Deceased
Hassan Mohamed Youssef
Demographics
60y, male
Coroner
Deputy State Coroner Linton
Date of death
2018-11-08
Finding date
2021-08-06
Cause of death
Complications of gastrointestinal haemorrhage due to cirrhosis of the liver secondary to hepatitis B
AI-generated summary
Hassan Mohamed Youssef, a 60-year-old sentenced prisoner, died from gastrointestinal haemorrhage complications secondary to cirrhosis from hepatitis B. He presented with multiple serious pre-existing conditions including oesophageal varices, ischaemic heart disease, and uncontrolled diabetes. In prison, his medication compliance improved significantly compared to community care, and he received excellent comprehensive medical support including specialist gastroenterology and cardiology input. He experienced major bleeding episodes managed by urgent hospital transfers and endoscopic banding procedures. The coroner found his prison medical care was equal to or better than community care, with no issues contributing to his death. While the Royal Prerogative of Mercy was not considered despite terminal illness status, parole denial was appropriate given community safety concerns. Clinical lessons include the importance of ensuring medication compliance in complex patients and proactive management of known variceal risk.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
[2021] WACOR 27 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 29 JULY 2021 DELIVERED : 6 AUGUST 2021 FILE NO/S : CORC 1398 of 2018
DECEASED : YOUSSEF, HASSAN MOHAMED Catchwords: Nil Legislation: Nil Counsel Appearing: Sergeant A Becker assisted the Coroner.
Ms A Seen (SSO) appeared for the Department of Justice.
Case(s) referred to in decision(s): Nil
[2021] WACOR 27 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Hassan Mohamed YOUSSEF with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 29 July 2021, find that the identity of the deceased person was Hassan Mohamed YOUSSEF and that death occurred on 8 November 2018 at Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, from complications of gastrointestinal haemorrhage due to cirrhosis of the liver secondary to hepatitis B in the following circumstances:
Hassan Youssef was a sentenced prisoner serving a three year sentence imposed on 11 November 2016 for child sexual offences. He had been receiving medical treatment for various conditions while in custody, including liver failure, and it had been identified that he was at risk of internal bleeding and had a shortened life expectancy.
Mr Youssef was transferred urgently to hospital by ambulance from Casuarina Prison on 6 November 2018 after he reported feeling sick and began coughing up blood. Mr Youssef was admitted to Fiona Stanley Hospital and underwent an emergency gastroscopy. He was then transferred to the intensive care unit for ongoing care. His condition continued to deteriorate and he developed organ failure. In consultation with Mr Youssef’s family, a decision was made to withdraw active support, and he died during the evening of 8 November 2018.
As Mr Youssef was a prisoner at the time of his death, he was a ‘person held in care’ under the terms of the Coroners Act 1996 (WA) and a coronial inquest into his death is, therefore, mandatory.1
I held an inquest on 29 July 2021. At the inquest, extensive written material was tendered in relation to the investigations into Mr Youssef’s death and, of particular relevance in this case, the medical care he received prior to his death.2 Two witnesses from the Department of Justice were called to give evidence at the inquest in person, to speak further to the information provided.
At the conclusion of the inquest, I indicated that I was satisfied that Mr Youssef had preexisting medical conditions when he was first taken into custody, and he received a high standard of medical care for those conditions while incarcerated. Unfortunately, his health deteriorated over time, and he became terminally ill. He died in hospital, while receiving at least the same standard of medical care he could have expected to receive in the community.
Mr Youssef was born in Cairo, Egypt. He had limited formal schooling but was a talented musician, specialising in Middle Eastern music, in particular the tabla (drums). He also worked as a house painter. Mr Youssef married and had children in Egypt, but his marriage eventually broke down.3
Mr Youssef first came to Australia in 2000 on a cultural exchange. While in Australia, he met a woman and they formed a relationship. After Mr Youssef returned to Egypt, the woman went to Egypt to visit him and his family and in 2003 they married. Mr Youssef returned to Australia in 2004 to live with his wife and her daughter and son. Mr Youssef’s children from his first marriage remained in Egypt.4 1 Section 22(1)(a) Coroners Act.
2 Exhibit 1.
3 Exhibit 1, Tab 12.
4 Exhibit 1, Tab 12.
Mr Youssef’s second wife ran a belly dancing school in Western Australia and, after their marriage, he helped her with running the school, as well as teaching students how to play the tabla. He also helped to put together a female dervish dancing group.5
After a few years, the marriage broke down. Mr Youssef and his wife divorced in 2007 or
Nevertheless, Mr Youssef and his ex-wife remained on good terms and they often visited each other and continued to provide support when required.6
Around the time his divorce was finalised, Mr Youssef began a new relationship with a woman who was a friend and student of his ex-wife and also a tabla student with Mr Youssef. This woman had a young daughter, who later became the victim of his offending.7
In July 2009, Mr Youssef purchased a house in Forrestfield and began arrangements to bring his son from his first marriage out to Australia from Egypt. In March 2010 Mr Youssef became an Australian citizen.8
After a significant financial and emotional endeavour, Mr Youssef’s efforts to relocate his son were successful and his son came to Australia in August 2013 to live with him in the house in Forrestfield.9
Mr Youssef had a number of health issues, in particular problems with his heart. He first underwent heart surgery in 2010 and then underwent three other heart operations. He also suffered from diabetes and kidney problems. Mr Youssef’s health problems affected his ability to work and led to financial difficulties, including his ability to pay the mortgage repayments on his Forrestfield home.10
The offending related to the child of a woman he was in a romantic relationship with at the time.11
6 Exhibit 1, Tab 12.
7 Exhibit 1, Tab 12.
8 Exhibit 1, Tab 13.
9 Exhibit 1, Tab 12.
10 Exhibit 1, Tab 12.
11 Exhibit 1, Tab 12.
[2021] WACOR 27 myocardial infarction (NSTEMI) and coronary artery bypass, heart failure and depression.12
Once incarcerated, Mr Youssef was referred to both the Liver Clinic and a cardiologist for ongoing opinions about his management. He was also commenced on insulin for his diabetes.13
A report summarising Mr Youssef’s health issues was before the learned sentencing judge at the time his sentence was imposed. It was noted that Mr Youssef suffered from ischaemic heart disease, diabetes and hepatitis B and severe liver disease, with a number of complications, which made him at higher risk of bleeding than the average person. It was also noted he had only taken his medications intermittently while in the community due to financial pressures.14
Mr Youssef had three episodes of chest pain in November and December 2016 and again in January 2017. Each time he was sent to a hospital emergency department for investigations and, on each occasion, the source of the pain was not heart-related. He was given medication for gastro-oesophageal reflux and diagnosed with panic attacks.15
The learned sentencing Judge noted that Mr Youssef was receiving appropriate medical care for his ongoing medical conditions and had referrals pending for further review by hepatology for his liver and cardiology for his heart.16
The learned sentencing Judge acknowledged Mr Youssef’s medical conditions were a relevant mitigatory factor, but found no evidence to suggest that he could not receive appropriate treatment in prison or that imprisonment would have an adverse effect on his health. There was also no evidence at that time to suggest that he was likely to die in prison, given his age at the time and the length of the sentence imposed.17 As it turns out, Mr Youssef did unfortunately die while still serving his sentence, but it was not an event that seemed likely at the time the sentence was imposed.
Mr Youssef was ultimately sentenced on 9 February 2017 to a total effect term of three years’ imprisonment with eligibility for parole, backdated to commence on 11 November
13 Exhibit 1, Tab 12.
14 Exhibit 1, Tab 12.
15 Exhibit 1, Tab 12.
16 Exhibit 1, Tab 12.
17 Exhibit 1, Tab 12.
18 Exhibit 1, Tab 12.
[2021] WACOR 27 but was not well enough to be transferred to Karnet Prison Farm, where there was more limited nursing and medical support. He was later moved to Casuarina Prison so that he could be housed in the Infirmary and receive closer monitoring of his health conditions.19
He had limited opportunities to work given his medical conditions, but he was able to engage in some education to improve his English. Early on, another prison who spoke Mr Youssef’s native language and English assisted him with some translating, but Mr Youssef then indicated he felt uncomfortable with this arrangement, so a translating service was utilised whenever important information needed to be communicated.20 He received phone calls and social visits from some of his family and a friend.21
On 25 July 2017 Mr Youssef’s case management officer noted he was a very ill prisoner and did not leave his cell very often. This continued for the rest of his incarceration.22
In terms of his overall health, it is relevant that Mr Youssef had referrals to specialists in Hepato-gastroenterology, Cardiology, ENT and Urology. One of his primary health concerns was his oesophageal varices. Dr Joy Rowland, the Director of Medical Services for the Department of Justice, explained that this was related to his liver disease, which created pressure in the veins and resulted in enlarged blood vessels, which can actually burst through and haemorrhage. He attended several gastroscopies for varices oesophageal banding to prevent massive bleeding.23
On 6 April 2018, a month before his earliest eligibility date, Mr Youssef was denied release on parole by the Prisoners Review Board. The Board noted Mr Youssef continued to deny his offending and his proposed release plan did not include sufficient protective strategies to reduce the risk to the safety of the community. It was indicated that he was likely to serve his full term, so he was unlikely to be released until 10 May 2019.24
Mr Youssef was moved to the Causarina Prison Infirmary in July 2018 as his health was continuing to deteriorate and he had been registered on the Department’s terminally ill prisoner register at stage 3. He was reviewed by the palliative care consultancy services on 19 July 2018 and it was noted he remained at high risk of bleeding. A plan was made for him to be referred to hospital by ambulance immediately if he suffered major bleeding, and steps were put in place to limit his distress and ensure the safety of prison staff for the time period before an ambulance could attend. He received daily nursing care and reviews from 20 July 2018 to 20 August 2018.25
At about 8.10 pm on 21 August 2018 a prison officer answered a cell call from the infirmary cell occupied by Mr Youssef. The prison officer noticed blood on Mr Youssef’s face, so he immediately contacted medical staff to attend. A code red medical emergency was called over the radio and other prison officers attended so Mr Youssef’s cell could be 19 Exhibit 1, Tab 55.
21 Exhibit 1, Tab 12 – 14 and Tab 18.
22 Exhibit 1, Tab 16 - 17.
23 T 10; Exhibit 1, Tab 55.
24 Exhibit 1, Tab 14D – E and Tab 23.
25 Exhibit 1, Tab 55.
[2021] WACOR 27 opened. His cell was unlocked at 8.15 pm and nursing staff immediately went to provide assistance to Mr Youssef and an ambulance was requested to attend priority one.26
The nurses found a large amount of blood present in and around the toilet in Mr Youssef’s cell. He indicated he needed to use the toilet, so he was assisted to do so, before being assisted back to his bed. It was clear he was in discomfort and pain. Oxygen therapy was commenced as Mr Youssef complained of shortness of breath and medication was also administered to calm him as he appeared quite anxious. He was seen to vomit a small amount of bright red blood and several sets of observations showed his condition was deteriorating.27
Ambulance staff arrived at Mr Youssef’s cell at 8.38 pm and he was then taken by ambulance to Fiona Stanley Hospital.28 Mr Youssef’ next of kin were notified by prison staff.29
Mr Youssef had indicated his wishes to palliative care staff for all steps to be taken to prolong his life as long as possible. He appeared to still be hopeful that he might be released on parole at some stage. Accordingly, while at FSH he was given proactive care and underwent further surgical banding procedures.30
Mr Youssef returned to the prison infirmary on 27 August 2018 and was reviewed by a doctor. It was noted that he had done well to survive this last major haemorrhage. He was weak and frail and it was explained to him by the doctor that he had a short life expectancy as he was at high risk of further catastrophic bleeding. He had been booked in at FSH endoscopy clinic for further banding to be performed soon.31
Mr Youssef underwent further oesophageal varices banding in mid-October 2018 before returning to prison for ongoing care in the infirmary.32 Mr Youssef had a management plan in place for when/if his oesophageal varices ruptured again, which in effect involved keeping him calm and protecting staff while arranging for urgent transfer to hospital by ambulance.
Mr Youssef reported feeling sick. He was escorted to the toilet by a prison officer, who observed Mr Youssef coughing up blood into the sink. Nursing staff were notified, who immediately attended to take over care of Mr Youssef and an ambulance was requested to attend. In the meantime, he was taken to the outpatient centre for medical assistance until the ambulance arrived and took him to the hospital.33 26 Exhibit 1, Tab 36B – G.
27 Exhibit 1, Tab 36B - G.
28 Exhibit 1, Tab 36B - G.
29 Exhibit 1, Tab 36G.
30 Exhibit 1, Tab 55.
31 Exhibit 1, Tab 55.
32 Exhibit 1, Tab 55.
33 Exhibit 1, Tab 37A – H.
Mr Youssef was admitted to FSH and underwent surgery to stop the internal bleeding and then was placed in an induced coma in the intensive care unit. While he was in an induced coma, approval was given for his restraints to be removed.34
The prison health staff were informed by his treating doctor at FSH that Mr Youssef was gravely ill on 8 November 2018. A call was made on 8 November 2018 for Mr Youssef’s son to be granted unlimited time for visits due to his father’s poor prognosis. Doctors anticipated that Mr Youssef would not survive the day. The request was granted and Mr Youssef’s son arrived at 11.00 am that morning with a family friend to interpret for him. His ex-wife was also allowed to visit later that day. Mr Youssef died just before 7.00 pm in the presence of his son and ex-wife.35
A post mortem examination was performed by Forensic Pathologist Dr Daniel Moss on 12 November 2018. After completing an external examination and reviewing the medical notes, Dr Moss felt a reasonable cause of death could be given without the need for a full internal post mortem examination. After consultation with Mr Youssef’s family, this course of action was approved by a coroner.36
Dr Moss formed the opinion the cause of death was complications of gastrointestinal haemorrhage due to cirrhosis of the liver secondary to Hepatitis B.37
Limited toxicology analysis was performed, which showed the presence of multiple prescribed-type medications in keeping with the medical history provided. The toxicology results did not alter the cause of death.38
I accept and adopt the opinion of Dr Moss as to the cause of death. I find the death occurred by way of natural causes.
34 Exhibit 1, Tab 45 and Tab 55.
35 Exhibit 1, Tab 45.
36 Exhibit 1, Tab 6.
37 Exhibit 1, Tab 6.
38 Exhibit 1, Tab 6 and Tab 7.
Unfortunately, over time, Mr Youssef’s health conditions progressed and he became increasingly unwell. He was assessed by palliative care services to ensure he was kept comfortable as his health deteriorated, and he continued to receive active medical interventions until immediately before his death, consistent with his request for everything to be done to prolong his life.
In the Department of Justice’s Death in Custody Review it was acknowledged that the Royal Prerogative of Mercy was not considered in Mr Youssef’s case. A referral for a recommendation to be considered would ordinarily occur once a prisoner is registered as a stage 3 terminally ill prisoners, although release in such cases is very rare. Further, I note Mr Youssef had recently been refused parole, which would make release on the RPOM even more unlikely in his case. I am aware from other matters that the Department of Justice has, since last year, reviewed all prisoners potentially eligible for release on the RPOM and a staff member at the Sentence Management Unit is now responsible for ensuring all cases are considered and referred through the hierarchy.
It is unfortunate that Mr Youssef was unable to be released on parole, given in the end he only had a few months to live, but it is the obligation of the Prisoners Review Board to give paramount consideration to the safety of the community and it was concluded he represented an unacceptable risk to the safety of the community at that time.
I am satisfied that the overall care, treatment and supervision provided to Mr Youssef was equal to, or better than, the treatment and care he would have received for his health conditions if he had remained free in the community. He died in hospital, receiving full medical care, in the presence of his family.
S H Linton Deputy State Coroner 6 August 2021
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