Inquest into the Death of Peter Johnnie YOUNG

[2022] WACOR 4 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, ACTING STATE CORONER HEARD : 7 DECEMBER 2021 DELIVERED : 14 JANUARY 2022 FILE NO/S : CORC 427 of 2019

DECEASED : YOUNG, PETER JOHNNIE Catchwords: Nil Legislation: Nil Counsel Appearing: Sgt A Becker assisted the Coroner.

Ms A.V. Barter (ALS) appeared for Mr Young’s partner, Lynne Charles.

Ms G Mullins (SSO) appeared for the Department of Justice.

Case(s) referred to in decision(s): Nil

[2022] WACOR 4 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Acting State Coroner, having investigated the death of Peter Johnnie YOUNG with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, PERTH, on 7 December 2021, find that the identity of the deceased person was Peter Johnnie YOUNG and that death occurred on 29 March 2019 at Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, from complications of alcohol and hepatitis Crelated liver disease in the following circumstances:

TABLE OF CONTENTS

[2022] WACOR 4 INTRODUCTION

1. Peter Young was an Aboriginal man who was born and raised in the region of Derby.

He spent a lot of time with his parents and siblings on cattle stations in the Kimberley, where his father worked as a stockman. By all reports, these were happy times for Mr Young. Mr Young’s family moved closer to Derby when he was a teenager, and from that time his family started to struggle with issues of alcohol abuse and family violence that they had not previously faced. Mr Young, who was still only a teenager, began to regularly abuse alcohol and he became involved in criminal behaviour. Sadly, his drinking led to serious liver issues, and his offending behaviour escalated so that he spent increasingly longer periods of time in custody.1

2. During his last period of incarceration, while a remand prisoner for charges relating to sexual offences, Mr Young developed worsening liver failure possibly as a result of recently acquired Hepatitis C infection. He was transferred to Fiona Stanley Hospital for medical treatment on 21 March 2019. Despite treatment, his prognosis was very poor, and doctors advised his family that it was unlikely he would recover.

Some family members were assisted to travel from Balgo to be at Mr Young’s bedside when he died on 29 March 2019. Unfortunately, Mr Young’s partner was unable to make the journey, so she was unable to see him before he died.

3. As Mr Young was a remand prisoner at the time of his death, he was a ‘person held in care’ for the purposes of the Coroners Act 1996 (WA). In such circumstances, a coronial inquest is mandatory.2 I held an inquest into Mr Young’s death on 7 December 2021. Mr Charles’ partner, Lynne Charles, made the long journey to Perth for the inquest.

4. I am required to comment on his treatment, supervision and care prior to his death, Further, Mr Young’s partner, Ms Charles, raised some concerns about why Mr Young had not been released on bail prior to his death, so that he could die in the care of his family, rather than in a hospital so far from home. I have attempted to address these concerns during the inquest and in my finding.

PERSONAL BACKGROUND

5. The information on Mr Young’s background comes largely from a letter written by Mr Young himself, prior to his death. He wrote eloquently about growing up with his family on remote stations, which were the best years of his life and where he learnt to be a stockman. He recalled that he worked hard but he enjoyed it, made friends and felt well respected by the Aboriginal elders who also worked there. When they left the stations and moved to town, he was excited about starting school, but his father quickly began drinking heavily and Mr Young’s life changed for the worse.

Mr Young described witnessing violence and recalled he couldn’t go to school as he had nothing to eat because his father had spent all the money on alcohol. He started stealing food and money and felt he lost the respect that he had felt towards others.

Mr Young said he began drinking to make the pain go away and the alcohol turned 1 Exhibit 1, Tab 2.

2 Section 22(1)(a) Coroners Act.

[2022] WACOR 4 him into a different person, who was aggressive and fought with others in public.

This was when he came to the attention of the law. Mr Young admitted to committing serious offences of violence while under the influence of alcohol.3

MEDICAL BACKGROUND

6. Mr Young’s family said he was fit and healthy when he was a young man, but over the years the drinking took its toll on his health.4 Mr Young developed cirrhosis of the liver due to his heavy alcohol consumption.5

7. Prior to 2017, Mr Young presented to hospital for various medical conditions, including pancreatitis, skin infections and minor ailments.

8. Mr Young had been with his partner, Ms Charles, for many years living around Jigalong, where Mr Young was a well-respected man doing work in the community looking after Country and providing food for the community as a hunter. Ms Charles remembers those years as some of their happiest times together. However, they then decided to move to Newman, where Mr Young’s drinking escalated, resulting in incidents of domestic violence that put a strain on their relationship. They relocated to Yandeyarra to be with family in a community where alcohol was limited, in the hopes of starting afresh. However, Mr Young’s health had started to suffer from his many years of drinking, so they then moved to Port Hedland to be closer to medical facilities. As his health worsened, Mr Young was told by doctors that there were few treatment options left to him. As a result, he made plans with Ms Charles to return to live with his family on Country. He flew home to be closer to family in Balgo and Halls Creek and Ms Charles made plans to go and join him in the north.6

9. Mr Young had multiple presentations to hospital in 2017. He was often intoxicated on presentation and presented for alcohol liver disease related conditions and pneumonia. He was also admitted for oesophageal varices bleeding, requiring an extended period of care in the intensive care unit at Royal Perth Hospital. Mr Young absconded from hospital or discharged himself against medical advice on several occasions.7

GUARDIANSHIP ORDER

10. On 11 May 2017 the State Administrative Tribunal appointed Mr Young a guardian and administrator. This appointment was apparently due to a decline in Mr Young’s cognitive functioning brought on by chronic alcohol abuse. The Tribunal declared that Mr Young was unable, by reason of a mental disability, to make reasonable judgments in respect of matters relating to his estate and was incapable of looking after his own health and safety and making reasonable judgments in respect of his person and keeping himself safe. Therefore, it was concluded he needed a guardian 3 Exhibit 1, Tab 53.

4 Exhibit 1, Tab 3.

5 Exhibit 1, Tab 53.

6 Letter to the Coroner from Lynne Charles dated 30 September 2021.

7 Exhibit 1, Tab 53.

[2022] WACOR 4 to manage his affairs. Mr Young’s brother, David, told police that he recalled Mr Young had a noticeably bad memory, which was consistent with his declining cognition.8

11. The Public Advocate was appointed as his limited guardian, with powers to determine where and with whom he lived, make treatment decisions for him and decide what services he should have access to, as well as make decisions in relation to the use of restraint, where necessary, for his health and safety.9

12. The Public Trustee was appointed as Mr Young’s administrator and took on the task of managing Mr Young’s finances. It appears Mr Young found the lack of personal control over his finances very challenging. There is evidence that he believed he was not receiving his full monetary entitlements from the Public Trustee and he wanted the role of the Public Trustee in his life reviewed.10 There is evidence he spoke to his guardian about financial issues, and sought crisis payments from Centrelink. He was encouraged by his guardian to manage his financial affairs more carefully and be guarded about others accessing his funds, but was also told he should speak to the Public Trustee about his finances generally. The Public Trustee was also informed by the guardian of these issues.11

REASON FOR IMPRISONMENT

13. On 11 April 2017, it was alleged that Mr Young had approached a woman in a carpark outside the Kmart in South Hedland and asked her for money. After she gave him money, he asked for a kiss, then without her consent touched her leg and groin.

She pushed him away and he then walked off. Mr Young was arrested on 13 April 2017 and charged with unlawful and indecent assault. He was released on bail and after subsequent court appearances it was noted that he had an upcoming guardianship hearing and then was in hospital. He remained on bail and made regular appearances in the Magistrates Court in South Hedland, Balgo and Halls Creek until April 2018.

14. On 29 April 2018, Mr Young was said to have been at a service station in Halls Creek. It was alleged that while at the service station, Mr Young approached two young boys who were strangers to him. He offered them money to perform sexual acts and showed them a pornographic video. They tried to run away, and he briefly detained them by holding their shirts before they broke free and ran home. The children immediately told their caregiver what had occurred, who took them to the police where they reported the incident. Mr Young was arrested at his home on 30 April 2018 and charged with sexual offences in relation to each child.

15. As Mr Young was already on bail for a serious offence (the April 2017 offence) when he allegedly committed the offences in April 2018, he needed exceptional 8 Exhibit 1, Tab 3.

9 Exhibit 1, Tab 52.

10 Exhibit 1, Tab 2.

11 Additional Information provided by Counsel from SSO dated 12 January 2022, Annexure 1.

[2022] WACOR 4 reasons under the Bail Act 1982 in order to be released on bail again. Mr Young was taken to Broome Regional Prison on 2 May 2018 to await a court appearance.

16. On 5 May 2018 the prison health services received records relating to Mr Young’s past medical history. Mr Young was transferred to Broome Hospital on 8 May 2018, six days after his admission to prison. He was confused and drowsy on presentation, and it was noted that Mr Young normally had some degree of cognitive impairment and that he had a guardian. The guardian was informed of his admission.12 A CT head scan was reportedly normal and blood tests showed essentially normal markers of infection/inflammation. His platelets were low, which was thought to be possibly related to his alcohol use and chronic liver disease. His liver function tests were abnormal. After a period of observation, Mr Young’s talking improved and he appeared to feel better, so he was returned to prison.13

17. Mr Young appeared in the Halls Creek Magistrates Court on 9 May 2018. There is information on the brief that suggests that Mr Young had told people, prior to his court appearance in May 2018, that he was upset that he could not access his own money as the Public Trustee was now managing his Centrelink disability payments, and he also believed he was owed money, so he requested that he go to prison so he could speak to a Magistrate and a lawyer.14 I note Mr Young also had a large number of convictions for breach of bail, court orders and failing to comply with his reporting obligations as a reportable offender under the Community Protection (Offender Reporting) Act 2004.15 He was initially remanded in custody.

18. Mr Young’s solicitor from the Kimberley Legal Service contacted Mr Young’s guardian on 3 July 2018 to discuss the belief of the solicitor and a nurse that Mr Young now had capacity and no longer required a guardianship order. The solicitor was told that the orders remained valid until revoked by the SAT, so they needed to make application to that tribunal.16

19. There were also discussions in September 2018 between Mr Young’s guardian and solicitor about the possibility that Mr Young would apply for bail and seek to be released to live in the Jigalong community. The guardian expressed some concern that Mr Young would be in harms way in that community and did not support that option, but suggested that they would support Mr Young being released to live in Balgo, which is a dry community and there would be less risk he would commit offences.17

20. It appears Mr Young made a bail application in the Kununurra Magistrates Court, which was not granted. He was committed to the Kununurra District Court on all charges.

12 Additional Information provided by Counsel from SSO dated 12 January 2022, Annexure 1.

13 Exhibit 2, DIC Review Report.

14 Exhibit 1, Tab 10C and Tab 25.

15 Exhibit 1, Tab 11.

16 Additional Information provided by Counsel from SSO dated 12 January 2022, Annexure 1.

17 Additional Information provided by Counsel from SSO dated 12 January 2022, Annexure 1.

[2022] WACOR 4

21. His matter came before the District Court in December 2018, January 2019 and March 2019 without a trial date being set. Mr Young was visited by his Legal Aid lawyer prior to the February and March 2019 court appearances.18 His matter was next listed in the District Court on 23 April 2019.19

22. I understand that Mr Young emphatically denied committing the second set of offences against the two young boys. He maintained that as a loving partner, father and grandfather he would never have behaved in that way towards children.20

23. Mr Young’s partner, Ms Charles, had not made it back to the Kimberley when Mr Young rang her from prison to tell her he had been arrested. She was unable to see him before he was transferred to Casuarina. From that time she was living in Jigalong, and she was unable to travel to visit him in Perth due to a lack of transport or finances to make the long journey. Eventually the letters stopped as he became seriously ill, and then Ms Charles was informed that Mr Young had passed away.21

LAST ADMISSION TO PRISON

24. Having initially been taken to Broome Prison, Mr Young was moved to the West Kimberley Regional Prison (WKRP) on 17 May 2018, where he remained until late

25. Mr Young was transferred to Derby Hospital a few days after his transfer, as he reported feeling dizzy and confused. It was recommended that his dose of risperidone be reused.22

26. A meeting was held on 31 May 2018 where it was noted that Mr Young had a cognitive disability and reported he was unhappy about being under guardianship.

The Transitional Manager was tasked with liaising with his lawyers regarding the guardianship issue. The lawyer took action to try and resolve the issue in June. As part of that process, a mental state exam was conducted with Mr Young using the Kimberley Indigenous Cognitive Assessment, which gave him a score of 39/39, indicating that at least while in custody at that time, his cognitive functioning was good.23

26. Mr Young had a comprehensive cardiac review while at WKRP and some investigations of his liver cirrhosis and related oesophageal varices. In September 2018, Mr Young became uncooperative and started to behave in an agitated and aggressive manner towards health staff and prison officers. He became annoyed when nursing staff asked him questions or tried to give him medications. Mr Young became increasingly threatening towards staff and other prisoners, both physically and verbally, which resulted in a period of confinement. Due to his ongoing behavioural issues, he was then transferred from WKRP to Casuarina Prison in October 2018, where he remained until shortly before his death.24 18 Exhibit 1, Tab 15.

19 Exhibit 1, Tab 10 and Tab 13.

20 Exhibit 1, Tab 53.

21 Letter from Lynne Charles to the Coroner dated 30 September 2021.

22 Exhibit 2, Tab 2.

23 Exhibit 2, Tab 2.

24 Exhibit 1, Tab 14 and Tab 20; Exhibit 2, Tab 2.

[2022] WACOR 4

27. In July 2018, prior to his transfer, Mr Young was reviewed by a physician and it was noted his main complaint was loss of libido and impotence, which he attributed to his medication therapy. He indicated he had no intention of taking medication after he was released from prison. Clinically, he looked excessively tired and was coughing throughout the consultation. The physician noted Mr Young’s advanced alcoholic liver disease, type 2 diabetes and ischaemic heart disease, and made some recommendations for his ongoing medical management for these conditions. It was planned for Mr Young to have a repeat gastroscopy in the future.25

TRANSFER TO FIONA STANLEY HOSPITAL –JANUARY 2019

28. After his transfer to Casuarina, Mr Young was reviewed by a psychiatrist on 27 December 2018. After a full assessment, he was diagnosed with an adjustment disorder compounded by factors such as frontal lobe impairment, antisocial character and over-reliance on alcohol and cannabis to manage negative effects. He was considered to have a distorted rationale for being in custody, blaming his actions on the Public Trustee for limiting his access to money. He was felt to be mildly depressed, although he did not have a mental illness per se. Mr Young also told the psychiatrists about his alcoholic liver disease and indicated he was fearful he would die in custody. He was prescribed the antidepressant sertraline and quetiapine to reduce his arousal.26

29. On 4 January 2019, Mr Young became noticeably drowsy and unwell. He was seen by the psychiatrist and a medical officer in prison and the psychiatrist had identified the drowsiness was likely related to the quetiapine, as Mr Young’s liver disease was affecting his sensitivity to the drug. Mr Young was transferred to Fiona Stanley Hospital and admitted under a General Physician. It was noted he had a long QT interval and acute confusion/drowsiness with hypotension. His quetiapine was ceased and he was given oral antibiotics for a presumed lower respiratory tract infection. His symptoms resolved and he was transferred back to Casuarina after two days, with a recommendation that any further antipsychotic/sedating medications should be prescribed with caution given Mr Young’s liver disease and QT prolongation.27

30. Mr Young was reviewed by the psychiatrist in prison on 11 January 2019 and it was noted that he appeared cognitively intact and he was more settled and happier. He was not felt to require any more quetiapine, but was left on the sertraline. He was seen again by the psychiatrist on 24 January 2019, and he appeared stable and settled, so no further psychiatric follow up was planned at that stage.28

31. On 3 February 2019 Mr Young saw a nurse and requested his regular injection that he received every two years in the community. It was not clear what he was seeking, so he said he would ask his family for more information. On 24 February 2019, a review was booked with a nurse at Mr Young’s request. However, when the nurse 25 Exhibit 3B, Report of Dr Lloyd Nash to West Kimberley Regional Prison dated 27 July 2018.

26 Exhibit 2, Tab 2.

27 Exhibit 2, Tab 2.

28 Exhibit 2, Tab 2.

[2022] WACOR 4 spoke to him, he stated that the issue was resolved and he did not require nursing intervention.29

32. Mr Young was booked for a doctor’s appointment on 6 March 2019, but he failed to attend. The appointment was rescheduled four more times in March 2019, but did not occur. It is not clear from the medical records why the appointment did not eventuate; but the evidence was that these appointments probably had to be rescheduled for a reason such as doctor availability, rather than Mr Young refusing to attend.30 As a result of these unsuccessful appointments, Mr Young was not seen by a doctor in relation to his general physical health after his hospital admission in early January 2019, although he did see a nurse and a psychiatrist more than once, and his discharge summary and medications were reviewed by a prison doctor. It was later noted in his medical records that he was overdue for several routine checks related to his liver disease at this time.31

TRANSFER TO FIONA STANLEY HOSPITAL – MARCH 2019

33. On the morning of 21 March 2019, Mr Young did not attend for his medication, so a nurse went to check on him in his cell. He was lying in bed and was described as having “yellowish eyes and unsteady on his feet and looking very lethargic,” although he was oriented to time and place and was able to speak in full sentences.

He was urgently reviewed by a doctor and then transferred by ambulance to Fiona Stanley Hospital.32

34. On assessment in the Emergency Department, Mr Young was noted to be very unwell, so he was admitted to the Intensive Care Unit. Dr Rowland added Mr Young to the Terminally Ill Register at Stage 3 as he was unstable and at risk of acute deterioration and his advanced liver disease carried a poor prognosis. The Director of Medical Services at the Department attempted to call Mr Young’s guardian to advise of his admission to hospital, but was unable to get through as it was after-hours.33

35. Mr Young’s guardian was contacted by a staff member from Casuarina Prison on 22 March 2019 and advised that Mr Young was at Fiona Stanley Hospital suffering complete liver failure and he was not expected to survive. Prison staff were attempting to contact his family but some of the numbers were disconnected. The guardian provided alternative telephone numbers for his brother and sister.34

36. On 25 March 2019 the prison health staff were advised that Mr Young remained intubated and had developed liver failure. Dr Rowland rang Dr Robin Wilkinson at Fiona Stanley Hospital the next day and was advised that Mr Young had presented with encephalopathy (which he had experienced before) and hepatorenal syndrome, a new diagnosis, which required dialysis. He had received full treatment but had become more unwell, with altered mental state and multi-organ failure, and was 29 Exhibit 2, Tab 2.

30 T 41.

31 Exhibit 2, Tab 2.

32 Exhibit 1, Tab 48; Exhibit 2, Tab 2.

33 Exhibit 2, Tab 2.

34 Additional Information provided by Counsel from SSO dated 12 January 2022, Annexure 1.

[2022] WACOR 4 currently unrousable due to hepatic encephalopathy. His liver failure was progressing, despite full care, and he was also experiencing renal failure and progressive cardiac failure. Dr Rowland was advised that the clinical team believed Mr Young’s prognosis was poor and they indicated they would like to discuss treatment with Mr Young’s family.35 His family in Balgo were notified, and some indicated they would travel to Perth to be by his bedside.36

37. On the same day, being 26 March 2019, the Superintendent of Casuarina Prison approved the removal of all restraints from Mr Young, due to his serious decline in health and the need for doctors to be able to provide emergency medical treatment at any time. It was noted that Mr Young was essentially comatose at that time and was not likely to significantly improve.37 Mr Young’s guardian was contacted by the Superintendent and told that the hospital wished to discuss making Mr Young palliative. The guardian signed a ‘not for resuscitation’ form and acknowledged he would be transitioned to palliation and there would be no escalation of treatment. It was noted that this decision could be discussed with Mr Young’s family and the guardian assisted doctors with what contact details were available. The guardian indicated that she supported Mr Young’s partner and other family members having an opportunity to be present with him in hospital as treatment was ceased.38

38. On 27 March 2019, the guardian was advised that the hospital’s social worker was attempting to contact Mr Young’s family as a priority, and contact was eventually made with Mr Young’s brother in Balgo, with arrangements made to urgently fly him to Perth.39

39. On 29 March 2019, Mr Young received visits from four family members, including his brother, and he was also visited by the hospital Chaplain. It was estimated that Mr Young had only hours to live. At 1.47 pm all life support was confirmed to have been withdrawn. Mr Young’s brother remained at his bedside. At 3.10 pm nurses identified that Mr Young was no longer showing any activity on the monitor. A doctor attended and, after conducting testing, confirmed Mr Young’s death at 3.47 pm.40

40. WA Police were notified and officers attended and began a coronial investigation into Mr Young’s death.

CAUSE AND MANNER OF DEATH

41. At the request of Mr Young’s family, a full internal post mortem examination was not conducted. An external post mortem examination conducted by Forensic Pathologist Dr Daniel Moss showed marked yellow discolouration of his eyes in keeping with jaundice and a review of his Fiona Stanley Hospital medical records 35 Exhibit 2, Tab 2.

36 Exhibit 1, Tab 49.

37 Exhibit 2, Tab 20 and Tab 33.

38 Exhibit 1, Tab 50; Additional Information provided by Counsel from SSO dated 12 January 2022, Annexure 1.

39 Additional Information provided by Counsel from SSO dated 12 January 2022, Annexure 1.

40 Exhibit 2, Tab 20 and Tab 32.

[2022] WACOR 4 revealed he was diagnosed with multi-organ failure, including liver and renal failure, and he developed aspiration pneumonia, an abnormal heart rhythm, electrolyte disturbance and gastrointestinal haemorrhage. Limited toxicology analysis showed the presence of multiple prescribed-type medications in keeping with the medical care provided.41

42. Testing for hepatitis C virus infection occurred while Mr Young was in prison in January 2016, July 2017 and May 2018. The results were all negative, meaning there was no sign of hepatitis C infection. However, blood tests requested by the forensic pathologist as part of Mr Young’s external post mortem examination detected the hepatitis C antibody, indicating current or past infection.42 It was, therefore, possible that Mr Young acquired hepatitis C while in prison on remand.

43. Based on the limited findings from the external post mortem examination, and his review of other materials, Dr Moss formed the opinion the cause of death was complications of alcohol and hepatitis C-related liver disease.43

44. I accept and adopt Dr Moss’ opinion as to the cause of death. I find that the manner of death was by way of natural causes.

HEPATOLOGY REVIEW

45. Dr Wendy Cheng, is a Specialist Gastroenterologist and Hepatologist and is currently the Head of Liver Service at the Department of Gastroenterology at Royal Perth Hospital and the Head of Department of Gastroenterology at St John of God Hospital Mount Lawley. Dr Cheng had no involvement in Mr Young’s medical care.

Dr Cheng was requested to review Mr Young’s medical care in relation to his liver disease while in prison, and provide an independent expert report to the Court.44

46. Dr Cheng noted that Mr Young had clinical and laboratory evidence of decompensated liver disease documented from 2017. The origin of his severe liver disease was thought to be from alcohol use. Prior to Mr Young’s final admission to hospital in March 2019, he had suffered complications of his cirrhosis in the form of variceal haemorrhage, an overactive spleen and hepatic encephalopathy (loss of brain function due to liver damage). He also had several other co-morbidities, including ischaemic heart disease Type 2 diabetes and chronic pancreatitis.45

47. Dr Cheng noted that without HCV-RNA as evidence of active infection, it is difficult to be sure of the role of hepatitis C in the course of Mr Young’s liver disease, although his positive test after death was suggestive of recent infection. Dr Cheng noted that in some instances, patients with liver disease are stable for years then show rapid liver decompensation. In Mr Young’s case, this could have been a 41 Exhibit 1, Tab 6 and Tab 8.

42 Exhibit 1, Tab 7.

43 Exhibit 1, Tab 6.

44 Exhibit 1, Tab 9.

45 Exhibit 1, Tab 9.

[2022] WACOR 4 response to an acute viral liver infection, such as hepatitis C, but it may have also been a response to hypotension or some other non-specific cause.46

48. Having reviewed the medical care provided to Mr Young by the Department of Justice and Fiona Stanley Hospital, Dr Cheng expressed the opinion that the medical care was appropriate, including screening, monitoring and treatment.47

TREATMENT, SUPERVISION AND CARE

49. Given Mr Young’s apparent allegations about funds being withheld by the Public Trustee, some enquiries were made about the management of his finances. The Public Trustee advised that there were no issues with Mr Young’s payments and no payments were withheld from him prior to, or after, his incarceration. His funds were being budgeted and managed for his benefit. However, there was a concern reported on 1 May 2017 that someone had taken Mr Young’s key card and was accessing his money, so there was a stop put on advancing his funds temporarily until that issue was resolved and he returned to Balgo. It then appears that he took some time to return to Balgo, which may have caused the problems with him accessing money.48

50. After his incarceration, the Public Trustee ensured that money was advanced to Mr Young’s prison account, including money to purchase a phone, television, stereo and fan, as well as other personal items.49

51. The Department conducted its own internal death in custody review to identify whether all the Department’s policies and procedures were followed. The review was unable to identify records of attempts to contact Mr Young’s guardian to advise of his terminally ill status and deteriorating health, it was noted that Mr Young’s registered next-of-kin must have been notified, as some family members were able to make their way to Perth and visit him before he died. To improve adequate recording of next-of-kin notifications, a subsequent Deputy Commissioner’s Broadcast dated 5 May 2021 was issued, instructing staff to always record next-of-kin notifications, whether successful or otherwise.50

52. The Department’s review also found that the Department’s policy to issue a briefing note to the Minister for Corrective Services to advise of Mr Young’s terminal illness status was not followed. Resource and process improvements have been introduced in the Sentence Management Directorate this year to address this issue, in particular a new position was created with that specific responsibility.51

53. The Department’s Health Services team also conducted their own review of Mr Young’s medical care while in custody. The review identified that alcohol was the predominant substance of concern for Mr Young and preventative health 46 Exhibit 1, Tab 9.

47 Exhibit 1, Tab 9.

48 Exhibit 1, Tab 54.

49 Exhibit 1, Tab 54.

50 Exhibit 2, Letter of Dr Tomison to State Coroner, dated 26 October 2021 and DIC Review Report and Tab 51 Exhibit 2, Letter of Dr Tomison to State Coroner, dated 26 October 2021 and DIC Review Report.

[2022] WACOR 4 strategies were implemented, including drug and alcohol counselling and referrals to community services for support when released, although it appears Mr Young did not experience any long-term success with abstinence. Consideration was also given to Mr Young’s chronic disease management, and it was noted that Mr Young was not always compliant with recommended care. It was clear that he understood the seriousness of his liver disease and the risk of future heart attacks, but he did not always accept his medication or attend appointments. However, he did on other occasions submit forms to request medical review, he consented to many investigations and he did not resist being transferred to hospital whenever that was recommended.52

54. The prison health services also had a good amount of information on Mr Young as a result of information provided by hospitals and doctors from time spent in the community. Dr Rowland noted that on his final admission to prison, medical records were provided within days, giving them a good picture of what had occurred in the years since he had last been in custody. This was important, as he had experienced a significant decline in his health, and a noted progression in the severity of his liver disease, in that period.53

55. Overall, the general opinion was that Mr Young received a high standard of medical care for his multiple medical conditions. The main issue arising in Mr Young’s care prior to his death was the lack of cooperation of Mr Young when he was seen and the rescheduling of a number of medical appointments in the month prior to his last admission to hospital. It was noted in the Department’s Health Services Review that it was a “mixture of Mr Young’s refusal to engage during successful appointments and multiple rescheduling required of the doctor review appointments” that led to some frustration of attempts to address his identified care requirements. It was also noted that his records lacked a comprehensive assessment and management plan, which sometimes made it challenging for clinicians to quickly find information. This meant that after Mr Young’s admission to hospital in January 2019, it became more difficult to identify the severity of his liver disease and focus attention upon that, and his risk of sudden deterioration.54

56. The report identified that management of the Casuarina Health Centre waitlist and identification of patients who have been cancelled or rescheduled is problematic, and was especially so during the period Mr Young was at Casuarina in 2018 and 2019. It was acknowledged that the management of cancelled appointments did not provide appropriate safety netting in Mr Young’s case. The issue of waitlist management had been recognised by relevant health managers prior to Mr Young arriving at Casuarina, but multidisciplinary meetings to resolve the bottlenecks in appointments and minimise risk had not been successful. Since that time, changes have been made, including development of detailed business rules to aid correct waitlist management, appointment allocation and management of failed appointments, and bi-monthly meetings between administrative staff and the Director of Nursing for problemsolving and information sharing.55 52 Exhibit 2, Tab 2.

53 T 18 – 19 54 Exhibit 2, Tab 2.

55 Exhibit 2, Tab 2.

[2022] WACOR 4

57. However, the report also acknowledged that another reason for the failure to provide regular monitoring of Mr Young’s health conditions in early 2019 was due to a lack of resources, including a limited number of doctors and clinic hours available, resulting in a focus on acute presentations at the expense of routine care. The lack of staffing resource flows down even to roles of staff education in the functionality of the EcHO medical record that is used for prison health services, which could be used to assist with managing patients’ health care. I note that the Department has indicated that Health Services has submitted business cases for three positions required for clinical and corporate governance, including one for a senior nurse to provide professional development and education, but the business case was not supported.56

58. Nevertheless, within the framework of what resources are currently available, Health Services have identified a gap in awareness and knowledge of the multi-system management of cirrhosis, which has been rectified by the development of a specific cirrhosis care plan for comprehensive annual review, designed and implemented in conjunction with Hepatologists at Fiona Stanley Hospital. Other education has also been provided in relation to documentation and management of results.57

59. Despite these initiatives, the essential problem of waitlist management remains due to the restraints of the available physical and human resources.58

60. The other issue was the fact that Mr Young had contracted hepatitis C at an unknown time, and through an unknown means, after being incarcerated for the last time.

Within the WA prison system, there is a blood borne virus screening on reception into prison. If that is negative, prisoners are given education to seek testing if they engage in risky behaviour, and then if health staff identify a risk factor at a later stage, they will encourage the prisoners to consider screening, or re-screening, for hepatitis C. Dr Rowland explained at the inquest that hepatitis C is a blood-borne virus that is frequently acquired through intravenous drug use. However, it can also be contracted through intimate contact, tattoos and even the use of toothbrushes; anything that can transmit blood from one person to another. There is a very effective treatment now available, with very few side-effects, so if diagnosed, active treatment is usually provided in the prison with good success.59

61. In Mr Young’s case, he tested negative on routine screening when he re-entered prison in May 2018, and there were no red flags at any stage to suggest he ought to be screened again. Dr Rowland explained that many people will not know they have it, as they may get no symptoms or just feel fatigued and a little ‘under the weather’.

The main complication of hepatitis C is cirrhosis, which Mr Young had already been diagnosed with as a result of his alcohol abuse. In cases of acute infection, the person may become jaundiced, amongst other things, which Mr Young was noted to be on the day he was taken to hospital. Therefore, it is possible he had only been recently 56 Exhibit 2, Tab 2.

57 Exhibit 2, Tab 2.

58 Exhibit 2, Tab 2.

59 T 26 - 28.

[2022] WACOR 4 infected. If anything had been identified at an earlier stage to suggest Mr Young had acquired hepatitis C, Dr Rowland was confident he would have been re-screened.60

62. Overall, Dr Rowland expressed the opinion that Mr Young received good overall wraparound care for his health conditions, and it appeared his health significantly improved whilst in custody, where his access to alcohol was limited. His recent perfect score on the cognitive assessment was an example of that.61

63. In terms of consideration for release, given his rapidly declining health, it was confirmed in evidence that Mr Young was not eligible for release on the Royal Prerogative of Mercy (RPOM) as he was a remand prisoner. In order for Mr Young to have been released, he would have needed to be granted bail in the District Court.

In the past, there was a dedicated staff member in the Department’s Sentence Management Unit whose role was to coordinate the Terminally Ill list, which included taking steps in relation to the RPOM or to make contact with a prisoner’s lawyers or family regarding initiating a bail application. This person worked closely with the Department’s senior health staff in that regard. However, the role did not exist at the time of Mr Young’s death, leaving a gap in the processes. I am advised that the position has now been reinstated, and that person is proactive in liaising with health staff to ensure all processes are completed in relation to terminally ill prisoners.62

64. Inquiries made as part of the Department’s review found no paperwork to indicate that any steps were taken by Department staff to alert Mr Young’s family, guardian or lawyer about the possibility of making a bail application, based on his changing health status. Dr Rowland did try to contact the guardian herself, as a courtesy, but did not get through in her first call, and then her plan to follow it up with another call was overlooked due to her busy work schedule.63

65. Dr Rowland observed that in terms of the health care Mr Young was receiving immediately prior to his death in Fiona Stanley Hospital, he was in the only place where he could receive the intensive care and dialysis he required. That type of medical care is not available in the Kimberley, so he could not have received appropriate medical care up near his home, even if he had been released on bail.64

66. I note that Dr Rowland works in her extremely busy role without the support of a professional administrative assistant, to assist her in diarising such appointments and keeping track of her many commitments, which include frequent appearances in court for inquests such as these. It is, therefore, not surprising that there are times when she overlooks some tasks. In my opinion, Dr Rowland provides an impressive service and it is clear she is always proactively considering where areas of improvement could be made to the provision of health services in prison facilities.

However, it is important that she is well supported in performing that role. I hope that with the plans to increase the types of health services that are provided within

60 T 26 – 28, 35.

61 T 30, 43 - 44.

62 T 9 - 13, 31 – 32.

63 T 33 – 36.

64 T 30 - 31.

[2022] WACOR 4 prisons, such as the new facilities planned for Casuarina, more administrative support will be made available to assist Dr Rowland in her important role, both through a professional assistant and also a Deputy Director of Health Services.

67. This inquest also demonstrates the ongoing need for increased health staff to manage prisoners with chronic health issues. Dr Rowland gave evidence that in Mr Young’s case, he would have benefited from seeing a GP at least every three months and had a nurse care plan visit for his combination of chronic health conditions. As noted above, Mr Young had a number of rescheduled appointments prior to his sudden decline in March 2019, which were attributed to resourcing issues.65 As I have noted in another recent inquest finding,66 I hope that when the new health facilities are constructed at Casuarina in the next couple of years, they are appropriately staffed in a way that allows for better ongoing management of these types of prisoners, to provide better preventative health care, rather than simply management of acute health events.

CONCLUSION

68. Mr Young was still a relatively young man when he succumbed to complications of his liver disease. He had been unwell for many years, due to progressively worsening liver disease in particular, and it was known that his life expectancy was shortened as a result. However, it seems likely that he contracted hepatitis C in prison, and may have accelerated his demise, due to the effect of this new infection on his already decompensated liver. I am satisfied that he received medical care of an appropriate standard throughout his final stay in prison.

69. Mr Young’s partner, Ms Charles, never got to see him before his death as he was arrested before she could reunite with him in the Kimberley. Her grief at being unable to see him or care for him in his final days is great. Ms Charles expressed concern about why he was held in custody when he was so gravely ill, noting that as a result he passed away far from his loved ones, family and Country.67

70. I acknowledge Ms Charles’ pain at her partner’s loss has been exacerbated by her inability to be with him as his health worsened and to provide the kind of loving care for him that she felt was appropriate as his long-term partner. I hope that the evidence heard at this inquest has helped Ms Charles to understand a little more of the sudden deterioration of Mr Young’s health, which made it difficult to take action to arrange his possible release from prison, and also to understand that his health needs at that time were so great that realistically he required more care than he would have been able to receive at home, even though that might have been his preference.

71. In the future, I emphasise the importance of the Department taking active steps to notify all family members as quickly as possible when a prisoner’s health suddenly deteriorates, so that they can have as much time as possible to make arrangements to see or contact them, and/or to seek legal advice about the possibility of bail

65 T 41.

66 James Alexander TILBURY [2021] WACOR 47, Paragraphs 29 & 30 67 Letter from Lynne Charles to the Coroner dated 30 September 2021.

[2022] WACOR 4 applications where the person is held on remand. While in Mr Young’s case I accept that it is unlikely that he would have been able to successfully arrange a bail application in the short time available before his death, it is still important that the opportunity is presented to the prisoner.

S H Linton Acting State Coroner 14 January 2022