Coroner's Court of Western Australia

Inquest into the Death of William Frederick ANDERSON

Inquest into the Death of William Frederick Anderson

Delivered on :13 December 2022

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : Yes

Recommendation 1

I recommend that the Superintendent of the Eastern Goldfields Regional Prison consider rephrasing the Local Emergency Plan for Medical Emergency –Injury or Illness at p. 126 and p. 129 to ensure that the prison officers in the roles of Senior Officer Gatehouse and Senior Officer –Night Shift, understand that preservation of life is more important than completion of paperwork and that communication with the Ambulance medics to ask them the level of urgency of the case is required, rather than simply expecting the Ambulance Medics to provide that information unprompted.

Recommendation 2

I recommend that the Department of Justice prioritise ensuring that all prison officers at the Eastern Goldfields Regional Prison are current in their First Aid Qualification, with the first priority given to ensuring that all Senior Officers are current as they will generally be required to be involved in making decisions during medical emergencies when no health staff are available.

Recommendation 3

I recommend that the Department of Justice should consider developing a formal online Senior Officer course so that prison officers who aspire to take on a promotion to a more supervisory role within Western Australian prisons, can complete the course at their own pace whilst still learning the practical aspects of the position ‘on the job’.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Anderson died on 24 December 2020 at Kalgoorlie Regional Hospital as a result of an intracerebral haemorrhage (stroke). Mr Anderson was serving a term of imprisonment at the Eastern Goldfields Regional Prison the time of his death, so an inquest into his death was mandatory.

Mr Anderson had a long history of traffic offences, and on 24 August 2020, he was arrested and charged with new driving offences. On 24 November 2020, he appeared in the Wiluna Magistrates Court and was sentenced to a term of six months and 30 days’ imprisonment. The earliest date he could be released on parole was 8 March 2021.

Upon his reception to prison on 24 November 2020, Mr Anderson advised that he suffered from anxiety, high blood pressure and diabetes and took regular medications for these conditions. Steps were taken to identify his medications from his community GP, and he was commenced on his usual medications, pending a medical review by a prison doctor at the end of December 2020. In the meantime, Mr Anderson saw nurses who regularly checked his blood pressure and also commenced him on a diabetes care plan and treated him for some other minor health issues, including ongoing pain from his knee due to gout. He was encouraged to eat well and exercise and was given approval to self-administer his own medications.

It was noted in the medical evidence that Mr Anderson was at increased risk of a stroke due to his health conditions, in particular his hypertension (high blood pressure).

On 23 December 2020, Mr Anderson was in his cell with his cell-mate, who was a relative and with whom he had a supportive relationship. Mr Anderson had seemed in good spirits before they went to bed. Not long after, Mr Anderson got up and took some pain medication for his knee. He then went to the toilet. When Mr Anderson stood up from the toilet, he collapsed and was caught by his cell-mate before he fell to the ground. The cell-mate pressed the cell-call button to ask prison officers to assist. Prison officers attended and, after establishing it was a medical emergency, they contacted the Night Officer in Charge, who attended and opened the cell. There are no nurses or doctors on night shift at the prison, so the prison officers telephoned the on-call prison doctor, who asked them some questions about Mr Anderson’s presentation then directed them to call an ambulance.

An ambulance was requested to attend the prison and it arrived not long after. Mr Anderson was put in the ambulance but then there was a delay in the ambulance leaving while the Night Officer In Charge prepared some transfer paperwork and arrangements were made for prison officers to accompany the ambulance to the hospital. The ambulance eventually left the prison and took Mr Anderson to hospital, where he was medically assessed. It was established that he had suffered an unsurvivable intracranial haemorrhage (stroke). His family were contacted and some family members who lived nearby were able to visit Mr Anderson before he died on the evening of 24 December 2020 at the hospital.

The Deputy State Coroner was satisfied Mr Anderson died as a result of an intracerebral haemorrhage and that his death was due to natural causes.

It was noted that the Department had, of its own accord, made a number of changes following Mr Anderson’s death and another inquest relating to the death of another prisoner. In addition, The Deputy State Coroner made a number of recommendations that arose from the evidence in relation to the lack of medical or nursing staff available on the night shift at the prison and the need to therefore assist prison officers to understand their role in a medical emergency.

Catch Words : Death in Custody: Intracerebral Haemorrhage: Natural Causes

Last updated: 30-Jan-2023

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