Coronial
WAhospital

Inquest into the Death of David Arthur RICE

Deceased

David Arthur RICE

Demographics

75y, male

Date of death

2021-01-23

Finding date

2022-10-05

Cause of death

acute bronchopneumonia in a man with comorbidities

AI-generated summary

A 75-year-old sentenced prisoner died from acute bronchopneumonia with comorbidities. Mr Rice had extensive medical complexity including COPD, cardiac disease, peripheral vascular disease, and diabetes. He was appropriately placed on the terminally ill register and received comprehensive medical care that exceeded community standards. However, system failures prevented consideration of early release via Royal Prerogative of Mercy: briefing notes required by policy were not sent when he was designated terminally ill, due to staff vacancies and resource constraints. While early release was unlikely given his serious criminal history, policy should have been followed. Mr Rice had declined recommended dietary modifications to reduce aspiration risk despite being warned of pneumonia and death risks; aspiration possibly contributed to his fatal bronchopneumonia. Prison medical care was appropriate and timely throughout his incarceration.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

general medicinecardiologyrespiratory medicinevascular surgeryintensive carecorrectional health

Error types

system

Drugs involved

apixabanbisoprolollidocainemetforminnortriptylineoxycodoneparacetamoltapentadolalteplasepregabalin

Clinical conditions

acute bronchopneumoniaaspiration pneumoniachronic obstructive pulmonary diseaseischaemic heart diseasecongestive cardiac failureatrial fibrillationperipheral vascular diseasechronic kidney diseaseseptic shockcardiac arrestleft ventricular dysfunctionurosepsisbowel obstruction

Procedures

angiographyangioplastycystoscopyindwelling catheter insertionechocardiographyMRIchest X-ray

Contributing factors

  • chronic obstructive pulmonary disease
  • ischaemic heart disease with previous cardiac arrest
  • peripheral vascular disease
  • aspiration risk due to swallowing difficulties
  • patient refusal to modify diet despite warnings
  • complex comorbidities including congestive cardiac failure, atrial fibrillation, chronic kidney disease
  • system failure to process early release paperwork for terminally ill prisoner

Coroner's recommendations

  1. DOJ has since reinstated the staff position responsible for generating briefing notes to the Minister regarding early release of prisoners under Royal Prerogative of Mercy
  2. Arrangements are now in place to ensure the terminally ill prisoner list in TOMS is closely monitored
  3. A delegate should be appointed to undertake briefing note preparation in the absence of the responsible person
  4. Two further positions have been established to monitor the Terminally Ill register to ensure Department Policy is followed
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