Inquest into the Death of David John HATCHER

[2026] WACOR 15 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : ROBYN MARY HARTLEY, CORONER HEARD : 19 AUGUST 2025 DELIVERED : 1 APRIL 2026 FILE NO/S : CORC 2899 of 2024

DECEASED : HATCHER, DAVID JOHN Catchwords: Nil Legislation: Nil Counsel Appearing: Counsel Assisting : Sgt C Martin Counsel : Mr M Caubo (State Solicitor’s Office) appeared on behalf of the Department of Justice Case(s) referred to in decision(s): Nil

[2026] WACOR 15 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Robyn Mary Hartley, Coroner, having investigated the death of David John HATCHER with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, PERTH, on 19 August 2025, find that the identity of the deceased person was David John HATCHER and that death occurred on 27 September 2024 at Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, from pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with terminal comfort care in the following circumstances:

TABLE OF CONTENTS

[2026] WACOR 15 INTRODUCTION David John Hatcher (Mr Hatcher) was 60 years old when he died at Fiona Stanley Hospital (FSH) while on remand at Hakea prison.

Mr Hatcher was remanded in custody in August 2023. He was suffering from lung disease upon admission to prison. Arrangements were made for him to receive specialist treatment at the FSH General Respiratory Clinic in January 2024.

On 7 May 2024 Mr Hatcher experienced a medical episode and was transferred to FSH where he was admitted and diagnosed with active tuberculosis. On 17 May 2024, while still in hospital, Mr Hatcher was listed as Stage 3 Terminally Ill. He was discharged from FSH back to prison on 6 June 2024.

On 10 June 2024 Mr Hatcher became very unwell, requiring transfer to FSH. He was admitted to the Intensive Care Unit (ICU) and listed as Stage 4 Terminally Ill on 11 June 2024. Mr Hatcher’s condition stabilised for a period, and he was de-escalated to Stage 3 Terminally Ill.

Three specialist teams at FSH provided comprehensive care to Mr Hatcher but were unable to halt his deterioration. He was escalated to Stage 4 Terminally Ill on 18 September and was declared life extinct on 27 September 2024.

As Mr Hatcher was a serving prisoner at the time of his death, he was a ‘person held in care’ as defined in the Coroners Act 1996 (WA) (the Act).1 1 Section 3 Coroners Act 1996 (WA).

[2026] WACOR 15 Any death of a person held in care must be the subject of an inquest.2 The Act requires that a Coroner who conducts an inquest into the death of a person held in care must comment on the quality of the supervision, treatment and care of the person while in that care, as well as finding the cause and manner of death.3 I held an inquest into Mr Hatcher’s death at the Perth Coroner’s Court on 19 August 2025. At the outset of the inquest a coronial brief was accepted into evidence. I heard oral evidence from two witnesses from the Department of Justice (the Department) – a representative from Performance Assurance and Risk (PAR) and another from Justice Health and Wellbeing Services.

Mr Hatcher’s wife and son attended the inquest and provided a valuable contribution to the process. His son took the opportunity to address me about concerns the family had in relation to the way Mr Hatcher was treated during his time in custody.

At the conclusion of the inquest, Counsel for the Department undertook to seek instructions from their client in order to provide a written response to the concerns raised by Mr Hatcher’s son.

BACKGROUND Mr Hatcher was born on 1 October 1963 in New Zealand. He moved to Australia as an adult. Mr Hatcher is survived by his wife and their son.

2 Section 22(1)(a) Coroners Act 1996 (WA).

3 Section 25(1) and 25(3) Coroners Act 1996 (WA).

[2026] WACOR 15 In March 2023 Mr Hatcher was charged with child pornography offences and released on a surety bail. In August 2023 he was charged with child sex offences and remanded in custody at Hakea prison.

TIME IN CUSTODY4 Upon his admission to the prison system on 8 August 2023 Mr Hatcher was identified as a first-time prisoner.

During the intake process Mr Hatcher disclosed that he had experienced previous thoughts of self-harm when he was first arrested and charged in March 2023. He advised that the thoughts had endured for about three months but were no longer present. Despite Mr Hatcher assuring staff that he had no current thoughts of self-harm, it was decided that his disclosure about previous suicidal ideation warranted placing him on the At Risk Management System (ARMS). He was placed on low ARMS which meant he was subject to four hourly observations.

Mr Hatcher was reviewed by the Prisoner Risk Assessment Group (PRAG) each week for four weeks after his admission. PRAG minutes show a progressive improvement in his mental state aligned with an acceptance of his situation, settling into prison, establishing internal and external supports and the emergence of a future focused mindset. On 29 August 2023 Mr Hatcher was removed from ARMS.

Due to concerns about the risk other prisoners could pose to Mr Hatcher’s safety he was accommodated in protection units throughout his period of imprisonment.

4 Exhibit 1, Tab 9 Review of Death in Custody Mr David John HATCHER; Tab 10 Health Services Summary relating to the Death in Custody HATCHER David John; Tab 11 Letter to Court from Fiona Stanley Hospital dated 13 August 2025.

[2026] WACOR 15 On 10 August 2023 Mr Hatcher had a medical admission assessment.

The Prison Medical Officer recorded that Mr Hatcher suffered from asthma and emphysema and was taking medication for these conditions.

Mr Hatcher reported smoking 10 – 12 cigarettes a day and was advised to quit smoking. He also told the Prison Medical Officer that he had seen his General Practitioner a week prior and had been referred to a respiratory specialist. Mr Hatcher’s consent was obtained in order to access the details of the specialist referral.

Mr Hatcher was not flagged as a tuberculosis risk by the Prison Medical Officer who completed his admission due to a lack of reported risk factors such as having lived overseas or recently arriving from a high tuberculosis burden county. Therefore, he was not screened for the disease at admission.

During the admission assessment Mr Hatcher declined routine investigations including blood tests.

It was established that Mr Hatcher had been referred to the General Respiratory Clinic at FSH for treatment of severe Chronic Obstructive Pulmonary Disease (COPD) and had an upcoming appointment booked.

Emphysema is a subset of COPD and the terms are used interchangeably throughout Mr Hatcher’s prison medical records.

On 17 January 2024 Mr Hatcher was seen by a FSH Respiratory Physician at the General Respiratory Clinic. He was educated about inhaler usage and a revised medication regime was communicated to the medical staff at the prison.

[2026] WACOR 15 The Respiratory Physician urged Mr Hatcher to quit smoking, but he declined to do so. He turned down the offer of nicotine replacement therapy. Given Mr Hatcher remained an active smoker, he was not suitable for referral for pulmonary rehabilitation.

Mr Hatcher did not attend a scheduled prison medical appointment on 22 March 2024. The appointment was rebooked for 27 March 2024, but Mr Hatcher again refused to attend.

On 7 May 2024 Mr Hatcher was struggling to stand upright and looked very unwell. A prison officer escorted him to the medical centre where Mr Hatcher told staff he was short of breath and had been feeling that way for a number of days. When he was asked why he hadn’t been attending his medical appointments, Mr Hatcher said that there wasn’t much anyone could do. Examinations revealed he had a low oxygen saturation and elevated respiratory and pulse rates. Mr Hatcher was taken by ambulance to FSH.

First FSH admission – 7 May to 6 June 2024 Mr Hatcher was admitted to the Acute Medical Unit at FSH before being transferred to a medical ward under the care of the Respiratory Medicine team for treatment of exacerbation of his COPD.

On 14 May 2024 FSH submitted Mr Hatcher’s sputum culture for testing.

The result showed that he had active pulmonary tuberculosis. Mr Hatcher was started on the standard four drug treatment regime for the disease.

Airborne precautions and infection control measures were implemented.

Given his diagnosis of active tuberculosis, on top of the existing COPD, Mr Hatcher was at risk of developing life-threatening respiratory sepsis.

[2026] WACOR 15 On 17 May 2024 the Department listed Mr Hatcher as Stage 3 Terminally Ill which signifies that death is likely to occur within three months, or sudden death is possible. Having been placed on the Terminally Ill Register, Mr Hatcher’s restraints should have been removed at this point.

The only justification for the restraints remaining in place would have been if an External Movement Risk Assessment (EMRA) was completed which showed that removal posed too great a risk.

Mr Hatcher ultimately had his restraints removed on 31 May 2024.

During the admission, FSH clinicians found that Mr Hatcher was malnourished and significantly deconditioned due to the exacerbation of his COPD and the active tuberculosis. He needed active rehabilitation, including dietetics, physiotherapy and occupational therapy, to assist with recovery from the acute infection and to manage the spike in his chronic condition. However, Mr Hatcher declined to engage with allied health teams for the purpose of active rehabilitation.

Mr Hatcher’s treating team at FSH consulted with the prison health staff and it was agreed that he would be discharged once he was clinically stable and had returned three negative tests for tuberculosis.

By 4 June 2024 Mr Hatcher had returned three negative sputum samples and was medically stable. He was transferred back to Hakea on 6 June 2024 and placed in the Crisis Care Unit.

Second and final FSH admission – 10 June 2024 to date of death On 10 June 2024 a prison officer received a cell call from Mr Hatcher’s cell mate advising that Mr Hatcher was having a seizure. Mr Hatcher was taken to the medical centre where he was reviewed by a Prison Medical

[2026] WACOR 15 Officer. He was found to have low blood pressure and oxygen saturation.

It was determined that Mr Hatcher needed to be transferred to hospital, but he expressed reluctance to go. A prison nurse was able to convince Mr Hatcher that he should go to hospital for treatment.

Despite being registered as Stage 3 Terminally Ill, Mr Hatcher was restrained using handcuffs and leg irons for the transfer by ambulance to

FSH.

At FSH Mr Hatcher was found to be suffering from multi-organ sepsis, an acute decline in kidney function, COPD exacerbation and elevated troponin levels (indicative of heart damage).

An Emergency Department doctor at FSH sent correspondence to the Department on 10 June 2024 requesting approval for Mr Hatcher’s restraints to be removed. The letter explained that Mr Hatcher was quite medically unwell and suffering from poor mobility. The Department was asked to consider allowing Mr Hatcher to be unshackled in the interests of patient comfort.5 Hakea declined the request, advising that staff from the prison would attend FSH the next day to conduct a further assessment in relation to the use of restraints.6 Mr Hatcher’s oxygen saturation continued to drop, necessitating transfer to the ICU.

On 11 June 2024, while in the ICU, Mr Hatcher was escalated to Stage 4 Terminally Ill (death is imminent) due to the deterioration in his health.

Mr Hatcher was too unwell to attend a scheduled court appearance on 11 June 2024. Hospital staff informed the court of Mr Hatcher’s medical 5 Exhibit 1, Tab 9.27 Letter from FSH Emergency Department to Department of Corrections dated 10 June 2024.

6 Exhibit 1, Tab 9.26 Ventia Record of Events from 10 - 11 June 2024.

[2026] WACOR 15 status and he was excused from appearing with the matter relisted for a future date.7 On 11 June 2024 Ventia (the company contracted to provide security for prisoners when in hospital) advised Hakea that Mr Hatcher’s condition was worsening. Ventia emailed Hakea asking that the request for removal of restraints from the previous day be reconsidered.

That same day the Department’s Operations Centre alerted Ventia and Hakea staff that, due to Mr Hatcher’s terminally ill status, he should not be restrained. Hakea’s Superintendent and Deputy Superintendent then gave approval for removal of Mr Hatcher’s restraints.

On 12 June 2024 two EMRAs were completed for Mr Hatcher. Both risk assessments referred to Commissioner’s Operating Policies and Procedures (COPP) 6.2 Prisoners with a Terminal Medical Condition in determining that the restraints should be removed.

Mr Hatcher’s restraints were removed at 6.41 am on 12 June 2024.

With intensive medical intervention Mr Hatcher was able to be stabilised.

He was transferred to a ward under the care of the Respiratory Medicine team on 13 June 2024.

Due to the improvement in his condition, Mr Hatcher’s Terminally Ill status was de-escalated from Stage 4 to Stage 3 when he was transferred out of ICU onto a ward.

Mr Hatcher’s treating team established that his tuberculosis had worsened. This was exacerbated by his pre-existing COPD and 7 Exhibit 1, Tab 9.29 Remand Warrant and medical certificate from FSH dated 10 June 2024.

[2026] WACOR 15 malnutrition. Given the recurrent tuberculosis, the Respiratory Medicine team sought input from the FSH Infectious Disease team in relation to Mr Hatcher’s treatment.

Investigations revealed Mr Hatcher’s lungs were progressively failing and his heart was now suffering as a result of his severe lung disease.

During his admission Mr Hatcher suffered a complication in the form of Tuberculosis-immune reconstitution inflammatory syndrome which is an exaggerated immune response to the antiretroviral therapy used to treat the disease.

On 9 July 2024 Mr Hatcher’s care was transferred from Respiratory Medicine to the Infectious Diseases team.

Mr Hatcher continued to refuse to allow the insertion of a nasogastric tube to assist with his malnutrition and would not mobilise out of bed.

His decision not to engage in nutritional restoration and physical rehabilitation significantly hindered his prospects of becoming well enough to be discharged from hospital.

Mr Hatcher was reviewed by FSH’s Mental Health Consultant Liaison Service on 26 August 2024. He was found to be feeling hopeless and unmotivated. Mr Hatcher disclosed that he was unhappy with the justice system and did not see much to recover for given the uncertainty around the likely length of the sentence he would receive.

Given his low mood, and the role it was playing in his physical decline, Mr Hatcher was prescribed multiple medications aimed at improving his mental health. Unfortunately, the Mental Health team did not see any meaningful response to the psychiatric medications Mr Hatcher took.

[2026] WACOR 15 During September Mr Hatcher withdrew further, choosing to have little to no engagement with allied health professionals or the Mental Health team. He did, however, agree to have a nasogastric tube inserted.

Active treatment was continued with input from a large number of clinicians. Advice was sought from interstate in a bid to assist Mr Hatcher to turn a corner in his health battle.

On 18 September 2024 Mr Hatcher was registered as Stage 4 Terminally Ill.

From that point onwards Mr Hatcher’s condition declined rapidly. He had reduced levels of consciousness, worsening shortness of breath and chest pain.

One of the Infectious Diseases Consultants treating Mr Hatcher had a discussion with his son about moving to palliation. Mr Hatcher’s son agreed that it was the best way forward for his father and comfort care measures were put in place.

According to his son, Mr Hatcher passed away peacefully at about 9.45 pm on 26 September 2024. He was officially declared life extinct following a thorough medical examination in the early hours of 27 September 2024.

A significant number of medical, nursing and allied health professionals across Respiratory Medicine, Infectious Diseases and Mental Health worked tirelessly to provide Mr Hatcher with optimal treatment over his 109-day admission to FSH.

[2026] WACOR 15 CAUSE AND MANNER OF DEATH Following an external postmortem examination, CT scan, toxicology analysis and consideration of Mr Hatcher’s medical records, Forensic Pathologist Dr Ong formed the opinion that the cause of death was Pulmonary Tuberculosis in a man with Chronic Obstructive Pulmonary Disease, with terminal comfort care. Dr Ong concluded that Mr Hatcher’s death was consistent with natural causes.8 I accept and adopt the opinion of Dr Ong as to the cause and manner of death.

SUPERVISION, TREATMENT AND CARE An internal review of Mr Hatcher’s custodial management, supervision and care conducted by the Department’s PAR Directorate found compliance with the majority of the applicable policies and procedures.9 The PAR review identified areas for improvement relating to the recording and awareness of Mr Hatcher’s Terminally Ill status.

Following on from this, the review uncovered a failure to comply with the policies setting out when restraints should be applied to a terminally ill prisoner during transfer and admission to hospital.

Use of restraints from 17 to 31 May 2024 Mr Hatcher was first placed on the Terminally Ill list on 17 May 2024 during his initial 30-day admission to FSH. The Total Offender Management System (TOMS) Terminally Ill Module reflects this date.

8 Exhibit 1, Tab 7 Supplementary Post Mortem Report HATCHER David John dated 6 March 2025.

9 Exhibit 1, Tab 9 Review of Death in Custody Mr David John HATCHER.

[2026] WACOR 15 According to the TOMS Terminally Ill Module, an email was generated on 20 May 2024 advising the Hakea Superintendent of Mr Hatcher’s Stage 3 Terminally Ill status. The email went on to confirm that Mr Hatcher would not be considered for early release under the Royal Prerogative of Mercy due to him being a remand prisoner.

Mr Hatcher’s terminally ill status was due to be subject of a Health Advice Review on 24 May 2024. However, for reasons that could not be established, the review did not occur until 29 May 2024.

On 28 May 2024 the Department’s Operational Compliance Team emailed Hakea advising that a review of Mr Hatcher’s restraints regime needed to take place due to his Stage 3 Terminally Ill status.

On 30 May 2024 the Hakea Superintendent provided approval for an EMRA to be conducted as a precursor to Mr Hatcher’s restraints being removed. The EMRA was completed the next day, with Mr Hatcher’s restraints removed shortly after.

The operation of COPP 6.2 Prisoners with a Terminal Medical Condition, COPP 11.3 Use of Force and Restraints and COPP 12.3 Conducting Escorts requires that restraints not be applied to a prisoner who is registered as Stage 3 or 4 Terminally Ill, unless an EMRA determines restraints are necessary. In the absence of any risk assessment, Mr Hatcher should have had his restraints removed on 17 May 2024 when he was declared Stage 3 Terminally Ill. The removal of restraints did not occur until 31 May 2024.

[2026] WACOR 15 Use of restraints from 10 to 12 June 2024 Given Mr Hatcher was registered as Stage 3 Terminally Ill at the time, COPP 12.3 Conducting Escorts stipulates that restraints could only be applied for the journey from Hakea to FSH on 10 June 2024 if an EMRA was undertaken and it was determined that he posed too great a risk to be transferred without restraints. No EMRA was completed for Mr Hatcher, nevertheless restraints were applied.

Upon arrival at FSH it was apparent to staff caring for Mr Hatcher in the Emergency Department that he was very unwell, with significantly reduced mobility. A request from FSH dated 10 June 2024 that the Department allow Mr Hatcher’s restraints to be removed10 was not approved.

The ED Registrar who sought permission to remove the restraints also wrote to the Court advising that Mr Hatcher was an inpatient at FSH and medically unfit to attend his scheduled court appearance on 11 June 2024.11 Mr Hatcher was admitted to the ICU on 11 June 2024 where he was escalated to Stage 4 Terminally Ill.12 Ventia contacted Hakea to advise of the decline in Mr Hatcher’s medical condition and asked that the request for authorisation to remove his restraints be reconsidered.13 Early in the afternoon on 11 June 2024 the Department’s Operational Compliance Team identified the failure to apply the applicable COPPs 10 Exhibit 1, Tab 9.27 Letter from FSH ED Registrar to Department of Correction dated 10 June 2024.

11 Exhibit 1, Tab 9.29 Letter from FSH ED Registrar to the Department of Justice dated 10 June 2024.

12 Exhibit 1, Tab 9.28 Terminally Ill Health Advice dated 11 June 2024.

13 Exhibit 1, Tab 9.30 Email from Ventia Hospital Sit Supervisor to Hakea at 11.56 am on 11 June 2024.

[2026] WACOR 15 relating to restraints.14 Having been informed that restraints were being applied to Mr Hatcher contrary to policy, approval came from Hakea for them to be removed.15 By 6.01 am on 12 June 2024 Mr Hatcher was no longer subject to restraints.16 Action taken by Department in relation to restraints On 28 June 2024 the Department completed a Thematic Compliance Review into the Use of restraints in the movement of terminally ill prisoners.17 The purpose of the review was to identify and eliminate systemic barriers to compliance with the restraint related COPPs during the provision of end-of-life care to terminally ill prisoners.

One theme that emerged in the Compliance Review was the importance of custodial staff having access to a prisoner’s up to date terminally ill status on TOMS.

A prisoner’s terminally ill status should be recorded on both the Terminally Ill list and Medical Status module on their TOMS page.

Prison officers generally don’t have access to the Terminally Ill list because it draws information from a prisoner’s confidential medical records. Access to medical records is restricted to health services staff such as prison doctors and nurses.

14 Exhibit 1, Tab 9.30 Email from Department of Justice State Operations Command Centre at 12.44 pm on 11 June 2024.

15 Exhibit 1, Tab 9.30 Email from Hakea to Ventia at 3.22 pm on 11 June 2024.

16 Exhibit 1, Tab 9.32 Ventia Record of Events from 12 - 14 June 2024.

17 Exhibit 1, Tab 9.46 Thematic Compliance Review Use of restraints in the movement of terminally ill prisoners dated 28 June 2024.

[2026] WACOR 15 This means that prison officers are reliant on the accuracy of a prisoner’s terminally ill status as recorded in the Medical Status module on TOMS when arranging a transfer to hospital during a medical emergency.

The PAR Review into Mr Hatcher’s death found that due to his terminally ill status not being recorded on the TOMS Medical Status module, an EMRA was not completed on 10 June 2024, resulting in him being restrained for the transfer to FSH in breach of COPP 12.3.18 Corrective Services Deputy Director, Medical Services Dr Gunson advised that responsibility for recording a prisoner’s terminally ill status on the Medical Status module on TOMS rests with health services staff.19 Dr Gunson gave evidence that the TOMS Medical Status module was updated in January 2024 to include a prisoner’s terminally ill status.

When the Terminal Illness field was first added to the Medical Status module there may have been some uncertainty around who was required to record a prisoner’s addition to or progression on the Terminally Ill Register on the TOMS Medical Status module.

When Dr Gunson became aware of the fact that the TOMS Medical Status module was not always being updated when a prisoner was added to the Terminally Ill Register, she took it upon herself to ensure that was occurring. She advised the Court that she is about to produce a short guide for other medical officers setting out the process of updating the Medical Status module on TOMS to reflect a prisoner’s terminally ill status. Health Services’ Medical Status on Total Offender Management 18 Exhibit 1, Tab 9 Review of Death in Custody Mr David John HATCHER, p 28.

19 Exhibit 1, Tab 9.42 Correspondence with Dr Gunson – Updating of Terminal Illness Field on TOMS dated 7 April 2025.

[2026] WACOR 15 System (TOMS) - PM30 Policy and Procedure is in the process of being updated to reflect this additional record keeping requirement.20 Both the Compliance Review and the PAR Review into Mr Hatcher’s death recommended changes to TOMS so that information about a prisoner’s terminally ill status is auto populated into other modules and sections of the system to prompt consideration of the need for an EMRA if restraints are going to be applied.

The PAR Review suggested upgrading TOMS so the Terminally Ill field within the Medical Status module is simultaneously updated when a prisoner is listed as terminally ill and when they transition through the terminally ill stages. This seems eminently sensible, and I understand it is supported in principle by the Department. I am hopeful the target date of 30 June 2026 will be met for this proposed improvement.21 In a similar vein, the Compliance Review recommended creating an interface on TOMS between the Terminally Ill list and the Offender Movement Information (OMI) that is completed when a prisoner is transferred to hospital.22 Of note is the fact that the OMI completed on 10 June 2024 when Mr Hatcher was transferred to FSH for his final admission recorded ‘N’ next to Terminal Illness despite the fact he was registered as Stage 3 Terminally Ill at that time.23 I urge the Department to stay focused on implementing any improvements to the systems that assist both health services and

20 T 26.

21 Exhibit 1, Tab 9 Review of Death in Custody Mr David John HATCHER, p 31.

22 Exhibit 1, tab 9.46 Thematic Compliance Review Use of restraints in the movement of terminally ill prisoners dated 28 June 2024, p 7.

23 Exhibit 1, Tab 9.24 Offender Movement Information Sheet dated 10 June 2024.

[2026] WACOR 15 custodial staff to undertake their duties in a way that complies with policy and ensures the comfort and dignity of prisoners with a terminal diagnosis.

As was highlighted at the inquest, it is clear that the review function performed by the Department’s Operational Compliance Team serves its intended purpose. During both his first and second admissions to FSH, Operational Compliance identified that Mr Hatcher was being restrained contrary to policy and escalated the issue accordingly.

I understand that the PAR Review into Mr Hatcher’s death received advice suggesting that the Department’s Operations Centre may be better suited to conducting this oversight role. This is due to the fact that the Operational Compliance Team has a role following an event and is only available on weekdays. The Operations Centre is notified of all hospital admissions and unscheduled medical appointments.24 Ideally a valuable gatekeeping function such as one which reviews the application of restraints against the applicable COPPs would operate every day of the week. Partucularly given the stated aim of conducting these reviews within 24 hours of a hospital admission.

However, I will leave this issue for the Department to explore further if the need is there.

As the updated restraints policies become embedded in custodial practice and the TOMS Medical Status and Offender Movement Information are automatically updated with a prisoner’s terminally ill status the hope is that the oversight reviews, whether they are conducted by Operational 24 Exhibit 1, Tab 9.45 Correspondence with Principal Operational Compliance Officer dated 3 February 2025.

[2026] WACOR 15 Compliance or a different team, will identify far less non-compliant applications of restraints.

Management of Mr Hatcher’s medical issues while in custody A third of the 416 days Mr Hatcher was in custody were spent as an inpatient at FSH, including 109 days leading up to his death.

I am satisfied that Mr Hatcher received a very high standard of care during his two admissions to FSH.

A substantial number of highly qualified health professionals worked hard to save Mr Hatcher’s life over an extended period. When a treatment regime proved unsuccessful it was altered, or another was trialled.

Despite optimal therapy, Mr Hatcher succumbed to his tuberculosis infection. This outcome was reflected upon by FSH, and it is clear those involved in treating Mr Hatcher did their utmost to avoid it.

FSH provided the Court with a detailed analysis of Mr Hatcher’s care, including an analysis of factors which contributed to his death: a) First was the fact that the tuberculosis infection occurred on a background of severe chronic emphysema with extensive lung damage; b) Secondly, Mr Hatcher was significantly underweight, with signs of malnutrition from his first admission onwards. As was his prerogative, he declined nutritional intervention. He eventually accepted nutrition by way of nasogastric tube in September 2024 but by then his condition had deteriorated beyond reversal; and

[2026] WACOR 15 c) Finally, Mr Hatcher’s low mood played a major role in his disease progression. Despite ongoing attempts by the FSH Psychiatry team to improve his mood, Mr Hatcher was clearly struggling to find the motivation to engage in active treatment of his physical and mental health as he felt he had little to recover for.25 Justice Health and Wellbeing Services Division conducted an internal review of the health care provided to Mr Hatcher during his time at Hakea. The review found that he received appropriate and holistic care while in custody.26 Mr Hatcher’s prison medical records include multiple instances where he failed to attend scheduled appointments. He was also reluctant to seek medical assistance when he was feeling unwell.

As was canvassed during Dr Gunson’s evidence at the inquest, Mr Hatcher was deemed to possess decision making capacity and was, therefore, entitled to make informed choices to decline or delay medical treatment if he wished.27 Concerns raised by Mr Hatcher’s son28 Mr Hatcher’s son asked for the opportunity to speak at the conclusion of the inquest. In listening to him speak it was clear he is a dedicated son who cared deeply for his father.

On the question of how Mr Hatcher contracted tuberculosis, his son explained that his father never lived in Asia, as might have been thought.

25 Exhibit 1, Tab 11 Letter to Court from Fiona Stanley Hospital dated 13 August 2025.

26 Exhibit 1, Tab 10 Health Services Summary relating to the Death in Custody HATCHER David John.

27 T 30 – 31.

28 T 41 – 48.

[2026] WACOR 15 Mr Hatcher did have a yellow fever vaccination but that was so he could travel to Panama to watch his son play in a baseball tournament.

Dr Gunson explained in her evidence that extensive contact tracing was conducted after another prisoner was diagnosed with tuberculosis a few months before Mr Hatcher. The contact tracing revealed no primary or secondary contact between that prisoner and Mr Hatcher.

After Mr Hatcher was diagnosed with tuberculosis, further contact tracing occurred but the Department remained unable to establish how he contracted the infection.

Due to the vulnerabilities of the cohort, there is a much higher incidence of latent tuberculosis in the prison population when compared with the general community. Latent tuberculosis is often asymptomatic and can lay dormant for years. It becomes active under certain conditions such as when a person is physically debilitated, rundown or immunocompromised.

While it was suggested that Mr Hatcher may have caught tuberculosis when living in Asia at some point in his earlier life (which we now know did not occur) the evidence provided at the inquest was that it is not impossible he caught it in Australia.

Dr Gunson advised that prisoners are now being tested for tuberculosis as part of the routine blood tests done upon admission.29 Mr Hatcher’s son raised the fact that his father thought he caught tuberculosis from a pillow at Hakea prison that had mould on it and had

29 T 36 – 37.

[2026] WACOR 15 a musty smell. He said his father asked a prison guard if he could change his pillow, but the request was denied.

Dr Gunson was able to provide information from the Australian Department of Health and Aged Care clarifying that tuberculosis is spread via inhalation of small particle aerosols. Given it is only transmitted through air containing microdroplets of tuberculosis organisms, it cannot be caught by touching surfaces such as bed linen.

Further, the Department advised that it could not find any record of Mr Hatcher requesting a new pillow and having that request refused.30 Mr Hatcher’s son raised concerns about the chemicals used to clean the floors and bathrooms at Hakea causing his father breathing difficulties.

The Department looked into this issue after the inquest and provided the Court with the Safety Data Sheet for the product used to clean the cell floors and bathrooms at Hakea. It is a multi-purpose disinfectant, cleaner and deodoriser which is deemed fit for purpose and not harmful to prisoners. The product does not contain bleach or ethanol. Once it has been used on a particular area, prisoners are kept away until the product has dried, there is adequate ventilation and prison staff wearing PPE have inspected the area.31 This is not to diminish Mr Hatcher’s son’s evidence about witnessing his father struggling to breathe when he visited him at Hakea. Or Mr Hatcher’s concern that the cleaning products were causing him breathing 30 Letter from State Solicitor’s Office to Sergeant Assisting the Coroner dated 1 September 2025 including attachment DJH.009 Email from Dr Gunson dated 19 August 2025.

31 Letter from State Solicitor’s Office to Sergeant Assisting the Coroner dated 1 September 2025 including attachment DJH.005 Lesman Safety Data Sheet.

[2026] WACOR 15 difficulties. However, the evidence points towards responsible use of an approved cleaning product at Hakea.

Finally, the Department was able to explain in the letter provided to the Court after the inquest, why it was that Mr Hatcher’s son was not informed about his father’s admissions to FSH. Enquiries revealed that only Mr Hatcher’s wife was listed as his Next of Kin when he was taken into Custody.32 It may well be that Mr Hatcher did not realise the significance of the Next of Kin listing when he provided just his wife’s details. If he had known he needed to list his son to ensure he was advised of developments such as hospital admissions I am sure he would have done so.

Mr Hatcher’s son persisted in his attempts to establish his father’s whereabouts and, once he made contact with him at FSH, regular visits were facilitated.33 I have no doubt those visits at the end of his life meant a lot to Mr Hatcher.

CONCLUSION Mr Hatcher was already suffering from severe lung disease when he was taken into custody in August 2023. When he was diagnosed with active tuberculosis in May 2024 his health became even more significantly compromised.

32 Letter from State Solicitor’s Office to Sergeant Assisting the Coroner dated 1 September 2025 including attachment DJH.006 Offender Summary.

33 Letter from State Solicitor’s Office to Sergeant Assisting the Coroner dated 1 September 2025 including attachments DJH.007 Email from Ventia to Hakea and DJH.008 Email from Hakea regarding visits.

[2026] WACOR 15 The supervision, treatment and care he received in prison was of an acceptable standard, with the exception of the non-compliant application of restraints on two occasions.

Staff at FSH worked tirelessly to save Mr Hatcher but were ultimately unsuccessful.

It is clear that Mr Hatcher’s decision to decline treatment, both in prison and in hospital, played a role in the irreversible trajectory of his ill health.

I wish to extend to Mr Hatcher’s family, on behalf of the Court, my sincere condolences for their loss.

RM Hartley Coroner 1 April 2026