Deceased
Wayne Frederick Leese
Demographics
54y, male
Coroner
Coroner Urquhart
Date of death
2018-05-20
Finding date
2020-10-08
Cause of death
Complications including hepatic encephalopathy, pneumonia and multi-organ failure, of hepatitis C and hepatocellular carcinoma
AI-generated summary
Wayne Frederick Leese, a 54-year-old prisoner, died from complications of hepatitis C and hepatocellular carcinoma including hepatic encephalopathy, pneumonia and multi-organ failure. He collapsed at Acacia Prison on 4 May 2018 with seizures and was rapidly transferred to St John of God Hospital Midland where he was admitted to ICU. He had received comprehensive medical care throughout his 16-year imprisonment including specialist hepatology referrals, interferon therapy, microwave ablation of liver tumours, and regular monitoring. The coroner found the standard of supervision, treatment and care was reasonable and comparable to or better than community care. A minor delay in surveillance MRI scheduling was outside departmental control and unlikely to have changed the outcome. Rapid decompensation of cirrhotic liver disease is a recognised phenomenon and death was a likely outcome despite appropriate hospitalisation and treatment.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
[2020] WACOR 29 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : Philip John Urquhart, Coroner
HEARD : 8 SEPTEMBER 2020 DELIVERED : 8 OCTOBER 2020 FILE NO/S : CORC 596 of 2018
DECEASED : LEESE, WAYNE FREDERICK Catchwords: Nil Legislation: Nil Counsel Appearing: Sergeant L Housiaux assisted the Coroner.
Louise O’Connor (State Solicitor’s Office) appeared on behalf of the Department of Justice.
[2020] WACOR 29 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH Inq no.: 596/2018 Ref: [2020] WACOR 29 I, Philip John Urquhart, Coroner, having investigated the death of Wayne Frederick LEESE with an inquest held at Perth Coroner’s Court, Central Law Courts, Court 83, 501 Hay Street, Perth, on 8 September 2020, find that the identity of the deceased person was Wayne Frederick LEESE and that death occurred on 20 May 2018 at St John of God Hospital, Midland, from complications, including hepatic encephalopathy, pneumonia and multi-organ failure, of hepatitis C and hepatocellular carcinoma.
Table of Contents
Mr Leese died on 20 May 2018 at St John of God Hospital, Midland (SJGHM), from complications arising from a number of identified comorbidities. At the time of his death, Mr Leese was a sentenced prisoner in the custody of the Chief Executive Officer of the Department of Justice.1
Accordingly, immediately before his death, Mr Leese was a “person held in care” within the meaning of the Coroners Act 1996 (WA) and his death was a “reportable death”.2 In such circumstances, a coronial inquest is mandatory.3
Where, as here, the death is of a person held in care, I am required to comment on the quality of the supervision and care the person received while in that care.4
I held an inquest into Mr Leese’s death on 8 September 2020. The documentary evidence adduced at the inquest comprised of three volumes and included independent reports of Mr Leese’s death prepared by the Western Australian Police5 and by the Department of Justice.6
Dr Joy Rowland, the Director of Medical Services for the Department of Justice, was called as a witness at the inquest. She was a co-author of the Health Services Summary into the Death in Custody.
The inquest focused on the care provided to Mr Leese while he was a prisoner, as well as on the circumstances of his death.
THE DECEASED Background 7,8,9
He enjoyed playing football, fishing, and motorcycle racing.
1 Section 16, Prison Acts 1981 (WA) 2 Sections 3 and 22(1)(a) Coroners Act 1996 (WA) 3 Section 22(1)(a) Coroners Act 1996 (WA) 4 Section 25(3) Coroners Act 1996 (WA) 5 Exhibit 1, Vol. 1, Tab 2, Police Investigation Report 6 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody 7 Exhibit 1, Vol. 1, Tab 2, Police Investigation Report, p2 8 Exhibit 1, Vol. 3, Tab 52, Supreme Court of WA: Sentencing remarks (20 February 2003) 9 Exhibit 1, Vol. 1, Tab 25, Department of Correctives Services Treatment Needs Assessment, p2
Mr Leese witnessed his father die of a heart attack when he was 16. He had a close relationship with his father and he was greatly affected by his death.
Mr Leese was in a relationship for a number of years sometime in the 1990s. He and his partner had three children together before they separated. His partner and the three children moved to Queensland to live and Mr Leese lost contact with his children due to his poor relationship with their mother.
Mr Leese had a variety of unskilled jobs in his adult life, the longest being for several years at a saw-mill. However, he was generally either unemployed or incarcerated for much of his adult life. From an early age he began drinking excessively and using illicit drugs which significantly affected his capacity to maintain a job. He also became dependent on prescription medication.
At the time of his reception into custody on 8 February 2002, Mr Leese had a background of hepatitis C, depression, a diagnosed anti-social personality disorder and drug and alcohol dependency.10 Offending History
Mr Leese had an extensive criminal record. During the period from 1980 to 2003 he had accumulated 30 convictions in Western Australia for offences; mainly related to violence, dishonesty, drugs and traffic. It appears he also had an additional 14 convictions for interstate offences.11 He was sentenced to 7 years’ imprisonment in December 1986 for an armed robbery in company and a breaking and entering.12
However, Mr Leese’s most serious conviction was for wilful murder on 19 February 2003 in the Albany Supreme Court of Western Australia. The circumstances of this offence was that on 6 February 2002, when heavily intoxicated, he attacked his housemate with an axe following an argument.
On 20 February 2003, Mr Leese was sentenced to strict security life imprisonment with a non-parole period of 20 years.13 His earliest release date was 6 February 2022.14 10 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p3 11 Exhibit 1, Vol. 1, Tab 25, Department of Correctives Services Treatment Needs Assessment, p5 12 Exhibit 1, Vol. 1, Tab 10, Mr Leese’s Criminal and Traffic History for Court 13 On the same day he was also sentenced to 6 months’ imprisonment, to be served concurrently, for breaching a suspended sentence imposed in November 2001 for assaulting a public officer: Exhibit 1, Vol. 3, Tab 52, Supreme Court of WA: Sentencing remarks (20 February 2003), p6 14 Exhibit 1, Vol. 3, Tab 52, Supreme Court of WA: Sentencing remarks (20 February 2003), p6
[2020] WACOR 29 Prison History
After his arrest and being charged with wilful murder, Mr Leese had the following prison placements and transfers: 15 a. Albany Regional Prison: 8 - 19 February 2002 (11 days) b. Casuarina Prison: 19 February 2002 - 14 March 2002 (23 days) c. Hakea Prison: 14 March 2002 - 16 April 2002 (33 days) d. Albany Regional Prison: 16 - 23 April 2002 (7 days) e. Hakea Prison: 23 April 2002 - 14 May 2002 (21 days) f. Albany Regional Prison: 14 May 2002 - 17 March 2006 (1,403 days) g. Casuarina Prison: 17 March 2006 - 27 July 2015 (3,419 days) h. Acacia Prison: 27 July 2015 - 4 May 201816 (1,013 days)
Mr Leese incurred a significant charge history during his final term of imprisonment. He was found guilty of at least 15 disciplinary charges which included cannabis use, abusive language and assaulting a prison officer.17 However, by 2013 he was assessed as a quiet prisoner who was polite, respectful and compliant towards staff and who required minimal supervision. He was not viewed as a management problem.18 Overview of Medical Conditions
On reception, Mr Leese disclosed a history of previous self-harm, depression, a dependency on alcohol and benzodiazepines, hepatitis C, anger management problems and a diagnosed anti-social personality disorder. He was commenced on methadone as part of a drug rehabilitation program which was maintained until shortly before his death.19 He was also prescribed antipsychotic and antidepressant medications to treat his mental health conditions.20
Throughout his incarceration, Mr Leese was regularly reviewed by psychiatrists, prison doctors and nurses and, when appropriate, external health care services.
On admission to prison and given his psychiatric history, Mr Leese was placed on the At Risk Management System (ARMS) and subjected to 15 Exhibit 1, Vol. 3, Tab 52, Prisoner Transfer Request, p3; Exhibit 1, Vol. 3, Tab 47, Acacia Prison Reception Intake Form 16 On 4 May 2018, Mr Leese was transferred to SJGHM, where he remained until his death on 20 May 2018 17 Exhibit 1, Vol. 1, Tab 22, Request for Transfer; Exhibit 1, Vol. 2, Tab 25, Department of Corrective Services Treatment Needs assessment, p7 18 Exhibit 1, Vol. 3, Tab 51, Individual Management Plan dated 20 June 2013 19 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p3 and p25 20 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody
[2020] WACOR 29 frequent observations when in his cell.21 Mr Leese was placed back on ARMS on two further occasions in 2006.22
With respect to those medical conditions that contributed to his death, Mr Leese received the following treatment during his term of imprisonment.
When in Albany Prison, Mr Leese complained of abdominal pain and was transferred to Perth for further investigations. On 10 March 2006, a liver function pathology showed abnormal results.23 These results were monitored.
On 15 December 2009, Mr Leese was reviewed via a telehealth link by a hepatologist (a liver specialist) at Fremantle Hospital (FH) for management of his chronic hepatitis C genotype 3 and abnormal liver function blood tests. The use of interferon to treat his hepatitis C was recommended, subject to a review by his psychiatrist as to the potential side-effects relating to depression and mood.24 A review by the psychiatrist on 11 January 2010 determined he was fit for interferon therapy which commenced nine days later.25
Mr Leese’s course of interferon medication continued into 2011, however it failed to clear the virus, and by June 2011 he had ceased taking it after electrocardiogram results showed prolongation of the QTc interval.26 Following a further assessment in August 2011, Mr Leese recommenced interferon medication, self-administering the weekly injections and having cardiology reviews.27 He completed this course in January 2012 and although he had a negative PCR (polymerase chain reaction) test result for the hepatitis C virus in December 2011, another PCR test on 2 July 2012 was positive. The prison doctor referred him to FH’s hepatology clinic.28
In September 2012, Mr Leese had an appointment with the FH’s hepatology clinic. As there was no alternative course of medication then available, Mr Leese was advised to maintain a healthy lifestyle and have six monthly pathology reviews of his liver.29 21 Exhibit 1, Vol. 2, Tab 30, Prisoner at Risk of Self Harm 22 Exhibit 1, Vol. 3, Tab 50B, At Risk Management System records 23 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p3 24 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p4 25 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p5 26 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p10 27 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, pp10-11 28 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, pp12-13 29 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p13
An ultrasound scan on 4 July 2014 showed liver cirrhosis (advanced scarring of the liver) with underlying portal hypertension (high blood pressure within the portal vein).
On 23 March 2015, an abdominal ultrasound showed that Mr Leese had a developed liver cirrhosis with micro-nodular change and splenomegaly (an enlarged spleen).30
On 14 March 2016, another abdominal ultrasound showed suspicious lesions in the liver, however an MRI scan on 28 June 2016 detected no hepatocellular carcinoma.31
On 12 July 2016, the hepatology clinic at Fiona Stanley Hospital (FSH) proposed a new 24 week treatment course for Mr Leese’s hepatitis C virus consisting of ribavirin, sofosbuvir and daclatasvir and this commenced on 12 September 2016.32
On 22 March 2017, blood tests no longer detected the hepatitis C virus, suggesting the latest treatment had been successful.33 On 25 July 2017, however, an MRI scan showed new liver lesions that were characteristic of hepatocellular carcinoma.34
On 22 September 2017, Mr Leese underwent an hepatic angiography and microwave ablation of the hepatocellular carcinoma at FSH. An MRI scan on 4 October 2017 showed a successful ablation of the two tumours.35
On 22 January 2018, a further MRI scan showed no recurrent tumour at the ablation sites. On 31 January 2018, Mr Leese had a telehealth link with a hepatologist at FSH. The scan results were discussed and Mr Leese was referred for a further MRI scan in three months.36 He was very pleased with the success of the ablation procedure.
At that time he reported feeling well with no symptoms or signs of liver disease. The MRI scan that was referred on 31 January 2018 had been requested; however, there were difficulties accessing MRI scans through 30 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p15 31 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p18 32 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p18 33 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p21 34 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p22 35 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p23 36 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p24
[2020] WACOR 29 the public health system at the time. Blood tests were taken and showed stable liver and normal kidney functions.37
EVENTS LEADING TO DEATH Mr Leese’s collapse
At about 3.00 pm on 4 May 2018, Mr Leese was attending a class in the prison education centre at Acacia Prison. After getting up from his chair, he appeared unsteady. He then fell and bumped his head on a wall and began having a seizure for approximately 20 seconds.38 Mr Leese was assisted to a chair and a Code Blue (the highest medical emergency code for Acacia Prison) was called over the prison’s radio.39
Prison medical staff attended and he was taken to the prison’s medical centre. Mr Leese appeared disorientated and his abdomen was distended.
A decision was made to convey him to hospital and an ambulance arrived at 3.48 pm and transferred him to SJGHM at 4.10 pm.40 Admission to SJGHM - 4 May 2018
Blood tests showed a very low sodium level and a CT scan showed early cerebral oedema (brain swelling). He was intubated and admitted to SJGHM’s intensive care unit in an induced coma. A nasogastric tube was inserted and he was administered intravenous sodium chloride, antibiotics, enemas to treat encephalopathy albumin and diuretics to manage his ascites.41
On 6 May 2018, a further diagnosis of a right-lower lobe chest infection was made and this was treated with intravenous antibiotics. The following day, Mr Leese’s left-lower lobe collapsed and on 8 May 2018, following a review by a hepatologist, Mr Leese’s poor prognosis was confirmed.42
On 11 May 2018, Mr Leese was reviewed by surgeons who diagnosed ileus (intestinal obstruction) and it was recommended that conservative 37 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p25 38 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p26 39 Exhibit 1, Vol. 2, Tab 27, Acacia Prison Death in Custody Review, p3 40 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p26 41 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, pp26-27 42 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p26-27
[2020] WACOR 29 treatment should commence due to his comorbidities. Mr Leese was commenced on total parenteral (intravenous administration) nutrition.
On 15 May 2018, Mr Leese developed signs of left-sided pneumonia and his condition was upgraded to critical.43
On 18 May 2018, a CT scan showed an occlusive thrombosis (blood flow cut off) of the superior mesenteric and portal veins and ascites thickening of the small bowel. Mr Leese had developed clinical illness myopathy with a peripheral wasting of muscles and multi-organ failure. The decision was taken, in conjunction with his family, to move Mr Leese into the palliative care unit at SJGHM where he died at 1.22 am on 20 May 2018.44
A forensic pathologist (Dr Moss) conducted an external post mortem examination of Mr Leese’s body on 22 May 2018. Dr Moss was of the view that an examination of the SJGHM medical records would allow a reasonable cause of death to be given without a full internal post mortem examination. The external post mortem examination revealed evidence of medical interventions and that Mr Leese’s abdomen was distended and fluid filled.45 A toxicology analysis showed the presence of multiple prescribed medications, including morphine, in keeping with the medical care provided.46
At the conclusion of the external post mortem examination, Dr Moss expressed the opinion that the cause of Mr Leese’s death was complications; including hepatic encephalopathy, pneumonia and multiorgan failure, of hepatitis C and hepatocellular carcinoma.47 I accept and adopt that conclusion and I find that Mr Leese’s death occurred by way of natural causes.
[2020] WACOR 29 appropriately referred to specialists and underwent the necessary testing and screening when required. As noted by the Department:48 During his time in prison, Mr Leese received comprehensive care overall including routine screening and vaccinations with all care being well documented in his EcHO medical record. His health care included appropriate referrals and engagement with tertiary health care services including treatment of Hepatitis C, hepatocellular carcinoma and maintenance under the hospital hepatology service regarding cirrhosis and surveillance. All responses to new symptoms and presentations were appropriate as was the monitoring of his existing chronic disease including liver disease. There was a noted delay in the surveillance MRI for hepatocellular carcinoma but, as was noted by his Fiona Stanley Hospital doctor, this was outside of the control of the Department of Justice and did not contribute to his death.
Mr Leese continued to engage well with Health Services during his time in prison and was involved in his self-care which resulted in successful management of his drug and alcohol problems by a long-term investment in counselling and opioid substitution therapy.
As to the delay in the MRI referred to in the above passage, I note that this delay was not of a significant duration as the MRI was scheduled for on or about the end of April 2018, a matter of days before Mr Leese’s collapse. I also note Dr Rowland’s evidence that had this MRI scan been undertaken it was not likely to have made a difference in the outcome.49
Dr Rowland expressed the view that the health care provided to Mr Leese while he was in custody from 2002 was not only comparable to what he would have received in the community but was probably better.50
Having carefully assessed the documents tendered into evidence and the evidence of Dr Rowland, I agree with this assessment made by Dr Rowland. I am therefore satisfied that Mr Leese’s various medical conditions were appropriately managed and that the standard of supervision, treatment and care he received whilst he was in custody was reasonable.
48 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p28 49 ts 8.09.20 (Rowland), p12 50 ts 8.09.20 (Rowland), p8
CORONER P Urquhart
8 OCTOBER 2020 51 Exhibit 1, Vol. 3, Tab 53, Health Services Summary into the Death in Custody, p28
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