Inquest into the Death of Jeffrey Lee STRETTLES

[2022] WACOR 13 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : PHILIP JOHN URQUHART, CORONER HEARD : 13 JANUARY 2022 DELIVERED : 14 FEBRUARY 2022 FILE NO/S : CORC 1077 of 2019

DECEASED : STRETTLES, JEFFREY LEE Catchwords: Nil Legislation: Nil Counsel Appearing: Sergeant A Becker assisted the Coroner Ms A Westerside (State Solicitor’s Office) appeared on behalf of the Department of Justice Case(s) referred to in decision(s): Nil

[2022] WACOR 13 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Philip John Urquhart, Coroner, having investigated the death of Jeffrey Lee STRETTLES with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 13 January 2022, find that the death of Jeffrey Lee STRETTLES occurred on 8 August 2019 at St John Of God Midland Public Hospital, 1 Clayton Street, Midland, from complications in association with advanced malignancy (hepatocellular carcinoma), end-stage liver disease (cirrhosis) and generalised sepsis in a man under medical palliative care in the following circumstances: Table of Contents

OVERVIEW OF MR STRETTLES’ MEDICAL CONDITIONS AND TREATMENT IN PRISON

[2022] WACOR 13 INTRODUCTION The deceased (Mr Strettles) died on 8 August 2019 at St John of God Hospital, Midland, from complications in association with advanced malignancy (hepatocellular carcinoma), end-stage liver disease (cirrhosis) and generalised sepsis in a man under medical palliative care. At the time of his death, Mr Strettles was a sentenced prisoner in the custody of the Chief Executive Officer (CEO) of the Department of Justice (the Department).1 Accordingly, immediately before his death, Mr Strettles 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 I held an inquest into Mr Strettles’ death at Perth on 13 January 2022. The following witnesses gave oral evidence: i. Toni Palmer (Senior Review Officer with the Department); and ii. Dr Catherine Gunson (Acting Director of Medical Services with the Department) The documentary evidence at the inquest comprised of two volumes of the brief which were tendered as exhibit 1.

The inquest focused on the medical care provided to Mr Strettles while he was a prisoner, with an emphasis on the care provided to him regarding his pre-existing hepatocellular carcinoma (liver cancer) and cirrhosis.

1 Section 16, Prisons Act 1981 (WA) 2 Sections 3, 22(1)(a), Coroners Act 1996 (WA) 3 Section 25(3), Coroners Act 1996 (WA)

[2022] WACOR 13 THE DECEASED Background 4 Mr Strettles was born on 9 July 1967 in Campbelltown, New South Wales. He had two sisters and a brother. He was 52 years old when he died.

Mr Strettles attended school in Campbelltown before his family moved to Tamworth. He attended high school in Tamworth before leaving school in year 9.

As an adult, Mr Strettles moved around a lot and never really settled. He worked as a handy man and did odd jobs. He enjoyed singing, particularly karaoke.

Mr Strettles had three significant relationships, fathering eight children. He moved to Western Australia in about 1986.

Offending history 5 Mr Strettles’ first court appearance was in the Children’s Court in New South Wales when he was 13 years old. He was convicted of a break, enter and steal and was placed on probation for 12 months. He had a further appearance in the Children’s Court in 1983 as a 16-year-old and was again placed on probation for a matter relating to the theft of a car and failing to appear.

His adult convictions in New South Wales included possession of amphetamine.

After moving to Western Australia, Mr Strettles had a number of criminal and traffic convictions which included drug offences, making threats and offences of dishonesty.

4 Exhibit 1, Volume 1, Tab 8, File note of Senior Constable Laura Riley dated 24 August 2019 5 Exhibit 1, Volume 1, Tab 10A, Western Australia Criminal and Traffic History; Exhibit 1, Volume 1, Tab 10B, New South Wales Police Force – Criminal History

[2022] WACOR 13 Up until October 2017, Mr Strettles had never been sentenced to a term of imprisonment, although in November 2010, he was remanded in custody for a short period in Hakea Prison (Hakea) before being released on bail.

Circumstances of final imprisonment 6 On 19 October 2017 in the Perth District Court of Western Australia, Mr Strettles pleaded guilty to 17 sexual offences against children. On that date, he was sentenced to a term of immediate imprisonment for each offence, ranging from 12 months to 3½ years’ imprisonment. The total sentence imposed was 12 years’ imprisonment and Mr Strettles was made eligible for parole. His earliest date for release on parole was 18 October 2027.

Prison history 7 Mr Strettles had the following prison placements and transfers: a. Hakea Prison: 19 October 2017 – 22 November 2017 (34 days) b. Acacia Prison: 22 November 2017 – 8 August 2019 (624 days) Although Mr Strettles made an application to be transferred to a prison in Queensland so that he could receive visits from family members, he later withdrew his application following the diagnosis of his liver cancer. In a handwritten letter dated 1 September 2018 which stated his intention to withdraw the application, Mr Strettles wrote, “I believe I will receive better medical attention in Western Australia compared to my potential location in Queensland.”8 Throughout his 22 months of incarceration, Mr Strettles was reported to be a respectful individual and that he responded well to instructions from prison staff.

He interacted with other prisoners and completed all tasks required to an 6 Exhibit 1, Volume 1, Tab 9, Transcript of District Court sentencing remarks dated 19 October 2017 7 Exhibit 1, Volume 2, Tab A, Death in Custody Report dated December 2021 8 Exhibit 1, Volume 1, Tab 19, Hand-written letter by Mr Strettles dated 1 September 2019

[2022] WACOR 13 acceptable standard. He participated in education classes and maintained his cell and personal hygiene to a high standard.

OVERVIEW OF MR STRETTLES’ MEDICAL CONDITIONS AND TREATMENT IN PRISON AND IN HOSPITAL 9 Pre-existing medical conditions Mr Strettles had a long history of alcohol and illicit drug dependency. He also smoked cigarettes. In addition, he had a history of mental health issues and was prescribed various antidepressant and antipsychotic medications over the years.

Mr Strettles contracted Hepatitis C in the late 1980’s and was reviewed regularly at the liver clinic in Fiona Stanley Hospital (FSH).

In March 2017, Mr Strettles was prescribed a 12-week course of Harvoni (sofosbuvir ledipasvir) in an effort to eradicate the Hepatitis C virus.

In early 2017, he was diagnosed with hepatocellular carcinoma in segment 8 of his liver. This was treated in February 2017 with combined TACE (transarterial chemoembolization) and RAF (radiofrequency ablation).

Hepatocellular carcinoma is the most common form of primary cancer and can be either a small tumour or any number of small tumours. It is an aggressive cancer and often symptoms only appear in the later stages of progression. This means it is often only detected when it is at an advanced stage, hence it is very difficult to cure.

9 Exhibit 1, Volume 2, Tab 29, Health Services Summary into the Death in Custody – Acacia Prison dated December 2021; Exhibit 1, Volume 2, Tab 30, Health Services Summary into the Death in Custody – Hakea Prison dated January 2021; Department of Justice EcHo medical records; St John of God Midland Hospital medical records; Fiona Stanley Hospital medical records

[2022] WACOR 13 Hakea Prison On 19 October 2017, Mr Strettles was received at Hakea reception. The At-Risk Management System (ARMS) Reception In-Take Assessment Report indicated that Mr Strettles had advised he was diagnosed with liver cancer earlier that year, for which he was receiving medication. He also said he had Hepatitis C and sciatica, amongst other ailments. He disclosed he had used methylamphetamine and cannabis daily, and had excessively consumed alcohol at times.

Mr Strettles reported he had attempted to hang himself two years earlier and had more recently attempted to overdose. Although he denied any current thoughts of self-harm or suicidal ideation, he was placed on a moderate ARMS placement, with two-hourly observations as a precautionary measure. He remained on ARMS until 31 October 2017 when it was determined he no longer had thoughts of self-harm or suicidal ideation.

On examination by the prison doctor on 20 October 2017, Mr Strettles’ liver was palpable and although firm, did not appear to be enlarged. No obvious stigmata of advanced liver disease was noted. The prison doctor requested information from the Health Services Medical Bookings team regarding Mr Strettles’ cancer treatment at FSH, and requested that FSH be advised he was incarcerated. A pre-existing appointment for his cancer treatment that had been booked for 8 November 2017 was re-scheduled.

On 22 November 2017, Mr Strettles’ security rating was reduced to medium security and he was transferred to Acacia Prison (Acacia).

Acacia Prison Upon his admission to Acacia, Mr Strettles was seen by a prison nurse.

He stated that he felt happy and was pleased to be at Acacia.

[2022] WACOR 13 On 29 November 2017, Mr Strettles attended an appointment at the gastroenterology clinic at FSH. A blood test taken at that appointment still detected Hepatitis C, which suggested the previous treatment to eradicate the virus had been unsuccessful.

On 31 December 2017, Mr Strettles was moved to the Crisis Care Unit (CCU) at Acacia and placed on ARMS with two-hourly observations after he indicated that he wanted to self-harm by hanging.

On 2 January 2018, the Prisoner Review Assessment Group (PRAG) assessed the ARMS status of Mr Strettles and he was subsequently reduced to a lower category of ARMS with four-hourly observations. On 9 January 2018, PRAG reassessed Mr Strettles and he was removed from ARMS and placed on the Support and Monitoring Systems (SAMS). He subsequently remained on SAMS for ongoing support due to his chronic health risk until 22 May 2018.

On 18 January 2018, Mr Strettles was taken to St John of God Hospital, Midland (SJOG) with suspected appendicitis, after he had attended the medical centre at Acacia because he was experiencing abdominal pain. He was discharged from SJOG the same day after it was determined his stomach pain was not appendicitis. However, the treating doctors at SJOG recommended a non-urgent colonoscopy. This took place on 6 June 2018.

After reporting back pain for the previous three days and being unable to mobilise, Mr Strettles was again admitted to SJOG on 24 March 2018. He was treated for urinary retention, back pain and gastritis. Scans at that time showed no evidence of the metastatic spread of cancer to his bones. The scan of his thoracic and lumbar spine showed no significant compromises.

[2022] WACOR 13 On 26 June 2018, a Magnetic Resonance Imaging (MRI)10 showed a new hepatocellular carcinoma, measuring 14 mm in segment 8 of Mr Strettles’ liver.

A 10 mm lesion in segment 7 and a 29 mm lesion in segment 5 were also suspicious for hepatocellular carcinoma.

Mr Strettles’ case was subsequently discussed at a multidisciplinary team meeting at FSH. He was diagnosed with multifocal hepatocellular carcinoma and it was recommended that he receive Selective Internal Radiation Therapy (SIRT).11 This treatment was to commence on 10 August 2018.

On 19 July 2018, Mr Strettles reported to a prison nurse and the prison doctor that he was very distressed at being informed that his liver cancer had returned.

However, he said he did not have any thoughts of self-harm.

On 10 August 2018, Mr Strettles underwent SIRT at FSH. It was reported to have been “technically successful”.

On 28 August 2018, Mr Strettles had a Telehealth review with a specialist at FSH. He was advised to undergo fortnightly blood tests, maintain a high protein diet, continue exercising and have another MRI scan in three months’ time.

On 7 October 2018, Mr Strettles reported to a prison nurse that he was feeling tearful. He subsequently spent several nights in the CCU before he returned to his cell.

On 10 November 2018, Mr Strettles suffered chest pain, with a productive cough and wheezing. He was prescribed antibiotics for a presumed chest infection. An E-consult took place with a doctor on 12 November 2018.

Mr Strettles stated that he was feeling “a bit better but not much.” 10 An MRI scan takes a detailed picture of the inside of the body. It will detect problems in the soft tissues and assists in developing plans of treatment without first doing investigative surgery.

11 This is a treatment for liver cancer or tumours that delivers tiny radioactive spheres or beads directly to the tumour with the aim to reduce the tumour, thereby prolonging the life or quality of life for the patient.

[2022] WACOR 13 Mr Strettles had the planned MRI scan at FSH on 13 November 2018. The results of that scan were not positive. It showed numerous solid nodules in his liver, which were too small and too numerous to document. There was also a larger indeterminate lesion in segment 6 of his liver.

On 11 December 2018, Mr Strettles had a Telehealth consult with his treating gastroenterologist. He was informed that his liver function had worsened, and the cirrhosis had a Child-Pugh B grading (i.e. a significant functional compromise). He was therefore no longer suitable for the SIRT treatment, although it was decided to commence a 12-week course of Epclusa in a further attempt to eradicate the Hepatitis C, which it was hoped would improve his liver function. Mr Strettles was advised that his life expectancy was about 18 months.

Mr Strettles commenced his Epclusa treatment on 31 December 2018.

On 27 February 2019, a gastroscopy showed a Grade 2 oesophageal varices (a complication of cirrhosis) and Mr Strettles was commenced on medication to treat that.

Mr Strettles attended FSH for a further MRI scan on 5 March 2019. This scan showed cirrhosis, portal hypertension, new ascites (fluid build-up) and the spread of the cancer to the left adrenal gland.

On 12 March 2019, Mr Strettles had a further Telehealth conference with his gastroenterologist. He was advised that his cancer had now progressed to his lungs. He was given the option of commencing oral chemotherapy, however he was informed that this would only prolong his life by three months on average.

On 17 March 2019, Mr Strettles developed abdominal pains and three days later, his abdomen had become swollen due to ascites.

[2022] WACOR 13 On 23 April 2019, Mr Strettles was commenced on diuretics to manage his ascites, however he had developed coagulopathy (excessive blood clotting) secondary to his liver disease.

On 23 April 2019, the Department upgraded Mr Strettles to Stage 3 on its Terminally Ill List.

At a Telehealth consultation on 21 May 2019, Mr Strettles reported that he had accepted, and felt calm about his diagnosis.

On 30 June 2019, Mr Strettles complained of blurred vision and headaches and he was taken to SJOG, where he was diagnosed with having a migraine and was discharged the following day.

On 5 July 2019, a case conference was held at Acacia and an Advanced Health Directive (the Directive) was completed. This was following reports from FSH that there had been further decompensation and progression of Mr Strettles’ illness. As a result, active treatment had been discontinued and supportive care was to commence. The Directive included daily welfare checks on Mr Strettles by a prison nurse.

On 16 July 2019, the gastroenterology clinic at FSH contacted Acacia to advise that Mr Strettles’ MRI scan from the previous day showed an extensive portal vein thrombosis and that he was to be commenced on the anti-coagulant, enoxaparin.

EVENTS LEADING TO DEATH On 19 July 2019, Mr Strettles started vomiting intermittently. By 31 July 2019, he had a fever and the prison doctor was of the view these symptoms were suggestive of an infection and sepsis arising from the decompensating (causing

[2022] WACOR 13 functional deterioration) hepatocellular carcinoma. He was transferred by ambulance to SJOG.

At SJOG, Mr Strettles underwent scans which revealed a disrupted mass lesion on the right side of his brain. It was determined he was too unwell to have further investigations and the differential diagnoses were metastasis with a new primary tumour or a brain abscess. Sepsis was confirmed and Mr Strettles was commenced on intravenous antibiotics. His ascites was managed with paracentesis (a needle placed in the abdomen to remove fluid) and albumin infusions. He was reviewed by the SJOG palliative care team on 2 August 2019.

On 5 August 2019, Mr Strettles developed worsening shortness of breath and increasing oxygen requirements. He was diagnosed with type 2 respiratory failure due to fluid overload. Further treatment was regarded to be futile. After discussions with Mr Strettles’ family, the decision was made to keep him comfortable with palliative care.

On 5 August 2019, the Department upgraded Mr Strettles to Stage 4 on its Terminally Ill List.

On 7 August 2019, a syringe driver was commenced for Mr Strettles, which contained hydromorphone and midazolam.

On the morning of 8 August 2019, Mr Strettles died.

CAUSE AND MANNER OF DEATH 12 A forensic pathologist (Dr Jodi White) conducted an external post mortem examination of Mr Strettles’ body on 12 August 2019. Dr White was of the view that an examination of SJOG medical records would allow a cause of death to be 12 Exhibit 1, Volume 1, Tab 6A-C, Supplementary Post Mortem Report by Dr Jodi White dated 12 August 2019; Forensic Consultation Post Mortem Report by Dr Jodi White dated 12 August 2019; Letter from Dr Jodi White to the State Coroner dated 16 August 2019; Exhibit 1, Volume 1, Tab 7, Toxicology Report dated 18 September 2019

[2022] WACOR 13 given without an internal post mortem examination. Part of the external examination involved a computerised tomography (CT) scan, which confirmed the enlargement of Mr Strettles’ liver and spleen with an advanced liver tumour and features in his lungs consistent with pneumonia. A large lesion in the right sphenoid portion of Mr Strettles’ skull was also noted. Toxicological analysis showed the presence of medications, including hydromorphone, in keeping with the palliative medical care provided to Mr Strettles.

At the conclusion of the external post mortem examination, and after reviewing the SJOG medical records and the results of the toxicological analysis, Dr White expressed the opinion that the cause of Mr Strettles’ death was complications in association with advanced malignancy (hepatocellular carcinoma), end-stage liver disease (cirrhosis) and generalised sepsis in a man under medical palliative care.

I accept and adopt that conclusion expressed by Dr White and I find that Mr Strettles’ death occurred by way of natural causes.

ISSUES RAISED BY THE EVIDENCE Royal Prerogative of Mercy not considered by the Department 13 As already noted, on 23 April 2019 Mr Strettles was classified at Stage 3 of the Department’s Terminally Ill List, and on 5 August 2019 that was upgraded to Stage 4.

One of the outcomes from these notifications is that a prisoner who has been classified at Stage 3 or Stage 4 can be considered for release on compassionate grounds by the Governor before the expiration of the term of their imprisonment 13 Exhibit 1, Volume 2, Tab A, Death in Custody Report dated December 2021; ts 13.1.22 (Palmer), pp.6-11; Letter from Mike Reynolds, Commissioner, Corrective Services to Counsel Assisting dated 8 February 2022; Exhibit 1, Volume 2, Tab 28, Policy Directive 8 – Prisoners with a Terminal Medical Condition – Procedures dated 8 December 2014

[2022] WACOR 13 (i.e. the grant of a pardon in the exercise of the Royal Prerogative of Mercy).

The Department had a policy and procedure in place at the time of Mr Strettles’ classifications governing what was to occur in these circumstances (the Policy).

A terminally ill prisoner is classified at Stage 3 if the Department’s Director of Health Services is of the opinion that the prisoner has a Terminal Medical Condition14 and “is likely to die within three months” and/or “has one or more medical conditions which may increase the potential for sudden death”. A terminally ill prisoner is to be classified at Stage 4 if the prisoner’s death is imminent.

The Policy required that certain tasks must be undertaken once a prisoner is classified at Stage 3. One of those tasks is that the Department’s Manager, Sentence Management (or their delegate) shall, within seven working days of the notification of the classification, “prepare a briefing note for the Minister for Corrective Services which notifies the Minister of the prisoner’s medical situation and life expectancy, the likelihood of the prisoner dying in custody and any other relevant information.” This briefing note commences the process for the exercise of the Royal Prerogative of Mercy.

A similar briefing note is to be prepared when a prisoner is classified at Stage 4.

Unfortunately, a briefing note was not prepared for Mr Strettles when he was classified at Stage 3 or at Stage 4. Ms Toni Palmer, the Senior Review Officer at the Department, was able to provide an explanation for this oversight at the inquest. It is an explanation that she has had to provide at a number of recent inquests regarding the deaths of prisoners that occurred in 2018 and 2019.

14 A Terminal Medical Condition is defined as “One or more medical conditions that on their own or as a group may significantly increase a prisoner’s potential to die in custody, having regard to the nature of the condition(s) and the length of the prisoner’s sentence”: Exhibit 1, Volume 2, Tab 28, Policy Directive 8 – Prisoners with a Terminal Medical Condition, p.2

[2022] WACOR 13 The explanation was as follows. In 2017, the Manager, Sentence Management, had made an application for voluntary severance which was accepted. This person subsequently left the employ of the Department in January 2018. The position was not filled, and the task regarding the preparation of briefing notes was not allocated to another employee. This allocation did not occur until early

2020. Therefore, there was a period of about two years when no briefing notes were prepared for prisoners who were classified at Stage 3 or Stage 4 of the Department’s Terminally Ill List.

At the inquest, I sought further information from the Department regarding the reason why it took approximately two years for this task to be reallocated. I also asked for the precise number of prisoners who were denied the opportunity of having briefing notes prepared for them during this period. Those questions were subsequently addressed in a letter dated 8 February 2022 from Mr Mike Reynolds, the Commissioner for Correctives Services at the Department.

That letter clarified that the estimated period when briefing notes were not being prepared was from January 2018 to June 2020. Sixty one prisoners were listed as being at Stage 3 or Stage 4 during that time. Although 17 of these prisoners were not eligible for the exercise of the Royal Prerogative of Mercy as they were on remand and had not been sentenced, 44 prisoners appeared to be eligible.15 That is a staggering number of prisoners who were denied the right to have their circumstances considered for an early release through the process of the Royal Prerogative of Mercy. Mr Reynolds conceded that the decision to remove 15 A mentally impaired accused as defined in s 23 of the Criminal Law (mentally Impaired Accused) Act 1996 (WA) who is classified with a terminal medical condition is to be considered for release in accordance with that Act and not through the exercise of the Royal Prerogative of Mercy. Similarly, a prisoner with a terminal medical condition who has been imprisoned pursuant to Commonwealth legislation is also subject to a different process. Mr Reynolds’ letter did not specify whether any of these 44 prisoners fell within one of these two categories. However, I note that the Manager, Sentence Management was also required to prepare similar briefing notes for these prisoners: Exhibit 1, Volume 2, Tab 28, Policy Directive 8 – Prisoners with a Terminal Medical Condition – Procedures dated 8 December 2014, pp.7-8. It is therefore safe to assume that if any of the 44 prisoners fell within these two additional categories, they also did not have their briefing notes prepared.

[2022] WACOR 13 the position of Manager, Sentence Management and not reassign the task of preparing the briefing notes “was a serious failure in judgement”. That concession was properly made. In my view, it was inexcusable that such an important task was not reassigned for a period of approximately 2½ years whilst dozens of terminally ill prisoners were being classified at Stage 3 or Stage 4. It rendered an important outcome of the classification process entirely nugatory.

Unfortunately Mr Reynolds was unable to enlighten me as to why it took so long for the Department to address this failure. His letter stated: We have been unable to determine why the decision was made to approve a VTSS16 considering the risk of not being able to ensure this work under PD 817 was undertaken.

None of the decision makers from that time are currently employed in Corrective Services. It is unlikely that we will be able to understand what their expectations were to ensure this function continued after the VTSS of the Manager Sentence Management position was approved, in light of the advice from the Director Sentence Management that there was no capacity or resourcing to fulfill the obligations related to the terminally ill workload of the position which received VTSS.

QUALITY OF THE DEPARTMENT’S SUPERVISION, TREATMENT AND CARE Having carefully considered the documents tendered into evidence and the evidence of Dr Gunson at the inquest, I am satisfied that Mr Strettles’ various medical conditions, most notably his pre-existing hepatocellular carcinoma and cirrhosis, were appropriately managed by the Department. Accordingly, I am satisfied that the standard of supervision, treatment and care he received whilst he was in custody at Hakea and Acacia (including when he was hospitalised) was appropriate.

16 The application for a voluntary redundancy made by the Manager, Sentence Management in 2017 17 Policy Directive 8 – Prisoners with a Terminal Medical Condition – Procedures dated 8 December 2014

[2022] WACOR 13 As to Mr Strettles’ care for the five weeks he was at Hakea, I agree with the following assessment made by the Department:18 On his arrival to Hakea Prison, Mr Strettles underwent a full nursing assessment, followed by a full assessment by the admitting Medical Officer the following day. His current acute health issues were identified at his time of arrival and his cancer treatment team at Fiona Stanley Hospital were notified that he was in custody, shortly after his arrival in prison.

During Mr Strettles’ brief time in Hakea Prison, he was provided with appropriate and timely care and follow-up commensurate with what he would have received in the community.

I also agree with the following assessment by the Department regarding Mr Strettles’ care at Acacia:19 Mr Strettles came into custody with a complex history of serious health issues including a diagnosis of Hepatocellular Carcinoma.

His health deterioration was recognised and acted upon by Acacia and external specialists through referral including Cancer Care and Palliative Care specialists at both Fiona Stanley Hospital and St John of God Hospital.

… Mr Strettles received a high level of care while in custody that was equal to or above what he would have received in the community as evidenced by the details in the medical record (EcHO).

All care provided to Mr Strettles during his incarceration was appropriate and timely.

On the available evidence before me, the only deficiency in the Department’s care of Mr Strettles was its failure to prepare a briefing note to the Minster for Corrective Services when he was classified at Stage 3 of the Department’s Terminally Ill List.20 Had the Department done so, the process for the grant of a pardon in the exercise of the Royal Prerogative of Mercy for Mr Strettles would have commenced. That should have occurred, notwithstanding the low prospect of Mr Strettles being released from prison through this process before his death.

18 Exhibit 1, Volume 2, Tab 30, Health Services Summary into the Death in Custody dated January 2021, p.5 19 Exhibit 1, Volume 2, Tab 29 Health Services Summary into the Death in Custody dated December 2021, pp.28-29 20 I do not make the same observation with respect to the Department’s failure to prepare a briefing note after Mr Strettles was classified at Stage 4, as this classification only occurred three days before his death.

[2022] WACOR 13 CONCLUSION Although convicted of particularly serious offending in October 2017, throughout nearly 22 months he was imprisoned, Mr Strettles always maintained a high level of behaviour and work ethic. He established good relationships with prison staff and fellow prisoners alike. He was never recorded as a management issue and he was, by all accounts, an exemplary prisoner. He attended education sessions and undertook work detail whenever his health allowed him to do so.

Unfortunately, Mr Strettles’ pre-existing health complications regarding his liver began to rapidly progress by June 2018. Although the subsequent treatment and care he received at the medical centre in Acacia and tertiary hospitals were of a high order, his liver complications were too advanced for him to be cured and he died on 8 August 2019.

I am satisfied that the medical care and treatment provided by the Department and the hospitals that cared for Mr Strettles were of the same standard that a person living in the general community would expect to receive.

Accordingly, I have found that the medical care and treatment that Mr Strettles received from the Department was appropriate at all times.

As the tyranny of distance and COVID-19 travel restrictions prevented interstate members of Mr Strettles’ family who were close to him from attending the inquest, I convey my condolences to them for their loss.

PJ Urquhart Coroner 14 February 2022