Coroner's Court of Western Australia

Inquest into the Death of Peter Johnnie YOUNG

Inquest into the Death of Peter Johnnie YOUNG

Delivered on : 17 January 2022

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Young died on 29 March 2019 at Fiona Stanley Hospital, Murdoch, as a result of complications of alcohol and hepatitis C-related liver disease.  At the time of his death, Mr Young was a sentenced prisoner and is therefore a ‘person held in care’ within the meaning of the Coroners Act 1996 (WA). Accordingly, a coronial inquest is mandated. The coroner is required to comment on the supervision, treatment and care provided to Mr Young while incarcerated at the prison, as well as the circumstances surrounding the death.

Mr Young was born and raised in the region of Derby and spent a lot of time with his family working on the cattle stations in the Kimberley area. When Mr Young was a teenager, the family moved closer to Derby where the family started to struggle with issues of alcohol abuse and family violence.  Mr Young began to abuse alcohol regularly and become involved in criminal behaviour. His drinking led to serious liver issues and his offending behaviour escalated. He spent increasingly longer periods of time in custody over the years.

In April 2018, Mr Young was charged with a serious offence while he was already on bail for another serious offence. As a result, he was remanded in custody. Mr Young was initially held in prisons in the Kimberley. He was comprehensively reviewed by doctors within the prison, as well as receiving treatment at Derby Hospital. Mr Young was eventually transferred from the Kimberley to Casuarina Prison in October 2018, due to ongoing behavioural issues that created a security risk. Prior to his transfer, Mr Young had undergone a culturally appropriate cognitive assessment that indicated he had good cognitive functioning. The significant improvement was attributed to Mr Young being unable to access alcohol while in custody. His other medical conditions appeared generally stable.

While in the care of Casuarina Prison, Mr Young was reviewed by a psychiatrist, but there appears to have been little ongoing medical review of his physical health, due to a number of cancelled appointments. On 29 March 2019, Mr Young  was transferred to Fiona Stanley Hospital by ambulance after he suddenly deteriorated. On admission, he was noted to be very unwell due to his advanced liver disease and was admitted to the Intensive Care Unit with a poor prognosis. On 25 March 2019 his became more unwell with altered mental state and multi-organ failure.  His life support was turned off and he died on 29 March 2019.

Following his death, it was identified that Mr Young had contracted hepatitis C, possibly while in prison. This may have precipitated Mr Young’s sudden decline prior to his death.

Overall, the Deputy State Coroner was satisfied with the supervision, treatment and care provided to Mr Young. However, the Coroner emphasised the importance of the Department providing sufficient resourcing to enable medical staff to provide ongoing management for prisoners with chronic health issues. Further, the Department should take active steps to notify all family members as quickly as possible when a prisoner’s health suddenly deteriorates.

The Deputy State Coroner found death was consistent with Natural Causes.

Catch Words : Death in Custody : Natural Causes

Last updated: 21-Mar-2022

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