Inquest into the Death of Alexander Robert EATTS

[2024] WACOR 12 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 20 MARCH 2024 DELIVERED : 28 MARCH 2024 FILE NO/S : CORC 1763 of 2022

DECEASED : EATTS, ALEXANDER ROBERT Catchwords: Nil Legislation: Nil Counsel Appearing: A/Sgt C Robertson assisted the Coroner.

Ms A Nowak (SSO) appeared on behalf of the Department of Justice.

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

[2024] WACOR 12 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Alexander Robert EATTS with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 20 March 2024, find that the identity of the deceased person was Alexander Robert EATTS and that death occurred on 5 July 2022 at St John Of God Midland Public Hospital Midland, 1 Clayton Street, Midland, from complications, including multiorgan failure and pneumonia, of chronic obstructive pulmonary disease, with terminal palliative care, in an elderly man with COVID-19 infection in the following circumstances:

TABLE OF CONTENTS

[2024] WACOR 12 INTRODUCTION

1. Alexander Eatts was a 73 year old man who was serving a prison sentence at Acacia Prison at the time of his death in July 2022. Mr Eatts had a long history of chronic obstructive pulmonary disease and his health had been deteriorating when he was admitted to St John of God Midland Public Hospital on 27 June 2022. He was diagnosed with multiorgan failure, including cardiac, renal and hepatic dysfunction, hyponatremia and urinary retention during his hospital stay, and shortly before his death a possibility of lung infection was raised. In consultation with Mr Eatts, the treating medical team decided to cease active treatment and institute palliative care.

Mr Eatts was kept comfortable until his death on 5 July 2022.

2. As Mr Eatts was a serving prisoner at the time of his death, he came within the definition of a ‘person held in care’ under the Coroners Act 1996 (WA) and a coronial inquest into his death was, therefore, mandatory. I held an inquest on 20 March 2024. I received a significant amount of documentary evidence and heard from two witnesses, Ms Pansey Stewart, who is the Health Services Manager for Serco in relation to Acacia Prison, and Ms Toni Palmer, who is the Senior Review Officer at the Death in Custody Team for the Department of Justice.

3. Following the inquest, I am required to comment on the quality of his treatment, supervision and care while in custody prior to his death.1

BRIEF BACKGROUND

4. Mr Eatts was born in Dalwallinu and grew up with his parents, two brothers and three sisters in that area. As an adult, Mr Eatts married and had four children of his own.

Mr Eatts worked as a mechanic, both as an employee and in his own business. He suffered a number of serious injuries in work and motor vehicle accidents over the years.2

5. On 10 August 2012, Mr Eatts was convicted after trial in the Perth District Court of multiple counts of historical sexual offending. He was sentenced on 19 October 2012 to 16 years’ imprisonment with eligibility for parole. His earliest eligibility date for release on parole was 8 August 2026. The learned sentencing Judge had regard to Mr Eatts’ age at the time of imposing sentence, but considered his age to be of limited significance in mitigation, although it was taken into account in considering the totality of the sentence.3

6. Leave to appeal against his convictions and sentence was refused by the Court of Appeal on 19 July 2013. His age and the fact his health would likely deteriorate in prison were noted, but not considered to be significant mitigating factors in the context of the seriousness of the offending. There was also no evidence to suggest he would not receive appropriate medical care while a prisoner, if required.4 1 Sections 22(1)(a) and 25(3) Coroners Act 1996 (WA).

2 Exhibit 1, Tab 8 and Tab 13.

3 Exhibit 1, Tab 10 and Tab 13.

4 Exhibit 1, Tab 11; ERA v The State of Western Australia [2013] WASCA 163.

[2024] WACOR 12

7. Mr Eatts had previously served a term of imprisonment for other sexual offending, so he was received at Hakea Prison in August 2012 as a returning prisoner. Mr Eatts remained at Hakea Prison for a few months after being sentenced, before being transferred to Acacia Prison on 20 December 2012 in line with his medium security rating and to facilitate visits. Mr Eatts remained a prisoner at Acacia Prison until his death.5

MEDICAL HISTORY

8. Mr Eatts’ medical records that he had been a heavy smoker earlier in his life, although he had eventually given up smoking. He was diagnosed with severe chronic obstructive pulmonary disease (COPD), believed to be associated with his smoking history. He was also diagnosed with congestive cardiac failure, hypertension, abdominal obesity, paroxysmal atrial fibrillation and pre-diabetic mellitus in October

9. He was diagnosed with asthma in August 2017 and pulmonary hypertension secondary to his COPD in January 2021.6

10. Between July 2020 and May 2021, Mr Eatts was reviewed on numerous occasions in relation to his various medical conditions. He received regular cardiac and COPD care plan reviews and ECG’s to monitor his cardiac activity. It was apparent over this time that Mr Eatts’ health was deteriorating, although he was compliant with his medication and tried to follow a healthy lifestyle.7

11. Mr Eatts also saw a dentist regularly between July to December 2020, which included the fitting of dentures.8

12. In May 2021, Mr Eatts was treated at St John of God Midland Public Hospital (SJOGH) for pneumonia. He was discharged back to Acacia on 14 May 2021. By this time, Mr Eatts was generally using a wheelchair to mobilise and was on oxygen supplementation, which had been approved by security after consultation with health staff. He was housed in a unit close to the medical centre to ensure he had easy access to health care, as required.9

13. On 11 June 2021, Mr Eatts was listed as Stage One Terminally Ill (potential of death in custody but unlikely to die within 12 months) due to his severe end-stage COPD and other medical conditions.10

14. Mr Eatts had an annual health assessment with a nurse on 12 August 2021 and it was recorded that had some lumps that required medical review. He was reviewed by a doctor on 20 August 2021 and no further action was planned at that time, although he did have some faecal occult blood tests and skin cancer checks over the following 5 Exhibit 1, Tab 13.

6 Exhibit 1, Tab 13.

7 Exhibit 1, Tab 13.

8 Exhibit 1, Tab 13.

9 T 9; Exhibit 1, Tab 13.

10 Exhibit 1, Tab 13.

[2024] WACOR 12 months. On 14 March 2022, Mr Eatts had a colonoscopy performed and on 30 March 2022 he received some topical chemotherapy treatment for a skin cancer.11

14. On 7 June 2022, Mr Eatts was escalated to Stage Two Terminally Ill (deterioration of a medical condition – likely to die within 12 months but unlikely to die within three months) due to experiencing a reduced ability to mobilise without additional supplemental oxygen. His oxygen saturations were recorded at levels as low as 78% and he required increased medication to manage his heart failure, which had led to significant oedema.12

15. On 26 June 2022, Mr Eatts received a welfare check from a prison nurse. He reported that he felt “shocking” and mentioned that he was unable to pass urine. He was also unable to shower himself by this stage. It was noted that he required a medical review by a medical officer as his health was in decline. The next day he was transferred to SJOGH by ambulance.13

SJOGH

16. Mr Eatts was admitted to SJOGH on 27 June 2022 and remained a patient until his death. On 28 June 2022, Mr Eatts was escalated to Stage Four Terminally Ill (death is imminent). By this time, Mr Eatts was in the end-stage of COPD with heart failure and multi-organ failure (including renal failure) and palliative care options were being discussed.14

17. On 28 June 2022, Acacia Prison staff contacted Mr Eatts’ next of kin to advise he had been admitted to hospital and that family visits had been approved.15

18. Mr Eatts’ condition stabilised a little by 1 July 2022 and he appeared to be responding to active treatment, so his prognosis improved slightly and he was de-escalated to Stage Three Terminally Ill.

19. A consultant physician discussed with Mr Eatts the difficult in balancing his multiple medical issues and that after five days of ‘trial of life’ there had been no improvement in his clinical symptoms. Mr Eatts indicated he did not want any further attempts to cure him. His daughter, who was his next of kin, was also consulted and she agreed that he should receive comfort measures only. Mr Eatts had told his daughter he was ready to go and was at peace with himself.16

20. On 4 July 2022, it was recorded that Mr Eatts had declined any further active treatment. He was noted to be drowsy and lethargic and was sleeping throughout the day. He was not mobile and required full assistance with hygiene. He had a chesty cough and was being given pain relief subcutaneously. A doctor at SJOGH requested 11 Exhibit 1, Tab 13.

12 Exhibit 1, Tab 13.

13 Exhibit 1, Tab 9 and Tab 13.

14 Exhibit 1, Tab 13.

15 Exhibit 1, Tab 13.

16 Exhibit 1, Tab 8 and Tab 12.

[2024] WACOR 12 that Mr Eatts’ restraints be removed at 11.10 am on 4 July 2022 and the request was approved and the restraints were removed by 2.00 pm that same day.17

21. A briefing note was prepared that day to the Minister for Corrective Services in relation to the possible consideration of release on the Royal Prerogative of Mercy for Mr Eatts. Mr Eatts was not recommended for release under this provision.18

22. On 5 July 2022, security officers who were monitoring Mr Eatts noticed that he appeared to have stopped breathing. They notified SJOGH staff. A doctor attended and assessed Mr Eatts and confirmed at 4.57 am that he had died. Given he was still a prisoner at this time, WA Police were notified so they could commence a mandatory coronial investigation.19

CAUSE AND MANNER OF DEATH

23. After reviewing Mr Eatts’ medical records, Forensic Pathologist Dr Daniel Moss performed an external post mortem examination with CT scan on 15 July 2022. The examination showed severe emphysematous change, probably pneumonia, arterial calcification and evidence of medical intervention. There was no evidence of significant recent injury. Mr Eatts was noted to be COVID-19 positive. In view of the evidence available, Dr Moss formed the opinion a reasonable cause of death could be given, without a full internal post mortem examination.20

24. Toxicology analysis showed the presence of multiple prescribed-type medications in keeping with Mr Eatts’ history of palliative medical care.21

25. Dr Moss expressed the opinion the cause of death was complications, including multiorgan failure and pneumonia, of chronic obstructive pulmonary disease, with terminal palliative care, in an elderly man with COVID-19 infection. Dr Moss also expressed the opinion the cause of death was due to natural causes.22

26. I accept and adopt Dr Moss’ opinion as to the cause and manner of death.

TREATMENT, SUPERVISION AND CARE

27. And internal Death in Custody review conducted by the Department of Justice, with the cooperation of Acacia Prison staff, found Mr Eatts’ custodial management, supervision and care was in accordance with the Department’s relevant policies and procedures. Mr Eatts was noted to have always been a polite and respectful prisoner who always complied with directions and participated in work when he was able. He declined to complete any Sex Offender education programs, but had indicated he 17 Exhibit 1, Tab 12 and tab 13.

18 Exhibit 1, Tab 13.

19 Exhibit 1, Tab 13.

20 Exhibit 1, Tab 6.

21 Exhibit 1, Tab 6 and Tab 7.

22 Exhibit 1, Tab 6.

[2024] WACOR 12 might consider doing so when he came closer to his earliest date for release on parole.23

28. A health services review completed by Ms Stewart indicated that on his admission to prison, Mr Eatts’ medical conditions were stable and he was living with his health conditions quite well for the early part of his incarceration. His condition deteriorated in 2019 and from that time he was managed closely by the medical services team at Acacia Prison, with regular external appointments with specialists as required. In January 2021, he was still self-reporting that he was exercising and managing quite well, despite his complex co-morbidities. By May 2021, his health had significantly deteriorated and he began to require the use of a wheelchair. He was also on oxygen therapy.24

29. Mr Eatts’ health then progressively worsened, so that in June 2022, he was considered to be at the end stage of his COPD disease. He was transferred to hospital in late June 2022, and remained there until his death.25

30. Having comprehensively reviewed Mr Eatts’ medical care, Ms Stewart expressed the opinion the care Mr Eatts received was of a high standard, equal to or above what he would be expected to receive in the community. I accept and agree with Ms Stewart’s opinion. It is apparent Mr Eatts was seen regularly by health practitioners as his health deteriorated. I am informed he was housed in a unit next to the medical centre, so he had easy access to health practitioners, he was given oxygen and walking aids as his breathing and mobility decreased, and he was fully vaccinated against COVID-19 and housed with other vulnerable prisoners, in order to try to protect him against the disease during the pandemic.

31. I note that Mr Eatts did test positive for COVID-19 at the time of his death, although it is unclear whether he contracted the disease in prison or in hospital.26 In any event, he was receiving a high level of medical care in hospital prior to his death.

CONCLUSION

32. Mr Eatts was an elderly man who already had significant health conditions when he was imprisoned in 2012. While serving a lengthy prison sentence, he initially remained stable and then slowly deteriorated, as would be expected of a man of his age with his medical history. As his health declined, he received regular and appropriate medical care that was consistent with what he could have expected to receive in the community. However, due to the progressive natural of the illnesses, particularly his lung disease, Mr Eatts’ health progressively deteriorated until June 2022, when he was hospitalised. His prognosis was poor and he was eventually transferred to palliative care on 4 July 2022 at Mr Eatts’ request, and with the approval of his doctors and family. He died peacefully the following day.

23 Exhibit 1, Tab 13.

24 T 5; Exhibit 1, Tab 14.

25 Exhibit 1, Tab 14.

26 T 6 - 7.

[2024] WACOR 12

33. I have reviewed the supervision, treatment and care Mr Eatts received prior to his death, in particular his medical care. I am satisfied he received an appropriate standard of treatment, care and supervision, commensurate with what he would be able to receive in the community.

S H Linton Deputy State Coroner 27 March 2024