Coroner's Court of Western Australia

Inquest into the Death of Samuel Edward ASHBY

Inquest into the Death of Samuel Edward ASHBY

Delivered on : 29 November 2023

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : N/A

Summary : Mr Samuel Edward Ashby (Mr Ashby) was 46 years of age when he died at St John of God Midland Public Hospital (SJOG) on 9 February 2021.  His cause of death was aspiration pneumonia in an obese man with a history of diabetes mellitus, obstructive sleep apnoea, recent right ankle fracture, and clozapine effect.

On 20 November 2015, in the Supreme Court of Western Australia, Mr Ashby was convicted of murder.  He was sentenced to life imprisonment with a minimum term of 17 years’ imprisonment, and made eligible for parole.  Mr Ashby’s earliest eligibility date for release calculated as 31 May 2031, at the time of his death, he was incarcerated at Acacia Prison (Acacia).

Mr Ashby’s medical history included high blood pressure, high cholesterol, type-1 diabetes, substance use disorder (including cannabis and alcohol), and intellectual impairment.  Mr Ashby was also diagnosed with paranoid schizophrenia (which was regarded as treatment-resistant), and he had obstructive sleep apnoea, for which he used a continuous positive airway pressure machine (CPAP).

In June 2017, Mr Ashby was started on clozapine, regarded as the “first-line treatment” for treatment-resistant schizophrenia.  Mr Ashby was also a very heavy smoker, and cigarettes have been found to lower clozapine levels in the blood by inhibiting by inducing the production of the primary liver enzyme which metabolises clozapine.

Mr Ashby’s use of his CPAP machine was noted to be inconsistent, and he often complained of oversedation, and at times, he was seen falling asleep during the day while sitting in a chair.  Although a pharmacological cause for his sleepiness was considered, it was also noted that during periods when he used his CPAP machine regularly, Mr Ashby’s daytime sleepiness reduced, and he also reported experiencing fewer auditory hallucinations.

At about 11.15 am on 7 February 2021, a “code blue” medical emergency was called when Mr Ashby collapsed in his block.  Mr Ashby was taken to the medical centre, where he denied any loss of consciousness or head strike.  However, he was unable to weight bear and was referred to St John of God Midland Public Hospital (SJOG) for an x-ray.

On 9 February 2021, Mr Ashby was taken to SJOG where an x-ray confirmed he had broken his ankle.  He was admitted for surgical repair, but his condition deteriorated, and at 10.20 pm, he experienced acute respiratory distress.  Although he was intubated, Mr Ashby continued to desaturate with what was suspected to be a massive aspiration.  Mr Ashby subsequently went into cardiac arrest and despite resuscitation efforts, he could not be revived and was declared deceased at 10.54 pm.

For several days prior to his admission to SJOG, Mr Ashby had been accommodated in the health centre at Acacia, where smoking is not permitted.  It appears that during this time, Mr Ashby’s clozapine levels rose and the coroner noted that it seemed likely that the aspiration event which led to Mr Ashby’s death was related to sedation caused either by his elevated clozapine levels and/or his obstructive sleep apnoea.

However, the coroner was unable to establish the precise role clozapine played in Mr Ashby’s death, the coroner made an open finding as to the manner of Mr Ashby’s death.

The coroner was satisfied that, in general terms, the standard of supervision, treatment and care provided to Mr Ashby whilst he was incarcerated was reasonable.  However, the coroner considered that Acacia’s failure to regularly monitor the cleanliness of Mr Ashby’s CPAP machine (which was in a deplorable condition at the time of his death) and its failure to provide Mr Ashby with ongoing support to maintain the device in a clean and hygienic state, was poor.

Catch Words : Death in custody : Clozapine : Treatment-resistant schizophrenia: Open finding

Last updated: 11-Dec-2023

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