Coroner's Court of Western Australia

Inquest into the Death of Tien Chung NGUYEN

Inquest into the Death of Tien Chung NGUYEN

Delivered on :29 July 2015

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased died while undergoing surgery at Royal Perth Hospital on 27 November 2010. At the time of his death the deceased was a sentenced prisoner.

The deceased was a 53 year old Vietnamese man with a significant medical history including brain aneurysm, which required surgery in 1982 and again in 1991. It resulted in memory loss, stuttering, paraesthesia down his right side and persistent headaches, which required regular medication. He also had chronic back pain as a result of a motor vehicle accident in 2000. The deceased had symptoms of lower urinary tract infection, which ultimately was diagnosed as a benign prostate hypertrophy, and was a carrier of Hepatitis B and an inactive Hepatitis C.

On 26 November 2010 the deceased was seen by a fellow prisoner sitting on a chair outside the shower block at Wooroloo Prison Farm, clutching his chest with his left hand.  The deceased was attended to by prison medical staff. An ambulance was arranged and the deceased was transferred to the Swan District Hospital. A fellow prisoner was allowed to accompany him in the ambulance to the hospital to assist with interpreting for the deceased. The deceased remained at the Swan District Hospital overnight where he was treated and undertook further tests.  Results suggested that the deceased required urgent imaging, which could not be done at Swan District Hospital.  Arrangements were made for the deceased to be urgently transferred to the Emergency Department at Royal Perth Hospital on 27 November 2010.

After being reviewed at Royal Perth Hospital by a cardiologist and consultant cardiothoracic surgeon the deceased was transferred to the operating theatre for urgent surgical management.  Because of the deceased’s critical condition, the Department of Corrective Services authorised telephone contact with the deceased’s family members prior to the deceased going in to theatre for surgery.  During the induction of the anaesthesia the deceased suddenly deteriorated and became hypotensive and bradycardic.  Despite all attempts at resuscitation the deceased failed to respond and died in theatre.

The Coroner was satisfied that the care, treatment and supervision of the deceased immediately before his death was of an appropriate standard.

The Coroner found the deceased died on 27 November 2010 at Royal Perth Hospital as a result of ruptured dissection of the thoracic aorta and that death arose by way of natural causes.

Catch Words : Death in Custody : Prison : Natural Causes.

Last updated: 13-Feb-2024

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