons under the care and control of the Director-General of the Department of Justice.

Summary : Mr Sathipittayayudh died at Karnet Prison Farm (Karnet) on 12 August 2018 from cardiac arrhythmia with acute circulatory failure after ingesting a synthetic cannabinoid product known as Kronic.  At the time of his death Mr Sathipittayayudh was a sentenced prisoner and was 38 years of age.

On 12 August 2018 Mr Sathipittayayudh completed his shift as head cook in the kitchen at Karnet at about 2.00 pm.  During the shift he showed no signs of being affected by illicit substances and completed all allocated tasks to his usual high standard.  During a muster check at 6.30 pm, Mr Sathipittayayudh was standing by the door of his hut in accordance with prison rules and appeared to be in good health.  A welfare check was conducted at 8.30 pm which was described as being “unremarkably quiet”.

At about 10.05 pm prison officers conducted a further routine muster check.  One of the officers lifted the observation hatch on Mr Sathipittayayudh’s hut door to look in, but found his view was obscured by a jacket that was hanging on a hook inside the door.  The officer entered Mr Sathipittayayudh’s hut and found him lying on his bed in the foetal position, with his head slightly bedded in his doona.  Mr Sathipittayayudh had blue coloured lips and was unresponsive and the officer and his partner started CPR and called a Code Red medical emergency call.  Other staff came to assist and resuscitation efforts continued until ambulance officers arrived and confirmed that Mr Sathipittayayudh had died.

The Coroner found that the standard of supervision, treatment and care provided to Mr Sathipittayayudh during his incarceration was appropriate, and that Mr Sathipittayayudh’s medical care was commensurate with community standards.

The Coroner made a recommendation asking the Department to consider delivering targeted education to prisoners with the aim of alerting them to the risks associated with the use of synthetic cannabinoids, including Kronic.

Catch Words : Death in custody : Treatment, Supervision and Care : Kronic : Synthetic cannabinoids : Education : Accident

Last updated: 6-Apr-2022

[ back to top ]