Deceased
Dragan Jacovic
Demographics
63y, male
Coroner
Coroner Linton
Date of death
2018-06-22
Finding date
2020-09-03
Cause of death
ischaemic heart disease
AI-generated summary
Dragan Jacovic, a 63-year-old life prisoner with extensive comorbidities including severe ischaemic heart disease, type 2 diabetes, chronic kidney disease, and chronic paranoid schizophrenia, was admitted to hospital on 12 June 2018 with acute coronary syndrome and pulmonary oedema. Investigations revealed end-stage heart failure with extensive coronary artery disease unsuitable for revascularisation. He was discharged to prison medical ward on 21 June 2018 on medical management with outpatient cardiology follow-up. He died suddenly the following day from cardiac arrest secondary to ischaemic heart disease. Expert cardiology review confirmed discharge was appropriate and medically reasonable; even with ICU-level intervention, survival probability was less than 20%. No failures in medical care, supervision, or monitoring were identified. Care standards met or exceeded community standards.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
[2020] WACOR 20 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON HEARD : 30 JUNE 2020 DELIVERED : 3 SEPTEMBER 2020 FILE NO/S : CORC 741 of 2018
DECEASED : JACOVIC, DRAGAN Catchwords: Nil Legislation: Nil Counsel Appearing: Sgt Lyle Housiaux assisting the Coroner.
Ms Emma Cavanagh (SSO) appearing on behalf of the Department of Justice.
Case(s) referred to in decision(s): Nil
[2020] WACOR 20 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Coroner, having investigated the death of Dragan JACOVIC with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, PERTH, on 30 June 2020, find that the identity of the deceased person was Dragan JACOVIC and that death occurred on 22 June 2018 at Acacia Prison from ischaemic heart disease in the following circumstances:
Dragan Jacovic was born in Serbia and moved to Australia with his family in 1971 when he was a teenager. He spent time travelling between the two countries thereafter, including a period of mandatory service in the Serbian army. Mr Jacovic was married twice. He met both of his wives on return visits to Serbia. He divorced his first wife and married his second wife in the late 1980’s. Mr Jacovic had four children with his second wife and the family lived in various places before moving to Perth.1
Mr Jacovic’s life had significant ups and downs, including sustaining serious leg injuries in an accident in 1992 and benefitting from a significant lottery win in 1999. The other major event in his later years was his conviction for murdering his second wife, the mother of his children. Mr Jacovic admitted he unlawfully killed his second wife, but maintained he was guilty of manslaughter only due to provocation. His plea was not accepted and he was convicted on 11 September 2001, after a trial before White AuJ and a jury in the Supreme Court of Western Australia, of murdering his second wife.2
The circumstances of the offence were described by the learned sentencing judge as a brutal and sustained assault, in which he attacked his wife with a sledgehammer in their home and then left her on the side of the road to die.3 The offence occurred on 19 December 1999 and Mr Jacovic was arrested that day and remained in custody thereafter.
Mr Jacovic was sentenced to life imprisonment with a minimum term of 14 years’, effective from 19 December 1999, before he could be considered for release on parole. Mr Jacovic was never released on parole and spent the rest of his life in prison.
From 12 to 21 June 2018 Mr Jacovic received treatment in hospital for heart failure with acute pulmonary oedema, a heart attack, community acquired pneumonia and acute on chronic renal failure. He was not suitable for surgery, so once he was stabilised he was discharged back to prison on 21 June 2018 with a plan for further cardiology follow-up as an outpatient and management of his heart failure with medication and fluid restriction. On his return to prison, Mr Jacovic was admitted to the 1 Exhibit 2, Death in Custody Report dated 11 November 2019.
2 Exhibit 1, Tab 40; Exhibit 2, Tab 13.
3 Exhibit 1, Tab 40, Sentencing Transcript.
[2020] WACOR 20 medical ward of Acacia Prison, where he appeared settled overnight and the following morning.
At about midday on 22 June 2018 Mr Jacovic was found unresponsive in his cell. Despite resuscitation attempts by nursing and medical staff, he could not be revived and his death was confirmed. Based upon an external post mortem examination, toxicology analysis and a review of Mr Jacovic’s medical records, a forensic pathologist formed the opinion the cause of death was ischaemic heart disease.
By virtue of being a sentenced prisoner at the time of his death, Mr Jacovic was a ‘person held in care’ for the purposes of the Coroners Act 1996 (WA). In such circumstances, a coronial inquest is mandatory.4 I held an inquest at the Perth Coroner’s Court on 30 June 2020.
The primary focus of the inquest was on the medical treatment provided to Mr Jacovic to ensure it was of an appropriate standard, particularly in the days prior to his death.
Mr Jacovic’s family had raised some concerns with this Court about his medical care, in particular his discharge back to prison from hospital the day prior to his death. In order to address those concerns, a cardiologist, Dr Johan Janssen, was asked to review Mr Jacovic’s medical and prison records and provide an expert opinion on the medical care provided to Mr Jacovic while he was incarcerated, particularly in relation to his cardiovascular health.5 Dr Janssen provided a written report and also gave evidence at the inquest. He expressed the opinion that the treatment of Mr Jacovic was consistent with the common approach for a patient with significant congestive heart failure and that his discharge was reasonable. Dr Janssen indicated that overall the course of events that led to Mr Jacovic’s death, whilst unfortunate, is not unknown in patients with several comorbidities and end stage heart failure.6
Dr Joy Rowland, the Director of Medical Services for the Department, also gave evidence at the inquest and spoke to a comprehensive Health Services Summary in relation to Mr Jacovic. Dr Rowland noted that Mr Jacovic was not always willing to cooperate with recommended medical care, and his decisions regarding the amount of care he would accept were respected. However, within the limitations of those decisions, Dr Rowland offered the opinion that Mr Jacovic received 4 Section 22(1)(a) Coroners Act.
5 Exhibit 1, Tab 9.
6 Exhibit 1, Tab 9.
[2020] WACOR 20 excellent care within the prison system, and at least to the level available in the community, if not higher.7
At the time Mr Jacovic was incarcerated he was in his mid-forties. He was already on treatments for high blood pressure and high cholesterol and had a history of heart disease not diagnosed till later and psychosis.9 Mr Jacovic was also a smoker and he was encouraged to give up smoking and offered nicotine patches and later a medication called bupropion to assist him with smoking cessation. However, he continued to smoke and indicated he did not intend to stop.10
Soon after admission Mr Jacovic had contact with the Prison Counselling Service and mental health services, predominantly related to monitoring his risk of self-harm or suicide, which was assessed as low.
Early in his prison term concerns were raised that Mr Jacovic may have had a delusional disorder as he frequently expressed paranoid type thoughts about his deceased wife’s behaviour. He was seen by psychiatrists and he reported hearing voices, including voices prior to killing his wife and later reviews revealed Mr Jacovic had complex delusional beliefs about the women in his life. He was commenced on various psychiatric medications, including the antipsychotic olanzapine, with apparent improvement in Mr Jacovic’s mental state.
Mr Jacovic was later reviewed by a forensic psychiatrist who assessed Mr Jacovic as having chronic paranoid schizophrenia. It was noted he had limited insight and did not acknowledge his mental health diagnosis but he agreed to continue to take his antipsychotic medication despite not believing he had a mental illness.
In 2005 Mr Jacovic began to exhibit symptoms typical for diabetes. He initially resisted having tests but when he eventually consented to undergo blood tests, they revealed Mr Jacovic had type 2 diabetes with very high blood sugars, a very high cholesterol and extremely high 7 Exhibit 2, Tab 14.
9 Exhibit 2, Tab 14.
10 Exhibit 2, Tab 14.
[2020] WACOR 20 triglyceride (blood fat) levels. He was commenced on medication for diabetes and provided with diabetic education. He was also referred to ophthalmology and podiatry, which is standard practice for diabetes. He had regular blood sugar checks and cholesterol tests, which showed marked improvement, so he was not started on cholesterol medication.11
In late 2005 Mr Jacovic was taken to Swan District Hospital with chest pain and was then transferred to Royal Perth Hospital, where he was diagnosed with an NSTEMI (Non ST elevation myocardial infarction), which is a type of heart attack. Investigations revealed severe disease in all three of his cardiac arteries. Mr Jacovic underwent coronary artery bypass grafting on 4 October 2005, suffering two cardiac arrests during the procedure. He was eventually discharged from hospital back to prison on 10 October 2005. He continued to receive regular cardiology review until he appeared stable.
Ongoing psychiatric reviews over the next few years found Mr Jacovic remained stable without any psychotic symptoms, although at times he was somewhat paranoid, especially about medication.
On most occasions he refused investigations or treatment. In 2009 in he was again sent to hospital with chest pain and was discharged against medical advice. Later in 2009 he was reviewed by hospital cardiology services. Mr Jacovic was sent to hospital with chest pain in September 2010 but he discharged himself against medical advice and no further investigations were undertaken.12
His symptoms and diagnosis varied over time and his medications were altered accordingly.13
Mr Jacovic was sent to Swan Districts Hospital on 12 February 2012 after feeling dizzy and was diagnosed with postural hypotension (low blood pressure). He was returned to prison with a suggestion that he undergo further investigations but throughout late 2012 Mr Jacovic refused to attend many medical, nursing and allied health appointments.
He did, however, appear to be travelling well in his psychiatric reviews.14 11 Exhibit 2, Tab 14.
12 Exhibit 2, Tab 14.
13 Exhibit 2, Tab 14.
14 Exhibit 2, Tab 14.
Mr Jacovic continued to suffer issues with postural hypotension in early 2013 and ongoing medication changes were made to try to control his blood pressure. He was also noted to have impaired kidney function, which was monitored, along with his diabetic control. Mr Jacovic’s mental state remained relatively stable but he reported memory problems. Changes were made to his olanzapine dose.15
Regular nursing and medical reviews continued in 2013 and 2014, with a focus on managing his diabetes, hypertension and psychiatric disorders.
He did not always attend his booked appointments and admitted to not always taking his medication.16
Mr Jacovic’s mental state also appeared to stabilise around this time and he made less unscheduled requests for medical attention.17
For a number of years leading up to his death Mr Jacovic’s mental state had been relatively stable on a regime of the antipsychotic olanzapine and an antidepressant. He also had medical, nursing and allied health reviews in regard to his diabetic and cardiac care, which generally appeared to manage his conditions. However, in late 2017 and early 2018 Mr Jacovic’s compliance with medical treatment worsened and he frequently failed to attend scheduled appointments, which made it difficult to monitor his conditions.
It does not appear that Mr Jacovic’s refusal to attend appointments was due to a deteriorating mental state, as he was stable when reviewed by a psychiatrist on 9 November 2017 and again on 27 April 2018, although a yearly cognitive assessment was suggested in light of Mr Jacovic’s medical co-morbidities and noted memory problems on occasion.18 15 Exhibit 2, Tab 14.
16 Exhibit 2, Tab 14.
17 Exhibit 2, Tab 14.
18 Exhibit 2, Tab 14.
After failing to attend a number of medical and nursing appointments in May and June 2018, on 12 June 2014 Mr Jacovic reported chest pain. He was assessed by medical staff in the infirmary and found to have ongoing chest pain and reduced oxygen saturations, so he was transferred to St John of God Hospital Murdoch by ambulance.
He was diagnosed with an acute coronary syndrome complicated by significant pulmonary oedema causing respiratory distress. There was also acute on chronic renal impairment. He was admitted and treated aggressively with intravenous medication and antibiotics. He was unwell and required respiratory support with non-invasive ventilation.
Mr Jacovic became very agitated and confused in hospital and refused medication and interventions. It was determined that he did not have the capacity to make decisions regarding his health, so he was sedated and treatment continued.19
Mr Jacovic had settled by that time and agreed to further treatment. The assessment was that he had a delirium due to his underlying medical conditions on a background of chronic delusional disorder. It was determined that he should be managed under a duty of care, with a possible option to make an application for guardianship. His agitation settled and he appeared to be accepting of treatment, so it does not seem the second option was progressed.20
Precautions were employed to protect Mr Jacovic’s kidneys in view of his poor renal function. The angiogram showed extensive coronary disease including blockages in two of the previous bypass grafts. It was documented that the narrowing in the coronary arteries was not suitable for opening with a stent. Medical management was initiated with dual antiplatelet therapy and he was transferred back to St John of God Midland Hospital.21
20 Exhibit 2, Tab 14.
21 Exhibit 1, Tab 9.
[2020] WACOR 20 seemed to be controlled. He was also switched from intravenous to oral treatment.22
Mr Jacovic was discharged from hospital on 21 June 2018 with a plan for further cardiology follow-up as an outpatient and management of his heart failure with medication and fluid restriction. The handover from the hospital to the prison medical staff had occurred a few days before the day of discharge. Prior to discharge Mr Jacovic was reported to be feeling good and his observations were within normal limits. There were no clinical signs of fluid overload and his renal function was checked and it had not deteriorated following the angiogram. He was felt to be stable at that time and it was anticipated that after a short stay in the prison health centre he would return to his normal accommodation.23
On his return to prison, Mr Jacovic was assessed then housed in the medical ward of Acacia Prison and kept under observation. He was able to walk to the health centre under escort and ate a sandwich before going to sleep in a single bed cell adjacent to the health centre. The ward is monitored by CCTV and he was the only prisoner present. Mr Jacovic appeared settled and had no complaints overnight.
On 22 June 2018 Mr Jacovic was checked by a prison nurse at 9.00 am and given some food and drink just before 11.00 am. At 11.05 am he went to the toilet before returning to bed at 11.10 am. He is shown on the CCTV footage getting up and down again and then watching television in bed until 11.28 am, after which no movement is observed, suggesting he suffered a cardiac event around this time.24
The CCTV was not being constantly monitored at that time, but at around midday a custodial officer working as the medical officer in the medical centre looked at the CCTV monitor and noticed that Mr Jacovic was sitting in an unusual way on his bed and did not appear to move while being observed for a few minutes. The officer became concerned and went to check on Mr Jacovic in his cell.25
At approximately 12.12 pm the medical officer approached Mr Jacovic’s cell and looked through the window before knocking on the window.
Mr Jacovic did not respond, so the officer opened the cell door and approached Mr Jacovic while calling out his name. Mr Jacovic was unresponsive and he also did not respond when the officer touched him 22 Exhibit 1, Tab 9.
24 Exhibit 1, Tab 2.
25 Exhibit 3.
[2020] WACOR 20 on the shoulder. The medical officer moved Mr Jacovic onto his back so he could check for a pulse. He could not detect a pulse, so the officer issued a coded emergency call over the radio and commenced CPR.
Other staff, included a doctor and nursing staff, came to assist with resuscitation. All resuscitation attempts were unsuccessful and Mr Jacovic’s death was declared by the on-duty Doctor at 12.28 pm.26
An external post mortem examination was performed by a forensic pathologist, Dr Daniel Moss, on 27 June 2018. There was no external evidence of significant injury and evidence of medical intervention was noted.28
Limited toxicology analysis was performed, which showed the presence of multiple prescribed-type medications in keeping with Mr Jacovic’s medical history. Alcohol and common drugs of abuse were not detected.29
Dr Moss also reviewed Mr Jacovic’s medical records and noted that he was recently admitted to hospital with severe heart failure, as well as a degree of acute renal failure, on a background of non-ST elevation myocardial infarction. An angiogram at RPH showed severe coronary artery atherosclerosis and echocardiogram showed severe ischaemic cardiomyopathy. While he was in hospital he developed possible pneumonia, however this was resolving by the time of discharge. The day after discharge he underwent a cardiac arrest in prison.30
Based on his review of all of this information, Dr Moss was able to give a reasonable cause of death without the need for a full post mortem examination, which was agreeable to the family. Based on the limited 26 Exhibit 1, Tab 2; Exhibit 2, Death In Custody Report dated 11 November 2019, p. 3; Tab 14; Exhibit 3.
27 Exhibit 1, Tab 2 and Tab 3.
28 Exhibit 1, Tab 6.
29 Exhibit 1, Tab 6 and Tab 7.
30 Exhibit 1, Tab 6.
[2020] WACOR 20 investigations performed, Dr Moss expressed the opinion the cause of death was ischaemic heart disease.31
Mr Jacovic was a 63 year old man at the time of death, who had spent the last approximately 19 years in prison serving life imprisonment for the murder of his wife. Mr Jacovic had well-established cardiac disease as well as significant mental illness, requiring long-term antipsychotic medication. Without treatment for his mental health disorder, his adherence to all other treatments was very poor, so it was felt necessary to continue with long-term antipsychotic treatment on balance.
Mr Jacovic often refused to take his prescribed medications or to remain in hospital for recommended tests, but until the last hospital admission he was considered to have the capacity to refuse medical care, so his wishes were respected. His engagement with health services in the last two years of his life was variable, but his mental health appeared stable so it appears to have been by deliberate choice on his part. Mr Jacovic also continued to smoke and make poor lifestyle choices in terms of diet and exercise, despite education and encouragement from nursing and medical staff. Again, this was his right to make those choices.
It was noted in a review by prison health services that Mr Jacovic’s risk factors were managed as well as he would allow and to at least community standards.32 Dr Rowland noted that the prison primary health care services work closely with mental health services, working from one set of medical notes, so in that way his care was better than community level of care, where these services are often fragmented.
Dr Rowland commented that if these health issues had not been able to be managed together, dealing with Mr Jacovic’s non-compliance with care and the side-effects of his medicines may not have been as well managed.33
32 Exhibit 2, Tab 14.
[2020] WACOR 20 his last admission to hospital. He was very unwell during his last hospital admission and it was determined that he had well-established severe cardiac disease and his prognosis was poor.
Mr Jacovic was registered on the Department’s Terminally Ill module on TOMS listed at Stage 3, which is for prisoners where death is considered likely within 3 months or they have one or more medical conditions with the potential for sudden death. Dr Rowland explained at the inquest that this is an internal process to ensure the provision of safe and optimal care by both medical and custodial staff. Mr Jacovic was included on the register as he was at risk of an acute event.34
On 18 June 2018 permission was granted for some of Mr Jacovic’s relatives to visit him in hospital, given his deteriorating health, and visits were subsequently facilitated with a number of family members.35
Mr Jacovic’s older sister visited him in hospital and was very concerned at how unwell he seemed. She advised police after his death that she had pleaded with the doctor who was treating Mr Jacovic that Mr Jacovic was not well enough to be returned to prison. She recalled being told by the doctor that his arteries were too blocked for surgery and he needed to stop smoking. She had counselled her brother in the past to stop smoking, but he hadn’t heeded her advice.36
A custodial officer conducted a welfare check with Mr Jacovic on the day of his discharge, before he left the hospital. He was reported to have stated that ‘everything was okay’ and he had some more tests and was “hoping to return to the Prison soon.”37 This suggests that Mr Jacovic himself was not opposed to the decision that he be discharged from hospital, which is not surprising as the regime for a prisoner in hospital is quite restrictive and, no doubt, uncomfortable and even without those additional constraints most people prefer not to remain in hospital longer than necessary.
Mr Jacovic was returned to prison with a management plan in place on 21 June 2018 and he died the following day. Mr Jacovic’s family were understandably distressed at the timing of his death, so quickly coming upon his discharge from hospital and after they had raised concerns with
35 Exhibit 2, Death in Custody Report dated 11 November 2019 and Tab 5 and Tab 7.
36 Exhibit 1, Tab 8.
37 Exhibit 1, Tab 37, p. 1, note 14:07.
[2020] WACOR 20 doctors about his fitness to return to prison. As noted at the start of this finding, to explore these concerns a cardiologist, Dr Johan Janssen, was asked to review Mr Jacovic’s medical and prison records and provide an expert opinion on the medical care provided to Mr Jacovic while he was incarcerated, particularly in relation to his cardiovascular health.38
Dr Janssen also noted Mr Jacovic’s psychiatric illness, which is a risk factor for the development of heart problems and makes patients more difficult to treat.
Following bypass surgery in 2005, Mr Jacovic had only infrequent symptoms until the chest pains on the day of his hospital admission on 23 June 2018. By this time he had reached end stage heart failure with a corresponding high mortality rate, although this was not apparent until he underwent investigations at the hospital. The angiogram showed the blockages in the bypass grafts, which were unsuitable for further bypass surgery or stenting, so it was decided to treat Mr Jacovic medically, which Dr Janssen considered to be adequate treatment. Dr Janssen noted that if Mr Jacovic had been a young man in otherwise good health, he would have been put on the cardiac transplant list at this stage, but he was unsuitable for such a step given his age and co-morbidities.39
Dr Janssen noted that Mr Jacovic did not have any clinical signs of heart failure at the time of his discharge and he felt his discharge was reasonable at the time, given the plan for Mr Jacovic to be housed in a medical ward in prison and placed on a medication regime with follow up by cardiologists as an outpatient. Dr Janssen noted that a patient in the same circumstances, who was not a prisoner, would have been discharged home, where there would have been even less supervision and less immediate access to medical care.40
Dr Janssen concluded that Mr Jacovic’s passing probably related to a ventricular arrhythmia on the basis of a poor left ventricular function caused by severe ischaemic heart disease. It is a common cause of death in people with a recent heart attack and poor heart function and most of 38 Exhibit 1, Tab 9.
40 T 5 – 7, 9; Exhibit 1, Tab 9.
[2020] WACOR 20 these people die suddenly in their sleep. Dr Janssen noted that even with full medical intervention in an intensive care setting at the time of this event, Mr Jacovic would have had a less than 20% chance of survival.
Further, even if he had recovered, over the course of six months to one year, his chances of survival would have been extremely poor.41
After a lengthy period of incarceration, during which Mr Jacovic received considerable medical input for his physical and mental health disorders, on 12 June 2018 Mr Jacovic suffered heart failure and a heart attack and was transferred to hospital for treatment. Investigations revealed severe impairment of his heart’s function and extensive coronary artery diseases that was not amenable to re-opening with stenting or further bypass grafting. The medical advice was to proceed with medical management of his conditions.
On 21 June 2018, Mr Jacovic was transferred back to prison with a long term plan for cardiology follow-up as an outpatient and ongoing medical management of his heart failure with medication and fluid restriction. He was housed in the medical ward of Acacia Prison, where he could be observed more closely by nursing staff. He initially appeared well, but the following day suffered a cardiac arrest. He was found unresponsive
[2020] WACOR 20 just after midday and resuscitation attempts were unsuccessful. While his death was, in a sense, unexpected, it was consistent with Mr Jacovic’s known history of progressively severe heart failure secondary to ischaemic heart disease.
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