Coroner's Court of Western Australia

Inquest into the Death of Robert Allan EXELL

Inquest into the Death of Robert Allan EXELL

Delivered on :  August 2024

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Robert Allan Exell died on 30 June 2022 at Bethesda Hospital. Mr Exell was a serving prisoner at the time of his death, so an inquest into his death was mandatory.

Mr Exell had been sentenced to a lengthy term of imprisonment in 2021 in relation to a violent assault against a former friend that occurred while he was intoxicated. The sentence was backdated to 23 June 2019, when he was first taken into custody. His earliest eligibility date for release on parole was 22 December 2024, but he died well before that date. Mr Exell had initially spent time on remand at Hakea Prison before being moved to Casuarina Prison, where he served the remainder of his sentence before being hospitalised at Bethesda Hospital immediately prior to his death.

Mr Exell had previously spent periods of time in custody, so when he was admitted to prison in mid-2019 there were already some medical records available. It was noted that he had a history of alcoholism and hepatitis C and had previously been diagnosed with a heart condition and cirrhosis of the liver. His hepatitis C had been successfully treated a few years before, and Mr Exell declined further voluntary testing for hepatitis C on his admission. He had previously been on a number of medications while in prison, but he indicated that he had only been taking a GTN spray for his angina recently.

A prison medical officer noted that Mr Exell required cirrhosis surveillance. Blood tests soon after showed possible diagnosis and abnormal liver function, but nothing was done in relation to these issues for some time. It was unclear why he was lost to medical follow-up, but on 8 June 2020, a prison medical officer did a routine audit and realised that Mr Exell’s comprehensive review for his cirrhosis had not occurred. He was transferred shortly after from Hakea to Casuarina Prison. Mr Exell then underwent blood tests on 8 July 2020, which showed results consistent with diabetes and cirrhosis. As his diabetes had previously been undiagnosed and his blood sugar results were at dangerous levels, this appears to have been the initial priority focus of treatment. However, when he was eventually seen by another doctor in November 2020, it became apparent that his liver testing was still overdue, so he was referred to the Fiona Stanley Hospital liver clinic and arrangements were made for a liver ultrasound.

On 21 December 2020, the liver ultrasound confirmed Mr Exell’s cirrhosis and further blood tests revealed he was once again positive for hepatitis C infection. He began treatment for the same.

In April 2021, Mr Exell’s liver specialists referred him for an urgent MRI of his liver, which showed two lesions that were suspicious but not positive for liver cancer. In August 2021, Mr Exell was diagnosed with oesophageal varices related to his history of alcoholism. He was encouraged to stop smoking, as this was making his varices worse, but he chose to keep smoking rather than using Champix. Mr Exell’s liver continued to be monitored. He was moved to Greenough Regional Prison in December 2021 so he could be closer to family.

On 7 April 2022, Mr Exell had an MRI on his liver in Geraldton. The radiologist found no convincing evidence of liver cancer.

A week later Mr Exell’s health deteriorated. He was transferred to Geraldton Hospital and decompensated with liver failure. He was transferred by RFDS to FSH where he was diagnosed with significant gastrointestinal bleeding and underwent banding of his oesophageal varices. He was then placed in the Infirmary at Casuarina Prison so he could be monitored more closely.

On 19 April 2022, the FSH treating team reviewed Mr Exell’s MRI taken in Geraldton and concluded it showed multifocal liver cancer. Due to his recent gastrointestinal bleeding and his overall liver and general health status, it was concluded that he was not suitable for active treatment. It was recommended he commence palliative care and he was given some counselling in this regard.

Mr Exell’s health deteriorated on 11 June 2022 and he was transferred to FSH by ambulance. He showed signs of further gastrointestinal bleeding but further treatment of his oesophageal varices was considered futile. He was transferred back to Casuarina Prison and referred to the Bethesda Hospital palliative care service. His health continued to deteriorate and a ‘Not for Resuscitation’ order ws put in place. Mr Exell had fourteen children and he had sons in custody at this time at the same prison, so they were able to visit him and were kept informed of his deteriorating health.

Mr Exell was eventually transferred to Bethesda Hospital on 27 June 2022 for end of life care and he was kept comfortable until he died in the early hours of 30 June 2022.

A limited post mortem examination found the cause of death was complications of liver cirrhosis and hepatocellular carcinoma in a man with multiple comorbidities with terminal palliative care.

The Department of Justice’s internal medical review noted there were some gaps in Mr Exell’s medical care, but suggested that due to the fact Mr Exell’s cirrhosis was in evidence from as early as 2012, earlier treatment may at best have delayed Mr Exell’s death, rather than prevented it.

The Deputy State Coroner was satisfied Mr Exell received a high standard of treatment, supervision and care, commensurate with what he would have received in the community. While there were some notable gaps in the continuity of his medical care during his last period of incarceration, particularly during his first year back in custody, the delay would not have prevented his death, particularly given his liver cancer did not become apparent for some time after the cirrhosis surveillance commenced.. Once his hepatitis C reinfection and liver cancer were diagnosed, along with his diabetes, he was provided with medical treatment to a high standard. Mr Exell ultimately died as a result of the progression of his pre-existing illnesses and his death was due to natural causes.

Catch Words : Mandatory Inquest : Death in Care : Natural Causes


Last updated: 19-Sep-2024

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