Inquest into the Death of Karl Frederick Dominic HOLMES

[2024] WACOR 15 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 27 MARCH 2024 DELIVERED : 4 APRIL 2024 FILE NO/S : CORC 121 of 2023

DECEASED : HOLMES, KARL FREDERICK DOMINIC Catchwords: Nil Legislation: Nil Counsel Appearing: A/Sgt C Robertson assisted the Coroner.

Ms H Cowie (SSO) appeared on behalf of the Department of Corrective Services.

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

[2024] WACOR 15 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Karl Frederick Dominic HOLMES with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 27 March 2024, find that the identity of the deceased person was Karl Frederick Dominic HOLMES and that death occurred on 14 January 2023 at Fiona Stanley Hospital, from complications of metastatic lung adenocarcinoma, with terminal palliative care, in a man with multiple medical comorbidities in the following circumstances:

TABLE OF CONTENTS

[2024] WACOR 15 INTRODUCTION

1. Karl Frederick Dominic Holmes was a serving prisoner at Casuarina Prison in January 2023. Mr Holmes had been diagnosed with Stage 4 metastatic lung and liver cancer and was known to be approaching the end of his life. On 13 January 2023, Mr Holmes’ condition deteriorated suddenly, so a decision was made to transfer him by ambulance from prison to Fiona Stanley Hospital for likely admission into palliative care.

2. Mr Holmes was admitted to the Acute Care Ward of Fiona Stanley Hospital in the early hours of 14 January 2023. His health continued to deteriorate and following discussions between medical staff and his family about his poor prognosis, palliative care was commenced. Mr Holmes died a few hours later, at 5.19 am on the morning of 14 January 2023.

3. As Mr Holmes 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 27 March 2024 and I am now required to comment on the quality of his treatment, supervision and care while in custody prior to his death.1

BRIEF BACKGROUND

4. Mr Holmes had been in three long term relationships and had two daughters. He was married at the time of his death.

5. Mr Holmes had a traumatic childhood as a result of the alcoholism of both his parents and abuse he suffered at the hands of various persons. He had little schooling and worked in manual employment as an adult until he suffered a back injury in the 1990’s, which rendered him unfit for manual work. He thereafter received a disability support pension.

6. In February 2022, Mr Holmes was convicted of a number of sexual offences involving children after a trial before a jury. He was sentenced on 1 June 2022 in the Busselton District Court to a total of 7 years’ imprisonment.2

7. At the time of sentencing, it was acknowledged that Mr Holmes had a number of significant health issues on a background of a long history of cigarette smoking, daily cannabis use and heavy alcohol use. He had been diagnosed with chronic obstructive pulmonary disease secondary to smoking, arthritis and chronic hip and knee pain. Further, a doctor had confirmed that Mr Holmes had been diagnosed with early stage lung cancer, that was potentially curable by radiotherapy, and multifocal carcinoma of the liver arising from hepatic cirrhosis, for which he had previously undergone partial liver excision, and it was thought it might not be curable. He had some mobility issues, but could still walk with assistance. In addition to his physical 1 Sections 22(1)(a) and 25(3) Coroners Act 1996 (WA).

2 Exhibit 1, Tab 9.

[2024] WACOR 15 issues, Mr Holmes had a documented history of mental health issues and had received psychiatric treatment at Graylands Hospital in the past.3

8. The learned sentencing Judge took into account Mr Holmes’ ill health in imposing sentence, acknowledging that his illness would make his service of his time in custody more onerous than for an ordinary prisoner in good health. However, it was not suggested that Mr Holmes would be unable to receive appropriate medical care while in prison.4

9. The total effective sentence of seven years’ imprisonment was backdated to commence on 9 February 2022, and he was made eligible for parole, so Mr Holmes’ earliest eligibility for release was 8 February 2027.5

ADMISSION TO CUSTODY

10. After being convicted, Mr Holmes was remanded in custody at Bunbury Regional Prison pending sentence. Upon reception on 10 February 2022, he was identified as a returning prisoner, as he had spent time in custody prior to his trial. Mr Holmes was noted to appear old and frail and was using a walking stick on admission. His medical history was already well documented in the Department’s ‘Echo’ medical notes and Mr Holmes advised the reception officers that he had no immediate acute medical issues at that time.6

11. Mr Holmes underwent a nurse admission the next day. His significant past medical history in the ‘Echo’ notes was identified and an urgent request was made for his community GP’s medical records that afternoon to ensure that information about his more recent medical care in the community and usual prescriptions were obtained.

The nurse identified Mr Holmes still had a few MS Contin tablets that had been dispensed to him while he was still out in the community, and he appeared to be in great discomfort at the time of the assessmen. Mr Holmes had not had any analgesia for four days, so the nurse contacted a prison medical officer and received permission for Mr Holmes to take the tablets until he was medically reviewed. A full health screen was then performed.7

12. A prison medical officer reviewed Mr Holmes in person three days’ later, on 14 February 2022. He appeared to be in pain, with limited mobility, so he was prescribed more analgesia to manage his ongoing pain as well as having a number of investigations ordered. Instructions were also given to ensure Mr Holmes was housed in a bottom bunk and in a prison unit in close proximity to the medical centre, so he could access nursing and medical care more easily when required.8 3 Exhibit 1, Tab 9.

4 Exhibit 1, Tab 9.

5 Exhibit 1, Tab 9 and Tab 15.2, p. 4.

6 Exhibit 1, Tab 15.2.

7 Exhibit 1, Tab 14.

8 Exhibit 1, Tab 14.

[2024] WACOR 15

13. He was seen again by the same doctor the next day as he was feeling worse than the day before and was barely able to stand due to his back pain and radiculopathy. It was thought he was likely withdrawing from his MS Contin as it had not been made available to him, despite prescriptions being given. He was given some diazepam to manage his withdrawals and some slow release morphine, as well as an increase in his other pain medication, until his MS Contin became available.9

14. Mr Holmes had blood samples collected on 16 February 2022 and his GP notes arrived on 17 February 2022 and were reviewed by a nurse. He was also seen by the prison doctor again on 17 February 2022 and it was noted he was still in pain but was walking more easily and was feeling much better. A plan was made to refer Mr Holmes for an MRI and then neurosurgical review and in the following days the doctor also sought advice from relevant specialists about Mr Holmes’ liver cancer and his ongoing neuropathic pain.10

15. Mr Holmes saw a nurse and doctor regularly over the next few weeks and underwent a number of investigations until eventually, on 21 March 2022, he was told by the prison medical officer, Dr Smith, that his recent CT result was suspicious for lung cancer, likely a second primary to the liver cancer rather than having metastasised from his original cancer. He was understandably distressed but cooperative with the suggested ongoing plan to continue to investigate and then consider treatment options. Mr Holmes also gave Dr Smith permission to speak to his lawyer about his diagnosis as he had an upcoming court appearance. The information about his diagnosis was then communicated to his lawyer and eventually included in consideration of the sentence that was imposed on Mr Holmes.11

16. Mr Holmes was transferred to Sir Charles Gairdner Hospital on 28 April 2022 for a liver biopsy and then was sent to Hakea Prison post procedure to recover as it was closer to the hospital. He had some pain issues while at Hakea as he did not have access to his usual medications that were held at Bunbury Prison, so steps were taken to give him alternative analgesia to try to manage his pain until he returned to Bunbury. He was transferred back to Bunbury Prison on 30 April 2022.12

17. Mr Holmes had another lung biopsy on 5 May 2022, which confirmed adenocarcinoma. He began radiation therapy as he was told his prognosis was significantly better with therapy. Mr Holmes also had some dental concerns around this time, so he was referred to a dentist.13

18. After being sentenced, Mr Holmes continued to receive regular treatment for his lung cancer, liver cancer and chronic pain issues. At a consultation with Dr Smith on 6 September 2022, Mr Holmes was told there was a new lesion noted on his latest scan. He indicated he would decide about his ongoing treatment after the outcome of his criminal appeal, as he was not interested in receiving treatment for his cancers if he “was going to spend years in jail and then die.” He had reduced his cigarette 9 Exhibit 1, Tab 14.

10 Exhibit 1, Tab 14.

11 Exhibit 1, Tab 9 and Tab 14.

12 Exhibit 1, Tab 9 and Tab 14.

13 Exhibit 1, Tab 9 and Tab 14.

[2024] WACOR 15 smoking significantly, but was still smoking at that time and had an ongoing heavy cough. He also continued to have a lot of arthritic pain so options were discussed, including referral to orthopaedics, to try to improve his quality of life. 14

19. Mr Holmes had a CT scan on 21 September 2022 but then declined to go to his radiology appointment in Perth on 23 September 2022. He indicated he wanted to wait for the results of his CT scan before he decided whether to continue with radiotherapy. Dr Smith saw Mr Holmes on 27 September 2022 and they discussed his prognosis and the results of his CT scan. Mr Holmes advised he had made the decision to not continue with treatment. He told Dr Smith that he was fully aware that this decision would worsen his prognosis and shorten his life expectancy. He also indicated he was aware there might be more complications down the track associated with the cancer. Dr Smith noted she was unsure how to manage his pain at this point as it was clear Mr Holmes was suffering.15

20. Dr Smith discussed Mr Holmes’ case with two other prison medical officers on 4 October 2022 to try to come up with options for Mr Holmes’ pain management. It was agreed that palliative management would be appropriate unless Mr Holmes changed his mind about accepting treatment. Mr Holmes had made it clear he had thought it through and did not want to prolong his life with treatment. He was felt to have capacity and his decision was clearly well considered, so the doctors respected he had made an informed choice. Mr Holmes was added to the terminally ill register at Stage 1 at this time and increased doses of his medications was arranged.16

21. Mr Holmes also had discussions with his external specialists and made it clear that he was only interested in pursuing treatment if his appeal was successful. He was advised his prognosis with treatment was good and delaying treatment might result in disease progression, but Mr Holmes indicated he would not want ongoing therapy to prolong his life if he was likely to serve his whole sentence.17

22. Mr Holmes was seen regularly from this time by health staff in the prison to try to manage his pain and various changes were made, including increased doses of his analgesia and other options such as a double mattress.18

23. Mr Holmes was seen again by Dr Smith on 3 November 2022 and she discussed with him the fact that the prognosis of his lung cancer with treatment was good. He remained firm that he was not interested in accepting any more treatment for his liver lesion but agreed to receive a letter from Sir Charles Gairdner Hospital specialists about his prognosis without treatment for his liver cancer.19

24. On 28 November 2022, Mr Holmes was sent to hospital by ambulance after experiencing dizziness and chest pain. He was found to be testing positive for COVID-19. Mr Holmes was fully vaccinated against the disease, having received his 14 Exhibit 1, Tab 9 and Tab 14.

15 Exhibit 1, Tab 9 and Tab 14.

16 Exhibit 1, Tab 9 and Tab 14.

17 Exhibit 1, Tab 12.

18 Exhibit 1, Tab 9 and Tab 14.

19 Exhibit 1, Tab 9 and Tab 14.

[2024] WACOR 15 fourth immunisation in August 2022, which would hopefully have reduced the severity of the infection’s course, but he was obviously vulnerable due to his preexisting lung disease. He was escalated to Stage 2 on the Terminally Ill register after his COVID-19 diagnosis as he was considered at high risk given his co-morbidities.20

25. Mr Holmes returned to the prison late on the evening of 28 November 2022. He agreed to go ahead with antiviral treatment for COVID-19, which was commenced on 29 November 2022. He was reviewed by health staff regularly until he tested negative and was symptom free on 13 December 2022.21

26. Mr Holmes still had not been seen by the prison dentist by mid-December 2022, and he continued to complain of dental pain. It was noted that given his current health issues, any difficulty with his eating was problematic as they did not want him to lose weight, so a new dental referral was sent and marked urgent. However, he didn’t see a dentist prior to his death as the Christmas period meant there were no dental clinics. Mr Holmes’ physical health then deteriorated and those issues took priority over dental care.22

27. Mr Holmes saw Dr Smith again on 5 January 2023 after having some CT scans performed. He indicated he was still unsure about whether he would agree to treatment and would like to know the results of the scans before he made any treatment decisions.23

28. Mr Holmes became unwell the following day and was sent to Bunbury Hospital by ambulance. He was admitted as a patient and his daughters were informed, given his terminal status and the need for the doctors to discuss the goals of care with his next of kin. He was escalated to Stage 3 on the Terminally Ill register the next day.24

29. Dr Smith made the effort to visit Mr Holmes at Bunbury Hospital on 10 January 2023 to check on him and discuss his situation and proposed treatment plan. He was orientated to time and place and understood why he was in hospital. They discussed the results of his recent scans and the fact his prognosis was not good and the time for treatment had likely passed. It was suggested Mr Holmes should now focus on palliative care with the goal of keeping him well and comfortable for as long as possible. They discussed end of life planning and he indicated he wasn’t ready to make any decisions yet and wanted to discuss matters with his daughter. Mr Holmes indicated he preferred to stay in Bunbury Prison rather than go to Casuarina Prison, despite the fact Casuarina has an Infirmary with 24-hour nursing/medical care.

However, due to his high medical needs, Mr Holmes was ultimately sent to Casuarina when he was discharged from hospital on 12 January 2023, while plans were made to refer him to a palliative care service.25 20 Exhibit 1, Tab 9, Tab 14 and Tab 19.

21 Exhibit 1, Tab 9 and Tab 14.

22 Exhibit 1, Tab 9 and Tab 14.

23 Exhibit 1, Tab 9 and Tab 14.

24 Exhibit 1, Tab 9 and Tab 14.

25 Exhibit 1, Tab 9 and Tab 14.

[2024] WACOR 15

30. In hindsight, it was suggested that another option might have been to keep Mr Holmes in hospital in Bunbury a little longer and see if palliative care could be commenced there, given he would have been closer to home and noting he very quickly had to return to hospital. However, the Department of Justice has to work in conjunction with the public hospitals, and in this case the Bunbury Hospital medical team considered him fit for discharge, so that is what occurred.

31. A Briefing Note was prepared and provided to the Minister for Corrective Services in relation to the application of the provisions of the Royal Prerogative of Mercy for Mr Holmes on 12 January 2023. It was not recommended that he be released given his outstanding treatment needs and a belief he lacked appropriate community support.26

32. Mr Holmes was seen by a prison medical officer on 13 January 2023, the day after being discharged from Bunbury Hospital. He was still smoking and his recent lung CT scan showed extensive emphysema. The discharge plan from the hospital was to manage his pain and other symptoms and no active treatment was planned.27

33. Later that same day, it was noted Mr Holmes became very confused and had difficulty breathing. He also had unexplained drops in his blood sugar levels. He was assessed as showing a significant and acute deterioration and was transferred to Fiona Stanley Hospital for emergency medical care. Mr Holmes was seen in the Emergency Department and given a principal diagnosis of acute renal failure as well as infective exacerbation of his respiratory illness. He was admitted to the Acute Medical Ward and his terminally ill status was changed to Stage 4 on the terminally ill prisoner register.28

FIONA STANLEY HOSPITAL ADMISSION

34. Mr Holmes was very unwell upon admission to Fiona Stanley Hospital on 13 January

35. His treatment was quickly changed to end of life care and it was felt he was likely to pass away soon. He was made comfortable with the administration of morphine. Mr Holmes’ family were notified of his hospital admission and they visited him at 6.18 pm that evening.29

36. Mr Holmes’ leg restraints were recorded to have been removed at 4.20 am on 14 January 2023. Mr Holmes died at 5.19 am on 14 January 2023 and his death was confirmed by a doctor at Fiona Stanley Hospital. Two Department of Justice officers were present at the time of his death for security reasons and they identified Mr Holmes to attending police officers. Mr Holmes was also identified by his daughter later that morning.30 26 Exhibit 1, Tab 15.2.

27 Exhibit 1, Tab 15.2.

28 Exhibit 1, Tab 9, Tab 10, Tab 14 and Tab 16.

29 Exhibit 1, Tab 9, Tab 14 and Tab 15.2.

30 Exhibit 1, Tab 3, Tab 4 and Tab 15.2.

[2024] WACOR 15 CAUSE AND MANNER OF DEATH

36. Following an objection to autopsy by Mr Holmes’ family, Forensic Pathologist Dr Daniel Moss performed an external post mortem examination and CT scan on 18 January 2023. He also reviewed the medical notes. There was no evidence of significant recent injury and there was evidence of recent medical intervention.

Review of the medical records confirmed Mr Holmes’ history of hepatocellular carcinoma had been treated with surgery and adjunct therapies but had possibly recurred, as well as a more recent diagnosis of adenocarcinoma of the left lung. He was noted to have extensive disease progression in the lungs as well hepatic metastases.31

37. Toxicology analysis showed the presence of multiple prescribed-type medications in keeping with Mr Holmes’ history of palliative medical care.32

38. At the conclusion of the limited investigations undertaken, Dr Moss formed the opinion the cause of death was complications of metastatic lung adenocarcinoma, with terminal palliative care, in a man with multiple medical comorbidities. Dr Moss expressed the opinion the death was due to natural causes. I accept and adopt Dr Moss’ opinion as to the cause and manner of death.

TREATMENT, SUPERVISION AND CARE Medical Care

39. Mr Holmes was in poor health when he was admitted to prison for the last time in February 2022. He had a prior history of liver cancer and shortly after admission he was diagnosed with lung cancer. I have reviewed Mr Holmes’ medical records for this last period of incarceration and I have formed the view that his medical care was of the highest standard. It is clear that the primary medical officer involved in Mr Holmes’ care, Dr Smith, took an active role in managing his care and went to great lengths to ensure he underwent appropriate investigations and understood his diagnosis and the choices he was making about his treatment options. Ongoing contact was maintained with the specialists Mr Holmes had been seeing while in the community and all efforts were made to ensure Mr Holmes had appropriate expert specialist care for his significant health conditions.

40. Ultimately, Mr Holmes made an informed choice not to pursue active treatment, despite the fact he had been told that his prognosis with treatment was good.

Mr Holmes’ right to refuse treatment was respected by the health practitioners involved in his care, although they did encourage him to reconsider at various times.

The time for treatment eventually passed and Mr Holmes was transitioned to palliative care shortly before his death. He died in hospital not long after from complications of his lung cancer.

31 Exhibit 1, Tab 6.3.

32 Exhibit 1, Tab 6.3 and Tab 7.

[2024] WACOR 15

41. I am satisfied Mr Holmes received excellent medical treatment while a prisoner leading up to his death, with a very caring and supportive GP consistently managing his medical care and appropriate referral to specialists and hospital as required. I am sure Mr Holmes would have appreciated Dr Smith’s efforts to not only keep him informed of his treatment options and prognosis as his health deteriorated, but also respecting his decisions as to what care he chose to accept. I understand his daughters were able to spend time with him before his death, at least in Bunbury, prior to his death, so he was able to have some closure with his family before he passed. These are all important things for a terminally ill person, whether a prisoner or in the community, and I am satisfied all efforts were made to treat Mr Holmes’ terminal illness appropriately.33 Dental Care

42. I did raise a query about the delays in Mr Holmes receiving dental treatment prior to his death, as it is clear from the records that he was experiencing dental pain and required dental work. He had apparently been reviewed by the dentist within three months of his arrival into custody in 2020, but did not see a dentist again after that time. Requests were lodged for Mr Holmes to be seen by a dentist in May 2022 and again in December 2022, but it did not occur. I was informed that Mr Holmes was on the waitlist both for the public dental clinic, provided by North Metropolitan Health Services, and the private dental clinic, although it was not clear that he would be able to pay to be seen privately when he came to the front of the queue. Some of the public clinics were cancelled due to a lack of dental staff.34

43. Dr Gunson, who gave evidence for the Department of Justice in relation to the medical services, agreed that good dental care is very important for overall physical health and total wellbeing, and it is clear Mr Holmes was experiencing ongoing discomfort and pain due to his poor dentition. Dr Gunson commented that she believes there are a “plethora of patients who absolutely need good dental care, just to get them back to a normal state,”35 but that is not often provided and it has been an ongoing issue for a long time. Dr Gunson advised that the dental service available at Hakea Prison is currently excellent, but it hasn’t been consistent at many other sites, including Bunbury Prison. Dr Gunson agreed that it is an area that requires improvement in the prisons overall.36

44. As part of providing an overall health service for prisoners, I consider good dental treatment an important part of that care. I accept that there are long delays to see a publicly funded dentist in the community, so the delays were not probably any different to what Mr Holmes might have experienced if he had remained in the community. However, this does not excuse the Department from working to provide a more consistent and readily accessible service to prisoners, particularly since it has been demonstrated that it can be done at Hakea Prison. It is generally accepted that good oral health can help control and/or lessen the risk associated with heart disease, 33 Exhibit 1, Tab 19.

34 T 11, 15.

35 T 11.

36 T 11.

[2024] WACOR 15 diabetes and other chronic health conditions, separate to the mental improvement associated with reduced pain and improved self-esteem. There could, therefore, be a significant cost benefit from providing better dental care, as it would likely reduce the need for other medical treatment.37

45. At this stage, I do not propose to me a specific recommendation in relation to dental services provided by the Department, as there was not sufficient information before me. However, I do make the comment that his dental treatment needs did not appear to have been met in a timely manner, despite being appropriately identified and followed up by prison health staff. In my view, it is an area that the Department should consider in terms of its arrangement with the Department of Health and consider how the model that is currently being provided at Hakea Prison, which I’m told by Dr Gunson is of a high standard, can be replicated in other prisons.

Restraints

46. The other issue that arose in relation to Mr Holmes’ care, treatment and supervision was in relation to his restraints in hospital prior to his death. This is an issue that has arisen in previous inquests, and relevant recommendations have been made by other coroners, which the Department of Justice has been working towards implementing.

47. I am informed that in June 2022, an External Movement Risk Assessment (EMRA) had been completed for Mr Holmes while he was in Bunbury Prison and he had met the criteria to be moved to and from hospital without restraints being applied, although they would obviously be available if it became necessary for his security or safety. This information was recorded in a movement alert on the Total Offender Management System (TOMS) on 9 January 2023. However, after Mr Holmes was transferred to Casuarina Prison, that information did not pass across, which meant that Mr Holmes was transferred from Casuarina Prison to Fiona Stanley Hospital with security chain links on 13 January 2023 and a single leg restraint was used whilst Mr Holmes was an inpatient at Fiona Stanley Hospital until it was removed shortly before his death.38

48. I was provided with a letter signed by Deputy Superintendent Pittard from Casuarina Prison in which it was acknowledged that Mr Holmes, who was terminally ill, appeared frail and had significant mobility issues, fell under section 5.3.1 of the Commissioner’s Operating Policy and Procedure 12.3 – Conducting Escort (COPP 12.3). Accordingly, a new EMRA at Casuarina Prison should have been conducted prior to his transfer on 13 January 2023. The failure to conduct an EMRA was an administrative error, although it was suggested it may have been overlooked or not prioritised, due to the urgency of Mr Holmes’ transfer by ambulance that day. Had it been undertaken, Deputy Superintendent Pittard believes Mr Holmes would likely have been permitted to be transferred without restraints applied.39 37 https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475.

38 Exhibit 1, Tab 17.

39 Exhibit 1, Tab 17.

[2024] WACOR 15

49. The failure to complete an EMRA prior to his transfer appears to have influenced the decision to keep Mr Holmes restrained with a leg restraint while he was then admitted to Fiona Stanley Hospital. The restraints were eventually removed at 4.20 am on 14 January 2023 and he died just under an hour later.40

50. Deputy Superintendent Pittard advised that due to deficiencies identified in the EMRA process, the Superintendent of Casuarina Prison implemented a Local Process on 27 February 2024 stating that “ALL unscheduled medical escorts”41 must have an EMRA completed on TOMS as soon as practicable.

51. In the letter from Deputy Superintendent Pittard, and also in an additional letter provided by Ms Duval after the inquest, I was informed that a number of amendments have been made to TOMS to assist prison officers in completing an EMRA and other medical movement information, by advising of a prisoner’s Terminally Ill status with a ‘Yes’ or ‘No’ advice, without breaching their patient confidentiality. This will help them in making the assessment.42

52. Deputy Superintendent Pittard noted that “Casuarina is the largest maximum-security facility in the State and manages an ever-growing cohort of complex and high-risk prisoners” 43 but has a high staff turnover, which means that there has been a reduction in experience of prison officers with the EMRA process and I note that often, as a high security prison, prisoners would require restraints as a matter of course during transfers. It was acknowledged that prison staff would benefit from more training about the correct application of s 5.3.1 of COPP 12.3 and efforts would be made to provide that training, subject to availability of staff. Given staff are often not available due to shortages and there is a priority to keeping prisoners out of lockdown as much as practicable, the Superintendent and his management staff are also considering other ways to provide that training.44

53. I am satisfied that the Department is conscious of the restraints issue in relation to terminally ill patients and the need to ensure staff are conscious of only imposing restraints on these patients when necessary for security and safety. I accept the Department is continually making efforts to improve in this area, and to respond to coroners’ recommendations. Accordingly, I do not consider there is a need to make any further recommendations on this point.

CONCLUSION

54. Mr Holmes was an elderly man in very poor health when he eventually succumbed to complications of his metastatic lung cancer while serving a lengthy prison sentence.

He was given regular and attentive medical care prior to his death, but he had chosen not to undergo potentially lifesaving treatment, preferring to be managed 40 Exhibit 1, Tab 17.

41 Exhibit 1, Tab 17, p. 3.

42 Exhibit 1, Tab 17 and Exhibit 2.

43 Exhibit 1, Tab 17, p. 3.

44 Exhibit 1, Tab 17.

[2024] WACOR 15 conservatively. That was his right as a patient. He rapidly deteriorated in January 2023 and died in hospital as a result of natural causes.

S H Linton Deputy State Coroner 4 April 2024