Deceased
Ronald Joseph Buckland
Demographics
70y, male
Coroner
Coroner Jenkin
Date of death
2020-07-09
Finding date
2022-08-03
Cause of death
bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidities, with terminal palliative care
AI-generated summary
Ronald Joseph Buckland, aged 70, died in custody at Fiona Stanley Hospital from bronchopneumonia with intra-abdominal carcinoma and multiple comorbidities. A life-sentenced prisoner, he had extensive medical conditions including cardiac disease, liver cirrhosis, and COPD. Key clinical issues included: (1) unauthorised self-administration of oxygen from Oxiboots without medical supervision, which masked deterioration and delayed recognition of acute coronary syndrome; (2) repeated refusals of diagnostic investigations (colonoscopy/gastroscopy) for anaemia, delaying cancer diagnosis; (3) inadequate staff appreciation of risks from unmonitored oxygen use in angina management. The coroner found medical care exceeded community standards and was well-supervised. The prisoner's autonomy in refusing treatment was appropriately respected, and he was competent to make these decisions.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
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Error types
[2022] WACOR 35 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : MICHAEL ANDREW GLIDDON JENKIN HEARD : 28 JULY 2022 DELIVERED : 3 AUGUST 2022 FILE NO/S : CORC 1394 of 2020
DECEASED : BUCKLAND, RONALD JOSEPH Catchwords: Nil Legislation: Coroners Act 1996 (WA) Prisons Act 1981 (WA) Counsel Appearing: Sergeant A. Becker assisted the coroner Mr C. Arnold (State Solicitor’s Office) appeared on behalf of the Department of Justice
[2022] WACOR 35 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Michael Andrew Gliddon Jenkin, Coroner, having investigated the death of Ronald Joseph BUCKLAND with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, PERTH, on 28 July 2022, find that the identity of the deceased person was Ronald Joseph BUCKLAND and that death occurred on 9 July 2020 at Fiona Stanley Hospital, from bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidities, with terminal palliative care in the following circumstances: Table of Contents
Accordingly, immediately before his death, Mr Buckland was a “person held in care” within the meaning of the Coroners Act 1996 (WA) and his death was a “reportable death”.1,2,3,4,5
In such circumstances, a coronial inquest is mandatory.6 Where, as here, the death is of a person held in care, I am required to comment on the quality of the supervision, treatment and care that the person received whilst in that care.7 Accordingly, I held an inquest into Mr Buckland’s death on 28 July 2022.
The documentary evidence adduced at the inquest included investigation reports death prepared by the Western Australia Police Force8 and DOJ9 respectively, which together comprised two volumes.
The following DOJ employees gave oral evidence at the inquest: a. Dr Joy Rowland, Medical Director;10 and b. Ms Toni Palmer, Senior Review Officer (and the author of the Death in Custody Review).11
The inquest focused on the care provided to Mr Buckland while he was in custody, as well as on the circumstances of his death.
1 Exhibit 1, Vol 1, Tab 1, P100 - Report of Death (09.07.20) 2 Exhibit 1, Vol 1, Tab 4, P92 - Identification of deceased person other than by visual means (10.07.20) 3 Exhibit 1, Vol 1, Tab 6, Supplementary Post Mortem Report (25.09.20) 4 Section 16, Prisons Act 1981 (WA) 5 Sections 3 & 22(1)(a), Coroners Act 1996 (WA) 6 Section 22(1)(a), Coroners Act 1996 (WA) 7 Section 25(3) Coroners Act 1996 (WA) 8 Exhibit 1, Vol 1, Tab 2, Report - Sen. Const. J Robinson (26.11.20) 9 Exhibit 1, Vol 2, Tab 19, Death in Custody Review (15.06.22) 10 ts 28.07.22 (Rowland), pp4-25 11 ts 28.07.22 (Palmer), pp27-32
[2022] WACOR 35 MR BUCKLAND Background12,13,14
Mr Buckland was born in Collie on 3 December 1949 and was 70-years of age when he died on 9 July 2020. He had two siblings, one of whom died in early childhood.15,16
When Mr Buckland was about four years of age he was sent to an orphanage, as his mother had reportedly left home when he was a baby and his father was unable to continue to care for the family due to illhealth. DOJ records indicate that Mr Buckland returned to his father’s care when he was about 12-years of age, and left home to work on a dairy farm when he was 13-years old.
Mr Buckland subsequently completed a trade certificate as a boiler attendant and later a plumbing trade certificate. He was employed in the plumbing industry for about five years and had also worked as a roof carpenter. Mr Buckland had a daughter from a previous relationship, and she visited him in prison from 2002 until 2014, when she moved interstate. They kept in touch thereafter by letters and phone calls.
Offending history17,18,19
Mr Buckland’s extensive criminal history began when he was about 12-years of age. As an adult, he accumulated a total of 59 convictions in New Zealand, New South Wales and Western Australia, for offences including assault, stealing, burglary, armed robbery escaping lawful custody and fraud.
Mr Buckland received numerous periods of imprisonment including a seven-year term in 1971 for armed robbery and a six-year term in 1982 in relation to 14 counts of breaking and entering.
12 Exhibit 1, Vol 1, Tab 18, Sentencing remakes, Pidgeon J, (01.03.95), pp1566-1567 13 Exhibit 1, Vol 1, Tab 9, Statement - Mr Buckland’s daughter, Ms Z (unsigned), paras 2-12 14 Exhibit 1, Vol 2, Tab 19, Death in Custody Review (15.06.22), p8 15 Exhibit 1, Vol 1, Tab 1, P100 - Report of Death 16 Exhibit 1, Vol 1, Tab 5, Death in Hospital form - Fiona Stanley Hospital 17 Exhibit 1, Vol 1, Tab 16, Criminal history - Western Australia, New Zealand & New South Wales 18 Exhibit 1, Vol 2, Tab 19, Death in Custody Review (15.06.22), pp8-9 19 Exhibit 1, Vol 2, Tab 19.5, Sentence Summary - Offender
On 1 March 1995, in the Supreme Court of Western Australia at Perth (Supreme Court), Mr Buckland was convicted of the wilful murder of his partner. He was sentenced to strict security life imprisonment and ordered to serve a minimum of 20-years imprisonment before being considered for parole.20
On 27 March 2001, the then State Coroner published his finding following an inquest into the death of Ms Radina Marie Djukich.
Ms Djukich was a 14-year old girl who had been living with Mr Buckland as his daughter. Ms Djukich went missing on or about 15 May 1992 and the then State Coroner was satisfied: “Mr Buckland must have been involved in the death of Radina or the disposal of her body”, but found the available evidence was insufficient for him to conclude that Mr Buckland had caused Ms Djukich’s death.21
Mr Buckland’s trial on that charge was due to start in the Supreme Court on 7 December 2020, but he died before the trial could be held.22,23,24 Prison history25,26,27,28
Assessments conducted in November 2001 found Mr Buckland would benefit from numeracy and literacy courses and recommended he attend a cognitive reasoning course. Mr Buckland was also assessed as suitable to attend an intensive violent offender program, but said he preferred to undertake the course closer to the time of his eventual release.29,30,31
Between 2001 and 2017, Mr Buckland underwent 24 classification reviews to determine his security rating and placement. His security rating fluctuated between maximum and medium depending on his behaviour in prison, and Mr Buckland was noted to be an active member of the Casuarina peer support team.32,33
Between October 2014 and March 2016, Mr Buckland was considered for parole several times, but on each occasion the recommendation was that parole be denied. The bases for this recommendation were Mr Buckland’s high risk of re-offending based on his extensive criminal record; his poor performance on previous supervision orders; and his lack of a viable parole plan.34,35,36
On 7 June 2017, Mr Buckland was recommended for a re-socialisation program at a medium security prison, and was transferred to Bunbury Regional Prison (Bunbury) on 5 September 2017 for that purpose. On 26 April 2018, it was recommended that Mr Buckland undergo an 18-month re-socialisation program involving a transfer to Karnet Prison Farm, followed by a gradual transition into the community.37,38,39
On 1 June 2018, the Prisoner Review Board determined that a report should be prepared for the Attorney General recommending that the Governor be advised to approve Mr Buckland’s 18-month resocialisation plan. However, the plan was not progressed because of Mr Buckland’s deteriorating health.40 29 Exhibit 1, Vol 2, Tab 19.1, Treatment - Violent offending checklist 30 Exhibit 1, Vol 2, Tab 19.9, Education and vocational training checklist 31 Exhibit 1, Vol 2, Tab 19.10, Cognitive skills - Initial assessment 32 Exhibit 1, Vol 2, Tab 19.11, Individual management plans (Various dates: 2002 - 2020) 33 For example, see: Exhibit 1, Vol 2, Tab 19.15, Classification Review (24.04.2013) 34 Exhibit 1, Vol 2, Tab 19.20, Parole review - ExCo approval report (2014 - 2017) 35 Exhibit 1, Vol 2, Tab 19.4, Escape, abscond or attempted escape - Offender (1979 - 1982) 36 Exhibit 1, Vol 2, Tab 19.7, Warrant for apprehension & Notice of cancellation of parole 37 Exhibit 1, Vol 2, Tab 19.6, Parole review - ExCo approval report (07.06.17) 38 Exhibit 1, Vol 2, Tab 19.25, Re-socialisation programme (26.04.18) 39 Exhibit 1, Vol 2, Tab 19.26, Orientation checklist (22.04.18) 40 Exhibit 1, Vol 2, Tab 19.29, Individual management plan (30.07.18)
Between 1992 and 2020, Mr Buckland was convicted of 22 serious prison offences including failing to supply a sample for drug analysis, inappropriate use of prescription drugs and possession and use of illicit substances. During the same period, Mr Buckland was convicted of six minor prison offences relating to insubordination and use of insulting language.41,42
Mr Buckland tested positive to cannabis and opioid medications on several occasions during his incarceration, and was the subject of five alerts on the Total Offender Management System (TOMS), the computer system DOJ uses to manage prisoners. The alerts included an advice that he was not to share a cell, and alerts that he was a risk to/from another prisoner.43,44
Between 1993 and 2014, Mr Buckland received visits from family members and an outreach service. His last recorded social visit was from his daughter and occurred on 24 August 2014. Between 1993 and 2020, Mr Buckland sent 168 letters, mainly to his family and between April 2018 and 2020, he regularly made phone calls, mostly to his daughter.
Mr Buckland variously worked as a cleaner, a gardener and as a peer support prisoner in the Casuarina infirmary.45,46,47,48 Management on ARMS
On 3 March 2010, Mr Buckland was diagnosed with a depressive disorder and started on antidepressant medication. He was placed on ARMS on 29 March 2010 when he displayed poor appetite and depressive symptoms, but was removed on 14 April 2010 when it was determined he was no longer at risk. Mr Buckland was also managed on ARMS briefly in August 2014 due to a deterioration in his health and his general demeanour.50,51
On 21 January 2015, Mr Buckland began a “hunger strike” in response to being told he was to be transferred to Acacia Prison for operational reasons. He was placed on ARMS, but discontinued his hunger strike voluntarily on 27 January 2015, and was removed from ARMS on 26 February 2015.52
Mr Buckland was placed on ARMS again on 6 March 2019 after being charged with manslaughter. He denied self-harm or suicidal ideation and said he had been expecting the manslaughter charge. He was removed from ARMS on 13 March 2019 and placed on the Support and Management System (SAMS) for ongoing monitoring. Mr Buckland remained on SAMS until 7 June 2019 by which time he was well settled in his unit and receiving support from his peers.53,54 Management on the terminally ill register
At the time of Mr Buckland’s death, prisoners with a terminal illness were managed in accordance with a DOJ policy known as “Policy Directive 8 Prisoners with a Terminal Medical Condition” (PD8).55,56 PD8 defined “terminal illness” in these terms: 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.57 50 Exhibit 1, Vol 2, Tab 19.13, PRAG Minutes (08.04.10) 51 Exhibit 1, Vol 2, Tab 19.17, PRAG Minutes (18.08.14 & 25.08.14) 52 Exhibit 1, Vol 2, Tab 19.19, EcHO medical records (27.01.15) 53 Exhibit 1, Vol 2, Tab 19.30, PRAG Minutes (06.03.19 & 13.03.19) 54 Exhibit 1, Vol 2, Tab 19.14, SAMS Notes (07.06.19) 55 From 28.06.21, prisoners with a terminal illness are managed under COPP 6.2 Prisoners with a Terminal Medical Condition 56 See: Ex 3.3 - COPP 6.2 Prisoners with a Terminal Medical Condition (2021) 57 Exhibit 3.1, Policy Directive 8 Prisoners with a Terminal Medical Condition, p2 (para 4)
In accordance with PD8, once a prisoner is identified as having a terminal medical condition, a note is made in the terminally ill module of TOMS for that prisoner. Under PD8, prisoners were categorised as Stage 1 - 4, depending on their expected prognosis.58
Mr Buckland was identified as a Stage 3 prisoner in the terminally ill module of TOMS on 28 June 2018, meaning that his death was expected within three months. His status was reviewed on 20 April 2020 and he was maintained at Stage 3, but on 8 May 2020 Mr Buckland was elevated to Stage 4 following a deterioration in his health.59,60,61,62
There are two main implications for a prisoner being identified as terminally ill. The first relates to the monitoring terminally ill prisoners receive, although all prisoners with serious health conditions are subject to regular reviews regardless of whether they are on the terminally ill list or not. The other implication is that sentenced prisoners who are Stage 3 and Stage 4, may be considered for early release by the exercise of the Royal Prerogative of Mercy (RPOM).63
Contrary to the provisions of PD8, a briefing note in relation to the RPOM was not sent to the Minister for Corrective Services (the Minister) when Mr Buckland was identified as a Stage 3 terminally ill prisoner. This occurred because the job of the person responsible for drafting such briefing notes had been abolished in about 2017.
However, a briefing note dealing with release pursuant to the RPOM was prepared when Mr Buckland was designated a Stage 4 terminally ill prisoner. By that time, the position responsible for drafting such briefings had been reinstated. In this case, the Director Sentence Management did not recommend Mr Buckland’s release, a decision that was subsequently endorsed by the CEO and the Minister.64,65 58 Exhibit 3.2, Prisoners with a Terminal Medical Condition - Procedures, pp2-6 (section 4) 59 Exhibit 1, Vol 2, Tab 19.27, Terminally ill health advice (28.06.18) 60 Exhibit 1, Vol 2, Tab 19.37, Terminally ill health advice (20.04.20) 61 Exhibit 1, Vol 2, Tab 19.38, EcHO medical records (08.05.20) 62 See also: Exhibit 1, Vol 2, Tab 19.39, Terminally ill health advice (15.06.20) 63 Exhibit 3.2, Prisoners with a Terminal Medical Condition - Procedures, pp6-9 (sections 5 & 6) 64 Exhibit 1, Vol 2, Tab 19.28, Email from Prisoners Review Board Delegate to Mr T Perrin (31.05.22) 65 ts 28.07.22 (Rowland), pp15-16 and ts 28.07.22 (Palmer), pp27-31
[2022] WACOR 35 Overview of medical conditions66
Mr Buckland had coronary artery bypass grafts in March 2018 and a coronary angiogram in June 2018.
Mr Buckland was a life-longer smoker of tobacco cigarettes and despite consistent advice that he should give up, he declined to do so. Whilst in the community, Mr Buckland reported daily intravenous use of methylamphetamine and in custody, he tested positive on several occasions for cannabinoids (indicating cannabis use), benzodiazepines, the opioid pain medication buprenorphine (Suboxone) and methylamphetamine. As a result of his intravenous drug use, Mr Buckland contracted hepatitis C and was treated in hospital for cellulitis.67 Medical management during incarceration68,69,70,71
Although Mr Buckland was regularly reviewed in the prison medical centre, he routinely declined recommended diagnostic tests and/or referrals to specialist medical practitioners. After Mr Buckland’s death, the Department conducted a review of the health services provided to him during his incarceration (the Review). The Review concluded Mr Buckland received comprehensive care whilst incarcerated and “excellent care” after being diagnosed with abdominal cancer. In relation to Mr Buckland’s treatment decisions, the Review noted: Although his care was affected by his refusal of treatment of several serious medical conditions, he was given every opportunity to change his mind and in fact did accept treatment for his final diagnosis of gastric cancer. However, at all times his autonomy and wishes were respected with regards to his management.72 66 Exhibit 1, Vol 2, Tab 20, Health Services Summary (25.07.22) 67 Exhibit 1, Vol 2, Tab 19.45, Substance use tests results (1993 - 2020) 68 Exhibit 1, Vol 2, Tab 19.12, EcHO medical records (2006-2009) 69 Exhibit 1, Vol 2, Tab 19.31, EcHO medical records (2009-2020) 70 Exhibit 1, Vol 2, Tab 20, Health Services Summary (25.07.22), pp3-4 & 23-25 and ts 28.07.22 (Rowland), pp5-15 71 Exhibit 1, Vol 2, Tab 19, Death in Custody Review (15.06.22), pp10-21 72 Exhibit 1, Vol 2, Tab 20, Health Services Summary (25.07.22), p25
Mr Buckland underwent cardiovascular assessments in 2010, 2011 and 2012 and was referred to a cardiologist in 2013, 2014 and 2017. There are several documented instances of Mr Buckland collapsing and being taken to hospital in relation to cardiac events. For example, he collapsed following a heart attack on 13 March 2018 and after being resuscitation, was taken to Bunbury Hospital (BH) and then FSH. Mr Buckland was discharged from FSH on 4 April 2018 and transferred to Casuarina.73,74
After being medically cleared, Mr Buckland was transferred back to Bunbury on 29 May 2018, but he experienced a further heart attack on 25 June 2018 and was taken to BH for treatment. Due to his deteriorating health, Mr Buckland was transferred to Casuarina on 30 July 2018 and placed in the prison infirmary. He remained there until death, apart than a brief admission to the Bethesda Hospice (Bethesda).
In 2019 and 2020, Mr Buckland was taken to the prison medical centre (and on occasion to hospital) several times after complaining of chest pain, shortness of breath and/or swelling in the legs.75,76,77,78 His cardiac care plan was updated on 13 March 2020, and Mr Buckland selfmanaged multiple episodes of angina.79 Although this commonly occurs in the general community, Mr Buckland was reportedly able to access oxygen from an Oxiboot80 on a number occasions.
Health staff who were made aware of Mr Buckland’s unauthorised use of oxygen do not appear to have appreciated the risks involved in his doing so. This is especially concerning given that the current treatment for angina does not involve oxygen therapy. Quite apart from the potential damage to Mr Buckland’s cardiac and lung vasculature, there is a further reason why his unmonitored use of oxygen was problematic.81 73 Exhibit 1, Vol 2, Tabs 19.21, 19.22 & 19.24, Incident description reports (13.03.18, 14.03.18 & 28.03.18) 74 Exhibit 1, Vol 2, Tab 19.23, EcHO medical records (15.03.18) 75 Exhibit 1, Vol 2, Tab 19.32, Incident description report (07.09.19) 76 Exhibit 1, Vol 2, Tab 19.34, Incident description report (02.11.19) 77 Exhibit 1, Vol 2, Tab 19.35, EcHO medical records - Cardiovascular plan (13.03.20) 78 Exhibit 1, Vol 2, Tab 19.36, Incident description report (22.03.20) 79 Angina is a type of chest pain caused by reduced blood flow to the heart 80 An Oxiboot is an oxygen resuscitator that can provide supplemental oxygen to a patient 81 ts 28.07.22 (Rowland), pp5-11 & 18
From 4 August 2019 onwards, Mr Buckland experienced increasingly more frequent and severe episodes of chest pain. Although this is indicative of acute coronary syndrome, this appears to have been overlooked by health professionals on several occasions, and as the Review observes: [Mr Buckland’s] access to self-administer oxygen, unprescribed and unmonitored, contributed to this failure because it was therefore less visible to health staff, and contributed to a delay in seeking help in September 2019. This included a significant episode of pain and shortness of breath on the 1st September 2019 when he was accessing oxygen on the unit but refused additional care of any type; and then on 7th September 2019 he had chest pain in the gym, but stayed in the gym using GTN (glyceryl trinitrate, a medication used to treat angina) and oxygen, before he collapsed with a VF arrest, from which he was successfully resuscitated.82
On 25 March 2020, Mr Buckland was reviewed by a prison medical officer and found to have a large circular mass in his abdomen. He initially declined to have the mass investigated, but on 30 March 2020, he experienced severe pain and was transferred to FSH, where a CT scan confirmed an abdominal mass involving his stomach, colon and liver.83,84
Mr Buckland was discharged back to Casuarina on 1 April 2020, but returned to FSH on 5 April 2020 for a gastroscopy and further tests. He was subsequently diagnosed with poorly differentiated adenocarcinoma of the upper aero-digestive tract (i.e.: the combined organs and tissues of the respiratory tract and the upper part of the digestive tract).85,86,87
Mr Buckland was returned to Casuarina on 8 April 2020, and although he was readmitted to FSH on 21 April 2020 for management of symptoms, he was returned to Casuarina the same day.88 82 Exhibit 1, Vol 2, Tab 20, Health Services Summary (25.07.22), p24 83 Exhibit 1, Vol 1, Tab 13E, FSH Discharge summary (01.04.20) 84 Exhibit 1, Vol 1, Tab 13C, Letter - Dr G Ooi (21.04.20) 85 Exhibit 1, Vol 1, Tab 13B, FSH Discharge summary (08.04.20) 86 Exhibit 1, Vol 1, Tab 13A, FSH Gastroenterology procedure report (07.04.20) 87 Exhibit 1, Vol 1, Tab 13C, Letter - Dr G Ooi (21.04.20) 88 Exhibit 1, Vol 1, Tab 13D, FSH Discharge summary (21.04.20)
Mr Buckland remained at Casuarina until 21 May 2020, when he was admitted to Bethesda. Whilst at Bethesda, Mr Buckland became increasingly upset at not being allowed to smoke and the fact he was obliged to wear shackles. He threated physical and verbal abuse if he was not returned to Casuarina, and he was transferred back to the infirmary there on 2 June 2020.
Between 3 - 6 June 2020, Mr Buckland presented to FSH on four occasions complaining of chest pain. He was last admitted on 6 June 2020, his discharge plan dated 8 June 2020 requested that he not be returned to FSH, because he was already on maximal cardiac therapy.
According to the Review, opportunities to diagnose Mr Buckland’s abdominal mass at an earlier stage were thwarted by his repeated refusals (throughout 2019) to undergo colonoscopies and/or gastroscopies to investigate his persistent anaemia. Mr Buckland’s refusal to undergo these procedures was documented by a geriatrician at FSH, who confirmed that Mr Buckland was competent to make these decisions.89
The Review makes the following comment about Mr Buckland’s care, once his abdominal cancer had been detected: Following the first hospital admission and investigation he received excellent multidisciplinary care across primary and multiple specialist services, including early connection with palliative care services and frequent opportunities for collaborative decision making. He did surprisingly well and was able to return to Casuarina Prison; and even returned to work for a very brief period, prior to his sudden and rapid deterioration and death.90
Following Mr Buckland’s death, the unsupervised use of Oxiboots by prisoners was clarified by way of a Deputy Commissioner’s Broadcast dated 29 July 2021. That document clarified that although Oxiboots were not to be removed from prisoner living units, they were only to be used by: “Clinical staff, or staff who have completed Provide Advanced Resuscitation Techniques training.91 89 ts 28.07.22 (Rowland), pp11-12 90 Exhibit 1, Vol 2, Tab 20, Health Services Summary (25.07.22), p24 and ts 28.07.22 (Rowland), p12 91 Exhibit 1, Vol 2, Tab 21, Deputy Commissioner’s Broadcast (29.07.21) and ts 28.07.22 (Rowland), pp10 & 18
At about 8.50 pm on 8 July 2020, Mr Buckland was in a shared cell in the Casuarina infirmary. After using the toilet, he made a cell call and a prison officer and a nurse attended. Mr Buckland told them he had passed blood in his stool and he complained of severe abdominal pain.
Mr Buckland was escorted to a treatment room in the infirmary for further assessment, where his condition declined. At 10.03 pm emergency services were called and Mr Buckland was taken to FSH by ambulance.97
At 5.07 am on 9 July 2020, Mr Buckland participated in a discussion with his treating team about his ceilings of care. During that discussion, Mr Buckland indicated he did not wish to be resuscitated in the event of an arrest. At about 5.20 am, Mr Buckland’s ongoing supervision was handed over to Broadspectrum, a departmental contractor that provides custodial officers who supervise prisoners in hospital.98,99
At 11.07 am, a nurse was conducting routine observations, when dark coloured liquid was noticed coming out of Mr Buckland’s mouth. A medical emergency call was initiated and two doctors attended.100,101,102,103,104
Mr Buckland was unresponsive and was pronounced deceased at 11.14 am. Resuscitation was not attempted in accordance with Mr Buckland’s wishes.105,106,107,108 92 Exhibit 1, Vol 2, Tab 19.43, Death in custody package related to admission to FSH (08-09.07.20) 93 Exhibit 1, Vol 2, Tab 19, Death in Custody Review (15.06.22), pp21-22 94 Exhibit 1, Vol 1, Tab 8, Statement - Prisoner MM, Mr Buckland’s cellmate on 08.07.20 (09.07.20), paras 3-26 95 Exhibit 1, Vol 1, Tab 15A, Broadspectrum PIC escort record (09.07.90) 96 Exhibit 1, Vol 1, Tab 15B, Offender movement information (08.07.90) 97 Exhibit 1, Vol 1, Tab 14, St John Ambulance patient care record (08.07.20) 98 Exhibit 1, Vol 1, Tab 12B, FSH Progress notes (09.07.20) 99 Exhibit 1, Vol 1, Tab 12D, DOJ Patient transfer emergency department (08.07.20) 100 Exhibit 1, Vol 1, Tab 12A, FSH Discharge summary (09.07.20) 101 Exhibit 1, Vol 1, Tab 12B, FSH Progress notes (09.07.20) 102 Exhibit 1, Vol 1, Tab 12C, FSH Emergency registration record (08.07.20) 103 Exhibit 1, Vol 1, Tab 12D, DOJ Patient transfer emergency department (08.07.20) 104 Exhibit 1, Vol 1, Tab 12F, FSH Goals of care record (5.07 am, 09.07.20) 105 Exhibit 1, Vol 1, Tab 1, P100 - Report of Death (09.07.20) 106 Exhibit 1, Vol 1, Tab 5, Death in Hospital form - Fiona Stanley Hospital 107 Exhibit 1, Vol 1, Tab 12B, FSH Progress notes (09.07.20) 108 Exhibit 1, Vol 1, Tab 12F, FSH Goals of care record (5.07 am, 09.07.20)
Two forensic pathologists (Dr Cooke and Dr Ong) conducted a post mortem examination of Mr Buckland’s body on 17 July 2020. A large mass was noted towards the centre of Mr Buckland’s abdomen involving his large intestine, stomach, gallbladder, duodenum, pancreas and liver.
Mr Buckland’s lungs were congested, raising the possibility of early pneumonia and there was hardening and thickening of the arteries supplying Mr Buckland’s heart (coronary artery arteriosclerosis).
Previous heart surgery was noted, including a stent and coronary artery bypass grafts.
Toxicological analysis found a number of medications in Mr Buckland’s system that were consistent with his hospital care. Alcohol and common drugs were not detected.111 Following their post mortem examination on 17 July 2020, Dr Cooke and Dr Ong expressed the opinion that the cause of death was “undetermined pending further investigations”.
Subsequent microscopic examination of tissues confirmed coronary artery arteriosclerosis and acute infective changes in the lungs (bronchopneumonia), along with areas of aspirated foreign material.
After reviewing the results of these further examinations, Dr Cooke and Dr Ong expressed the opinion that the cause of Mr Buckland’s death was: [B]ronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidities, with terminal palliative care.112
I accept and adopt the conclusion of Dr Cooke and Dr Ong as to the cause of Mr Buckland’s death and further, I find that death occurred by way of natural causes.
109 Exhibit 1, Vol 1, Tab 6, Post Mortem Report (17.07.20) 110 Exhibit 1, Vol 1, Tab 6, Supplementary Post Mortem Report (25.09.20) 111 Exhibit 1, Vol 1, Tab 7, ChemCentre Report (28.08.20) 112 Exhibit 1, Vol 1, Tab 6, Supplementary Post Mortem Report (25.09.20)
On the basis of the evidence before me, I am satisfied that Mr Buckland was appropriately managed whilst he was incarcerated, and that his supervision was of a good standard.
Mr Buckland was placed on ARMS and SAMS on several occasions and was entered into the terminally ill prisoner register on TOMS when his medical condition warranted it. Although Mr Buckland’s early release under the RPOM was not considered when he was made a Stage 3 terminally ill prisoner, this did occur (and was refused) when he was elevated to Stage 4.
Mr Buckland regularly attended the prison medical centre, but the management of his medical conditions was hampered by his persistent refusals to undergo recommended diagnostic tests and/or accept referrals to specialist medical practitioners.
Mr Buckland was obviously entitled to make such decisions and was assessed as competent to do so. However, Mr Buckland is also responsible for the consequences of his treatment decisions, including the late diagnosis of his abdominal cancer.
Having regard to all of the available evidence, I find the medical care and treatment that Mr Buckland received whilst he was in custody was of a very good standard and exceeded general community standards.
MAG Jenkin Coroner 3 August 2022
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